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In 2025, The European Association of Urology (EAU) guidelines acknowledged the promising potential of focal therapy in localized prostate cancer: reduced complications and preservation of quality of life.
According to the American Urological Association, Focal Therapy for prostate cancer is considered experimental with a lack of long-term data.
Asia follows a trend similar to Europe: focal therapy is generating significant interest, but it remains experimental.
To discuss about these emerging treatments, let’s go through the options with Prof. Peter Chiu’s feedback.
Needle-based focal therapy for prostate cancer
Needle-guided focal therapy is an approach that targets and treats only the identified tumor areas, while preserving the rest of the prostate gland. This allows energy to be delivered directly to the targeted area, sparing the surrounding healthy.
Today, several energy sources are used in focal therapy:
• Cryotherapy: freezes tumor cells at very low temperatures
• HIFU (High-Intensity Focused Ultrasound): locally raises the temperature (65–100°C), causing thermal destruction of tissue
• Laser: heats targeted tissue with laser energy until it is destroyed
• IRE (Irreversible Electroporation): delivers short high-voltage electrical pulses to the tumor
• Radiofrequency: uses high-frequency electrical currents to destroy tumor tissue
How should treatment options be selected?
Needle-based focal therapies are mainly performed by transperineal approach (except for HIFU which is performed by transrectal route). Physicians who used to perform prostate biopsy by transperineal route won’t need to learn new techniques to perform focal therapies.
Different focal energies are suitable for different tumor locations. For example, for very posterior lesions next to the rectum, HIFU would be a good option. Tumors that are anterior, particularly antero-lateral, cryotherapy microwave or IRE would be more suitable. For tumors that are next to the prostate urethra or anterior to the prostate urethra are those which are very challenging for cryotherapy.
“And in my personal experience, microwave ablations are particularly good in that locations. So in a way, microwave ablation can cater for most locations, except for the small region of the tumors that is just anterior or next to the rectum”
Prof. Peter Chiu, Hong-Kong.
Focus on Targeted-Microwave Ablation
Targeted-Microwave Ablation (TMA) is a minimally invasive focal therapy designed to destroy cancerous tissue in the prostate using microwave energy. In practice, the lesion mapping performed during diagnosis is fused with real-time ultrasound imaging to plan and precisely target the treatment area(s). This is exactly the same process used for performing biopsies. Once the planning is complete, the treatment is carried out by inserting the needle into the targeted area and allowing the energy to act for about five minutes per identified lesion to ensure adequate coverage.
“Compared with HIFU or cryotherapy, microwave ablation is a much quicker treatment. probably less than half of the time that you need for other treatments”
Prof. Peter Chiu, Hong-Kong
According to Prof. Peter Chiu, almost all of his patients are discharged from the hospital around six hours after the operation. They feel very good and do not have major complications.
Final results of our Targeted Microwave Ablation treatment trial (Violette study) are expected for fall 2025.
The criteria of choice of treatment
The choice of treatments offered to patients depends on several factors.
First, the urologist’s experience plays a key role. If they are used to performing transperineal fusion biopsies, if they offer multiple types of treatments, or if they aim to propose focal therapies, this will influence their approach. The decision also depends on the equipment and energy sources available in their healthcare facility. Not all diagnostic systems are compatible with certain treatment options…
Cost is, of course, another key factor to consider. Today, focal therapies are still under investigation and have not yet been included in the official guidelines of international urological associations. As a result, reimbursement and coverage are not yet in place, which limits access for both urologists and their patients.
Finally — and perhaps most importantly — the choice depends on the location of the lesions. According to Prof. Peter Chiu, for very posterior lesions next to the rectum, HIFU would be a good option. Whereas for tumors that are further away, like anterior, particularly antero-lateral, cryotherapy or any needle-based ablations like microwave or IRE would be more suitable.
Focal therapies are not yet considered standard of care, but more and more urologists are adopting these treatment options. Every day, new studies, clinical trials, and research are being conducted to demonstrate and validate the effectiveness of these therapies. There is little doubt that the coming years will be decisive in establishing focal therapy within international guidelines and the standard care pathways for prostate cancer.
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