Did you ever take one of those whirlwind bus tours of Europe as a way to survey the best tourist attractions? Your itinerary might start by landing in London, then moving on to The Netherlands, Germany, Switzerland, Austria and Italy before your homeward bound departure. A July, 2021 published paper by Rakauskas, et al.^[i] is a tour de force of top urologists from these countries. The topic of the paper concerns possible side effects of focal therapy and how to manage them.

A brief history of focal prostate cancer treatment

It’s interesting that the 15 European authors of this paper on focal treatment are almost all urologists. This is historically significant. Keep in mind that from the late 1990s onward, urologists as a group were largely resistant to the concept of focal treatment for prostate cancer (PCa), which was spearheaded in the years back then by interventional radiologists like Drs. Duke Bahn and Gary Onik; they were quickly joined by a handful of urologist outliers (notably Israel Barken, Aaron Katz and Stephen Scionti). All of these focal pioneers got their start with focal cryoablation, and all of them—including the urologists–were subjected to demeaning commentary by the urologic establishment: “You are irresponsible. It’s malpractice to leave untreated prostate tissue behind, because PCa is a multi-focal disease.”

Critics included the innovators of nerve-sparing prostatectomy. This surgical technique was a wake-up call for patients, who knew the physical and psychological price they might pay for radical (whole gland) treatments. As the paper’s authors point out, surgery and radiation came with a “substantial risk” of urinary and sexual side effects, and rectal problems due to radiation. It’s probably that the possibility of preserving sexual function acted ironically as a foot in the door for focal treatment as patient demand for better quality of life after PCa treatment began to soar.

It became clear to men that focal therapy was a viable alternative to radical treatments (including nerve-sparing prostatectomy) as well as Active Surveillance. According to the authors, focal therapy is also “now arguably seen as an alternative treatment modality for patients diagnosed with intermediate risk localized prostate cancer who would otherwise undergo radical therapy.” Eventually, as focal therapies became more varied and technologically improved (cryotherapy, HIFU, focal laser ablation, and photodynamic, with more on the way), the growing body of research demonstrates their safety and effectiveness—though long-term data and high-level studies still have yet to emerge.

Side effects of focal treatment

Reported urinary and sexual side effect rates for focal therapy range from zero to moderate. “Urinary incontinence following focal therapy is very rare (0–5%), and the vast majority of patients recover in few weeks. Erectile dysfunction can occur after focal therapy in 0–46%: the baseline function and the ablation template are the most important factors predicting post-operative erectile dysfunction,” write the authors. The occurrence of short-term or longer-term adverse effects depends on possible complicating factors:

• Baseline function before treatment, including pre-existing ED, lower urinary tract symptoms (LUTS), existing neurological conditions
• Gland size/anatomy
• PCa location
• The extent of applied treatment
• The energy source of the treatment
• Previous pelvic/prostate surgery

The possibility of post-therapy side effects is dealt with calmly and rationally by the authors. Urinary side effects such as blood in urine or semen, LUTS, urethral blockage from clotting or sloughing of tissue, and infection are addressed with recommendations for measures such as antibiotics, pain relievers or other medications, and use of a catheter during healing.

As for erectile dysfunction, the authors report statistics from several studies but note that most are not of high quality and difficult to compare on an apples-to-apples basis. However, most men (54-100%) with good baseline function experience erections sufficient for penetration after focal therapy within 12 months, with or without erectile drugs. There is no discussion of penile rehabilitation protocols.

On balance, this paper is explicit encouragement for focal treatment, particularly because of the favorable preservation and/or recovery of urinary and sexual performance. “Most complications are mild and follow the 30-day period after treatment, these can be managed with medication and do not require invasive procedures in the majority of patients. Urinary incontinence is rare, and the risk of new onset erectile dysfunction is much lower than for whole gland treatments.”

It is doubtful any urologist today would take issue with the principles of focal treatment for carefully qualified patients. While there may be traditionalists who do not themselves offer focal therapy, larger numbers of urologists are seeking training and experience in one or more focal modalities. In addition, the benefits of multiparametric MRI for detecting and diagnosing PCa, and for qualifying patients for any form of treatment as well as Active Surveillance, are widely acknowledged and embraced. In fact, our own Center specializes in three focal therapies guided by real-time MRI: Focal Laser Ablation (FLA), TULSA-PRO, and Exablate (MRI-guided Focused Ultrasound). In this “brave new world,” urologists agree on focal therapy’s benefits.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

[i] Rakauskas A, Marra G, Heidegger I, Kasivisvanathan V, Kretschmer A et al. Focal Therapy for Prostate Cancer: Complications and Their Treatment. Front Surg. 2021; 8: 696242.