Focal therapy in prostate cancer and advances in the use of androgen blockade

Carlos Hernandez^1*Juan Ignacio Martinez-Salamanca²Giuseppe Maiolino²Bernardino Miñana³Francisco Gómez-Veiga⁴

• ¹Servicio de Urología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
• ²Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
• ³University Clinic of Navarra, Pamplona, Navarre, Spain
• ⁴A Coruña University Hospital Complex (CHUAC), A Coruña, Spain

The widespread adoption of multiparametric magnetic resonance imaging (mpMRI) in most urology departments, together with the development of fusion biopsy (FB) techniques, has led to a growing number of early-stage prostate cancer (PCa) diagnoses—often at less aggressive stages. As observed in other solid organ tumors (kidney, breast, liver,…), focal treatment of localized lesions has become an established approach. However, due to the multifocal nature of PCa, the clinical implementation of focal therapy (FT) has progressed more slowly. The increasing recognition of the index lesion—the largest and most aggressive tumor focus—as the key driver of PCa progression has expanded the indications for FT [1]. Advances in technology have equipped urologists with highly precise and safe tissuedestructive techniques, which minimize side effects. These include cryotherapy, high-intensity focused ultrasound (HIFU), irreversible electroporation (IRE), radiofrequency ablation, and laser therapy. Since the 1990s, focal therapy for prostate cancer has advanced through progressively sophisticated strategies. Initially, focal cryotherapy offered a minimally invasive option, followed in the 2000s by high-intensity focused ultrasound (HIFU) and phototherapy for precise, lower-morbidity treatment. Between 2010 and 2014, techniques such as laser ablation guided by fusion biopsy and irreversible electroporation enhanced lesion targeting and nonthermal ablation. Histotripsy emerged in 2015, enabling ultrasound-based tumor destruction without heat, while the 2017 TULSA system integrated MRI-guided transurethral ablation with intraoperative control. Most recently, PSMA PET (2020) has refined lesion detection and posttreatment monitoring, underscoring the critical role of molecular imaging in focal therapy strategies.