Focal Therapy & HIFU

Who May Benefit

Focal therapy may be appropriate if you:

• Have localised prostate cancer confined to one side or one region of the gland
• Have low-risk or favourable intermediate-risk disease — typically Grade Group 1–2, sometimes selected Grade Group 3
• Have a clearly visible lesion on multiparametric MRI that corresponds to your biopsy findings
• Have had a transperineal mapping or targeted biopsy confirming the disease is not widespread within the gland
• Place a high priority on preserving urinary continence and erectile function
• Are unsuitable for, or wish to avoid, radical surgery or radiotherapy
• Have localised recurrence after radiotherapy and are being assessed for salvage treatment

When This Is Not Suitable

• Multifocal or bilateral cancer spread through the gland
• High-risk disease, extracapsular extension, or seminal vesicle involvement
• Any evidence of nodal or metastatic spread
• A very large prostate, heavy calcification, or previous rectal surgery that prevents adequate ultrasound access
• Cancer that is not visible on MRI, where the target cannot be defined reliably

The Procedure and the Alternatives

What Treatment Involves

HIFU is delivered under general or spinal anaesthesia using a probe placed in the rectum. Focused ultrasound energy is directed at the mapped lesion, heating it to a temperature that destroys the tissue. There is no incision. Most patients go home the same day or the following morning, with a catheter for a few days.

Other Forms of Focal Therapy

Cryotherapy, irreversible electroporation and focal laser ablation are alternative energy sources used in selected cases. Availability and suitability vary; the principle of targeted treatment with gland preservation is the same.

Alternatives to Focal Therapy

• Active surveillance — for low-risk disease, monitoring without treating; avoids all treatment side effects
• Robotic radical prostatectomy — removes the whole gland with the most mature long-term outcome data and definitive pathology
• Radiotherapy — external beam or brachytherapy, treating the whole gland

Follow-Up

PSA at regular intervals, MRI at around six to twelve months, and biopsy of the treated area where there is any concern. Follow-up after focal therapy is more intensive than after radical treatment, precisely because the gland remains in place.

Investigations Usually Required

Case selection for focal therapy is stricter than for other treatments, and the workup reflects that:

• Multiparametric MRI of the prostate — essential; the lesion must be clearly visible and its extent defined
• Transperineal targeted and mapping biopsy — to confirm the cancer is localised to the intended treatment zone and to exclude significant disease elsewhere in the gland
• PSA and PSA density — with previous values where available
• PSMA PET-CT — in selected cases, to exclude disease outside the prostate before committing to gland-preserving treatment
• Prostate volume measurement — and assessment of calcification, which can limit ultrasound access
• Baseline urinary and sexual function scores — IPSS and IIEF, so that any change afterwards can be measured against your own starting point
• Flexible cystoscopy or urodynamics — occasionally, where there are significant existing voiding symptoms

Important Limitations and Risks

• Long-term evidence is still maturing. Focal therapy has good medium-term functional results, but it does not yet have the decades of cancer-control data that surgery and radiotherapy have. Patients should understand they are choosing an option with a shorter evidence base.
• Residual or recurrent cancer. Because the rest of the prostate remains, cancer can persist in the treated zone or appear elsewhere in the gland. A meaningful proportion of patients need further treatment — repeat focal therapy, surgery or radiotherapy.
• Case selection is everything. Treating an unsuitable tumour focally risks leaving significant cancer behind. If assessment shows the disease is more extensive than hoped, the honest recommendation may be whole-gland treatment.
• Follow-up is demanding — repeated PSA, MRI and sometimes biopsy. This is not a treat-and-forget option.
• Side effects, though less frequent than after radical treatment, still occur — temporary urinary retention or difficulty passing urine, urinary infection, some change in erectile function, and rarely injury to the urethra or rectum.
• PSA after focal therapy is harder to interpret, because untreated prostate tissue continues to produce it.
• Not offered at every center, and suitability must be confirmed on a case-by-case basis after full assessment.

What a Consultation Involves

A consultation about focal therapy usually takes 30 to 45 minutes and covers:

• Detailed review of your MRI and biopsy — mapping where the cancer is and, just as importantly, confirming where it is not
• A frank suitability assessment — whether focal therapy is genuinely a reasonable option in your case, or whether whole-gland treatment would serve you better
• What the evidence does and does not show — including where the data is still developing
• Comparison with the alternatives — surveillance, surgery and radiotherapy, set out side by side
• The follow-up commitment — what monitoring will involve over the years ahead
• Baseline function assessment — urinary and sexual function documented before any treatment
• Your questions — with time to reflect before deciding

Please bring your MRI images on CD and full biopsy reports, including the location of each positive core.