Focal Therapy for Prostate Cancer

Q: Can I have focal therapy if I have Gleason 6 prostate cancer?

Most men with Grade Group 1 (Gleason 3+3) prostate cancer are better managed with active surveillance because many of these cancers grow so slowly that immediate treatment offers little benefit.

Q: Can Gleason 7 prostate cancer be treated with focal therapy?

Yes. Many men with Grade Group 2 (Gleason 3+4) prostate cancer—and selected men with Grade Group 3 (Gleason 4+3) disease—may be suitable, depending on the MRI findings, biopsy results and location of the tumour.

Q: How long does the procedure take?

Most focal therapy procedures take between one and two hours , although this varies depending on the treatment technology and the amount of prostate requiring treatment.

A Complete Guide to HIFU, NanoKnife, Cryotherapy and Targeted Treatment

Evidence-based information from Mr Neil Haldar, Consultant Urological Surgeon

At a Glance

✔ Treats only the significant area of prostate cancer

✔ Preserves as much healthy prostate tissue as possible

✔ Lower risk of urinary incontinence than whole-gland treatment in carefully selected men

✔ Better preservation of erectile function for many suitable patients

✔ Usually performed as a day-case procedure

✔ Requires ongoing PSA monitoring, MRI and follow-up biopsy

✔ Not suitable for every man with prostate cancer

Considering Focal Therapy for Prostate Cancer?

Receiving a diagnosis of prostate cancer can feel overwhelming.

Within a matter of days, many men find themselves trying to understand a bewildering range of treatment options. Should the prostate be removed? Is radiotherapy a better choice? Would active surveillance be safe? And increasingly, many patients ask another important question:

“Could I have focal therapy instead?”

It is an understandable question.

For decades, the treatment of localised prostate cancer was based on the principle that the entire prostate gland should be treated. Surgery removes the whole prostate. Radiotherapy treats the whole gland. Both remain excellent treatments and continue to save thousands of lives every year.

However, these treatments inevitably affect healthy tissue as well as the tumour itself. The nerves responsible for erections run immediately alongside the prostate. The urinary sphincter that maintains continence sits directly beneath it. The bladder and rectum are close neighbours. Even with modern nerve-sparing robotic surgery and highly sophisticated radiotherapy techniques, protecting these structures while completely treating the cancer remains one of the greatest challenges in prostate cancer care.

Advances in imaging have transformed that conversation.

Today, high-quality multiparametric MRI (mpMRI) combined with MRI-targeted transperineal biopsy allows us to identify the exact location, size and biological behaviour of many prostate cancers with far greater precision than ever before. Instead of viewing the prostate as a single organ, we can often map where the clinically significant cancer lies and distinguish it from healthy tissue.

This has led to the development of focal therapy.

Rather than removing or treating the whole prostate, focal therapy aims to destroy only the clinically significant tumour, preserving as much normal prostate tissue as possible. For carefully selected men, this may reduce the risk of urinary incontinence and erectile dysfunction while still providing excellent cancer control.

It is an exciting development in prostate cancer treatment—but it is not the right treatment for everyone.

One of the most important messages I hope to convey in this guide is that focal therapy should not be viewed as a replacement for robotic surgery, radiotherapy or active surveillance. Instead, it is another valuable treatment option within the modern management of localised prostate cancer.

Choosing between these treatments is rarely straightforward.

The best decision depends on several factors, including:

the size and location of the cancer
the Gleason Grade Group
PSA level and PSA trend
MRI findings
whether the cancer is confined to the prostate
your age and general health
your urinary and sexual function before treatment
and, perhaps most importantly, your own priorities.

Some men place the greatest importance on preserving urinary continence and erectile function.

Others want the reassurance of removing the entire prostate and achieving an undetectable PSA after surgery.

Neither approach is inherently right or wrong.

The aim is to choose the treatment that offers the best balance between long-term cancer control and quality of life for your individual circumstances.

Why You Can Trust This Guide

I have spent more than 25 years as a Consultant Urological Surgeon, specialising in the diagnosis and treatment of prostate cancer and other urological cancers.

During that time, I have performed more than 1,000 nerve-sparing robotic radical prostatectomies, helping men from across Buckinghamshire, Berkshire, Oxfordshire, Hertfordshire and London.

Alongside my clinical practice, I am currently the Buckinghamshire Healthcare NHS Trust Principal Investigator for the UK IP2-ATLANTA clinical trial. This important national study is investigating whether treating the prostate—including with focal ablative therapy in one treatment arm—can improve outcomes for selected men with newly diagnosed metastatic prostate cancer. It will help shape future practice across the UK.

Every week, I meet men facing exactly the same questions that you may be asking today:

Is focal therapy suitable for me?
How does it compare with robotic surgery?
Will I become incontinent?
What are the chances of preserving my erections?
What happens if the cancer comes back?
Would you recommend focal therapy to a member of your own family?

This guide has been written to answer those questions honestly and objectively.

It is based on the best available scientific evidence, current UK practice and my experience caring for men with prostate cancer. My aim is not to persuade you towards one particular treatment. Instead, it is to help you understand the advantages, limitations and uncertainties surrounding every option, so that you can make an informed decision together with your specialist.

What You’ll Learn in This Guide

In this comprehensive guide, we’ll cover:

What focal therapy is and how it works
Why focal therapy has become possible in recent years
The different technologies available, including HIFU, NanoKnife® and cryotherapy
Who is—and isn’t—a suitable candidate
How focal therapy compares with robotic surgery and radiotherapy
Side effects, recovery and quality of life
PSA monitoring after treatment
Success rates and the latest clinical evidence
NHS and private availability
Frequently asked questions
How to decide which treatment is right for you

By the end of this guide, you should have a clear understanding of where focal therapy fits within modern prostate cancer treatment and whether it is a discussion worth having with your urologist.

What Is Focal Therapy for Prostate Cancer?

The concept behind focal therapy is both simple and revolutionary.

Rather than treating the entire prostate gland, focal therapy aims to destroy only the area containing the clinically significant cancer, preserving as much healthy prostate tissue as possible.

To understand why this matters, it helps to think about how prostate cancer has traditionally been treated.

For many years, localised prostate cancer was managed using what doctors call whole-gland treatment.

This means treating the entire prostate because, until relatively recently, we had no reliable way of knowing exactly where the most important cancer was located.

As a result:

Robotic radical prostatectomy removes the whole prostate gland together with the seminal vesicles.
External beam radiotherapy treats the entire prostate with carefully targeted radiation.
Brachytherapy delivers radiation throughout the whole gland.

These treatments remain highly effective and continue to provide excellent long-term cancer control for many men.

However, they also expose healthy prostate tissue—and nearby structures—to treatment.

A Different Way of Thinking

Advances in prostate imaging have transformed our understanding of prostate cancer.

Today, high-quality multiparametric MRI (mpMRI) and MRI-targeted transperineal biopsy allow us to identify many clinically significant prostate cancers with remarkable precision.

Instead of simply knowing that cancer is present somewhere within the prostate, we can often determine:

exactly where the tumour is located
how large it is
how aggressive it appears to be
whether there is more than one significant tumour
and how close it lies to important structures such as the urinary sphincter and the nerves responsible for erections.

Once we know this, an obvious question follows:

If only one part of the prostate contains the significant cancer, do we really need to treat the whole gland?

For carefully selected men, the answer may be no.

That is the principle behind focal therapy.

What Is the “Index Lesion”?

One term you may come across when reading about focal therapy is the index lesion.

This refers to the largest or highest-grade tumour within the prostate.

Research has shown that this dominant tumour is often the one most likely to determine how the disease behaves.

Many prostates contain several tiny areas of low-grade cancer.

These smaller tumours are surprisingly common and, in many cases, may never become clinically important.

The aim of focal therapy is therefore to eradicate the clinically significant index lesion, while preserving the remainder of the prostate whenever it is safe to do so.

This approach differs fundamentally from traditional whole-gland treatment.

Is Prostate Cancer Always in One Place?

No.

This is one of the most important things to understand.

Unlike many other cancers, prostate cancer is often multifocal, meaning that more than one area of cancer may be present within the prostate.

Fortunately, not every tumour behaves in the same way.

Some small areas of low-grade prostate cancer grow so slowly that they are unlikely ever to threaten life or require treatment.

Others are much more aggressive.

The challenge is identifying which cancers matter.

This is why careful patient selection is absolutely essential.

Focal therapy is not appropriate simply because a patient would prefer a less invasive treatment.

It is appropriate only when detailed imaging and biopsy demonstrate that all clinically significant disease can be safely targeted.

Consultant’s Perspective

One of the biggest misconceptions I encounter is that focal therapy is simply a “smaller operation.”

It isn’t.

Focal therapy represents a completely different treatment philosophy.

Success depends less on the technology used—whether HIFU, NanoKnife® or cryotherapy—and far more on selecting the right patient and accurately identifying the significant cancer before treatment begins.

A Helpful Comparison

Patients sometimes hear focal therapy described as the “lumpectomy of prostate cancer.”

The comparison comes from breast cancer surgery.

Many women with early breast cancer no longer require removal of the entire breast.

Instead, surgeons remove the cancer together with a margin of healthy tissue, preserving the remainder of the breast whenever it is safe to do so.

Focal therapy follows a similar principle.

The comparison is helpful—but not perfect.

Breast cancer is often a single tumour.

Prostate cancer is frequently multifocal.

This means patient selection is considerably more complex.

For that reason, focal therapy should only be considered after thorough assessment with modern MRI, targeted biopsy and careful review by an experienced prostate cancer specialist.

Does Focal Therapy Cure Prostate Cancer?

This is one of the commonest questions I am asked.

The honest answer is:

Focal therapy can provide excellent long-term cancer control in carefully selected men, but no treatment can guarantee a cure.

That statement is true not only for focal therapy but also for surgery and radiotherapy.

The aim of focal therapy is to destroy all clinically significant cancer that has been identified while preserving urinary continence, erectile function and overall quality of life wherever possible.

Many men remain free of further treatment for many years.

Others may require additional focal treatment, robotic surgery or radiotherapy if new clinically significant cancer develops elsewhere in the prostate or if surveillance identifies persistent disease.

This possibility is not a failure of focal therapy.

Rather, it reflects the philosophy of preserving healthy tissue while maintaining careful long-term follow-up.

Why Has Interest in Focal Therapy Grown So Rapidly?

Over the last decade, three major developments have transformed prostate cancer care:

Better imaging, allowing us to identify significant tumours with much greater accuracy.
Safer biopsy techniques, particularly MRI-targeted transperineal biopsy.
Improved understanding of prostate cancer biology, helping us distinguish cancers that require treatment from those that can safely be monitored.

Together, these advances have made focal therapy a realistic option for carefully selected patients.

The emphasis is not on treating less cancer.

It is on treating the right cancer while preserving as much normal tissue as possible.

Key Points

Focal therapy aims to treat the clinically significant prostate cancer while preserving as much healthy prostate tissue as possible.

It is made possible by modern mpMRI and MRI-targeted transperineal biopsy, which accurately identify the location and extent of significant disease.

It is not suitable for every man with prostate cancer and requires careful patient selection.

The goal is to achieve excellent cancer control while reducing the impact of treatment on urinary continence, erectile function and quality of life.

Why Is Focal Therapy Possible Today?

One of the biggest misconceptions about focal therapy is that it became possible because someone invented a new treatment machine.

In reality, focal therapy became possible because we became much better at finding prostate cancer.

The greatest advance has not been HIFU, NanoKnife® or cryotherapy.

It has been our ability to identify exactly where clinically significant prostate cancer is located before treatment begins.

Without that knowledge, treating only part of the prostate would simply not be safe.

How Was Prostate Cancer Diagnosed in the Past?

Until relatively recently, diagnosing prostate cancer was rather like trying to find a needle in a haystack.

Men with a raised PSA or an abnormal prostate examination typically underwent a transrectal ultrasound (TRUS)-guided biopsy.

Although ultrasound allowed us to see the prostate itself, it could not reliably identify most prostate cancers.

Instead, the biopsy followed a standard pattern.

Small tissue samples were taken from different areas of the prostate in the hope of finding cancer.

It was a little like trying to understand the contents of a book by reading only a handful of randomly selected sentences.

This approach diagnosed many important cancers and saved countless lives.

However, it also had significant limitations.

It could:

miss clinically significant tumours
underestimate how aggressive a cancer really was
fail to show the exact size of a tumour
fail to show precisely where within the prostate the cancer was located.

Under those circumstances, treating only part of the prostate would have been unreliable.

The MRI Revolution

Everything changed with the introduction of multiparametric MRI (mpMRI).

Rather than simply showing the outline of the prostate, mpMRI allows us to examine the gland in remarkable detail.

Using several different imaging sequences, it helps us identify areas that are suspicious for clinically significant prostate cancer.

Today, an MRI can often tell us:

where the tumour is located
approximately how large it is
whether it appears aggressive
whether it has started to extend beyond the prostate
how close it lies to important structures such as the urinary sphincter and the neurovascular bundles.

For the first time, we could see what we were treating.

This represented a fundamental change in prostate cancer diagnosis.

The PROMIS Study Changed Clinical Practice

One of the landmark studies responsible for changing prostate cancer diagnosis in the UK was the PROMIS trial.

The study demonstrated that high-quality multiparametric MRI could identify clinically significant prostate cancer far more accurately than the traditional pathway of immediate TRUS biopsy.

As a result, MRI is now performed before biopsy for most men with suspected prostate cancer.

This has transformed modern prostate cancer care.

Rather than performing biopsies almost blindly, we can now direct them precisely towards suspicious areas identified on MRI.

Consultant’s Perspective

When I first became a consultant, we relied heavily on systematic TRUS biopsies because that was the best technology available.

Today, the diagnostic pathway is completely different.

High-quality multiparametric MRI has fundamentally changed how we diagnose prostate cancer and has allowed us to tailor treatment far more precisely than was ever possible before.

In my view, modern imaging has been one of the most important advances in prostate cancer care during my career.

MRI Is Only Part of the Story

Although MRI is extremely powerful, it cannot diagnose prostate cancer on its own.

A suspicious area seen on MRI must still be confirmed with a biopsy.

Today, this is usually performed using MRI-targeted transperineal biopsy.

Unlike older transrectal biopsies, the biopsy needles pass through the skin between the scrotum and anus rather than through the bowel.

This offers several important advantages.

It allows us to:

target suspicious MRI lesions much more accurately
sample difficult areas at the front of the prostate
reduce the risk of serious infection
obtain a much more detailed understanding of the cancer.

The biopsy then provides the information that MRI alone cannot.

It tells us:

whether cancer is actually present
the Gleason score (Grade Group)
the amount of cancer within each biopsy core
and whether the MRI findings truly represent clinically significant disease.

Only by combining MRI and biopsy can we decide whether focal therapy is appropriate.

Building a Three-Dimensional Map of the Prostate

One way I explain this to patients is to imagine creating a detailed map.

The MRI identifies the suspicious area.

The targeted biopsy confirms exactly what is there.

Together, they allow us to build a three-dimensional picture of the prostate.

We can see:

where the tumour starts
where it ends
how close it is to the urethra
whether it lies near the nerves responsible for erections
whether there are other significant tumours elsewhere in the gland.

Only once we have this information can we answer the question:

Can we safely treat only the cancer while preserving the remainder of the prostate?

For some men, the answer is yes.

For others, the cancer is too extensive, too close to critical structures or present in multiple areas of the prostate.

Those men are usually better served by whole-gland treatment with robotic surgery or radiotherapy.

Why Patient Selection Matters More Than the Technology

Patients often ask me:

“Is HIFU better than NanoKnife?”

In reality, this is usually the wrong question.

The most important factor is not the machine.

It is selecting the right patient.

A perfectly delivered focal treatment cannot compensate for incomplete imaging or inaccurate biopsy information.

Similarly, the newest technology cannot overcome a cancer that is simply too extensive for focal treatment.

Successful focal therapy begins long before treatment.

It begins with:

high-quality MRI
accurate targeted biopsy
careful interpretation of the results
honest discussion of every treatment option
and thoughtful patient selection.

In my experience, this is the single most important determinant of a good outcome.

Looking to the Future

Imaging technology continues to evolve rapidly.

Artificial intelligence is beginning to assist radiologists in identifying suspicious prostate lesions.

New MRI techniques are improving image quality.

PSMA PET-CT is enhancing staging in selected patients.

Genetic and molecular markers may soon help us distinguish aggressive cancers from those that can safely be monitored.

Together, these advances are likely to make prostate cancer treatment increasingly personalised.

As our ability to identify clinically significant disease improves, our ability to tailor treatment—including focal therapy—is likely to improve with it.

Key Points

Focal therapy became possible because prostate cancer diagnosis has improved dramatically—not because of new treatment machines.

Multiparametric MRI allows us to identify many clinically significant prostate cancers with remarkable accuracy before treatment begins.

MRI-targeted transperineal biopsy confirms the diagnosis and provides detailed information about the tumour’s location and aggressiveness.

Careful patient selection remains the single most important factor in successful focal therapy.

Modern imaging continues to evolve, making prostate cancer treatment increasingly precise and personalised.

Types of Focal Therapy Available in the UK

One of the commonest misconceptions is that focal therapy is a single treatment.

It isn’t.

Focal therapy is a treatment philosophy.

Several different technologies can be used to destroy the cancer. Each works in a different way, but they all share the same objective:

To eradicate the clinically significant tumour while preserving as much healthy prostate tissue as possible.

Patients often ask me:

“Which type of focal therapy is the best?”

The honest answer is that there is no universally superior treatment.

The most appropriate option depends far more on:

where the tumour is located
its size and shape
its relationship to the urethra and erectile nerves
the size of the prostate
and the experience of the treating specialist

than on the name of the machine itself.

In other words, selecting the right patient and choosing the right treatment for that particular cancer are far more important than choosing the newest technology.

High-Intensity Focused Ultrasound (HIFU)

HIFU is currently the most widely established focal therapy technique in the UK and has the largest body of published UK outcome data.

Rather than using radiation or surgery, HIFU uses precisely focused ultrasound waves.

These waves pass harmlessly through surrounding tissue before rapidly heating the targeted area to temperatures high enough to destroy cancer cells.

The treatment is remarkably precise.

The ultrasound energy can be focused within a few millimetres, allowing destruction of the tumour while minimising injury to surrounding healthy tissue.

The procedure is usually performed:

under general anaesthetic
as a day-case procedure
with a temporary urinary catheter for several days afterwards.

Which cancers is HIFU best suited to?

HIFU is particularly effective for cancers located:

towards the back (posterior) of the prostate
in the middle of the gland
away from major calcification within the prostate.

Large prostates or extensive calcification can sometimes make HIFU technically more challenging.

Advantages of HIFU

✓ Largest UK clinical experience

✓ Excellent published medium-term outcomes

✓ No surgical incision

✓ Usually rapid recovery

✓ Excellent preservation of urinary continence

Potential limitations

Not suitable for every tumour location
Very large prostates may require additional planning
Long-term comparative evidence continues to mature

Cryotherapy (Cryoablation)

Cryotherapy destroys prostate cancer by doing the exact opposite of HIFU.

Instead of heating tissue, it destroys cancer by freezing it.

During the procedure, several fine needles are inserted through the skin between the scrotum and anus (the perineum) using ultrasound guidance.

Extremely cold argon gas creates carefully controlled ice balls around the tumour.

Repeated freeze-thaw cycles permanently damage the cancer cells while preserving as much surrounding tissue as possible.

When is cryotherapy particularly useful?

Cryotherapy can be especially useful for:

cancers towards the front (anterior) of the prostate
larger prostates
tumours that may be technically difficult to reach using HIFU.

Like HIFU, cryotherapy is usually performed as a day-case procedure under general anaesthetic.

Advantages

✓ Excellent treatment of anterior tumours

✓ Less affected by prostate size

✓ Well-established technology

✓ Rapid recovery

Potential limitations

Treatment planning is particularly important when tumours lie close to:

the erectile nerves
the urinary sphincter
the urethra.

NanoKnife® (Irreversible Electroporation)

NanoKnife®, also known as Irreversible Electroporation (IRE), works in a completely different way.

Rather than using heat or freezing, NanoKnife delivers a series of carefully controlled electrical pulses between fine needles inserted into the prostate.

These electrical pulses create tiny permanent openings within the membranes of cancer cells.

Unable to repair this damage, the cells die naturally over the following days and weeks.

Because very little heat is produced, NanoKnife has attracted considerable interest for tumours located close to delicate structures.

Potential advantages

NanoKnife may be particularly attractive for cancers close to:

the urethra
the urinary sphincter
the neurovascular bundles responsible for erections.

This is because there is less thermal spread than with treatments that rely on heating or freezing.

Current evidence

Early and medium-term results are encouraging.

However, compared with HIFU and cryotherapy, NanoKnife currently has:

fewer published long-term studies
smaller patient numbers
a shorter duration of follow-up.

As a result, many clinicians believe further evidence is still required before its long-term role is fully established.

Other Types of Focal Therapy

Several additional focal therapies are available in selected centres or within clinical trials.

These include:

Focal brachytherapy

Delivering radiation to only the area containing significant cancer.

Focal laser ablation

Using laser energy to destroy the tumour.

Photodynamic therapy (TOOKAD®)

Using a light-sensitive drug activated by laser light to destroy cancer cells.

These treatments remain less commonly used in routine UK clinical practice than HIFU, cryotherapy and NanoKnife.

Consultant’s Perspective

Patients often arrive having read that one technology is “better” than another.

In reality, that is rarely how treatment decisions are made.

The first question should never be:

“Which machine should I choose?”

Instead, it should be:

“Am I actually the right patient for focal therapy?”

Once we know the answer to that question, selecting the most appropriate technology usually becomes much clearer.

Does the Type of Machine Matter Most?

Surprisingly, no.

Current evidence suggests that the most important factors influencing outcome are:

Careful patient selection.
High-quality MRI.
Accurate targeted biopsy.
Appropriate treatment planning.
Experience of the treating team.
Careful long-term follow-up.

The energy source is only one part of the overall treatment pathway.

Choosing the newest machine cannot compensate for selecting the wrong patient.

Which Treatment Would I Recommend?

Patients frequently ask me:

“If I am suitable for focal therapy, which treatment would you recommend?”

My answer is always the same.

I would recommend the treatment that is best suited to your individual cancer—not the one with the newest technology or the most impressive marketing.

Some tumours are ideally suited to HIFU.

Others are better treated with cryotherapy.

Some may be suitable for NanoKnife.

Others are not appropriate for focal therapy at all and are better managed with robotic surgery or radiotherapy.

That is why every treatment recommendation should begin with a careful review of:

your MRI
your biopsy
your PSA history
your overall health
and your own priorities.

Only then can the most appropriate treatment be selected.

Key Points

Focal therapy is a treatment strategy rather than a single procedure.

HIFU, cryotherapy and NanoKnife all aim to destroy clinically significant prostate cancer while preserving healthy tissue.

No technology has been shown to be universally superior.

The most important determinants of success are careful patient selection, accurate imaging, expert treatment planning and experienced follow-up.

The best focal therapy is the one that is most appropriate for your individual cancer—not necessarily the newest or most widely advertised technology.

Who Is a Candidate for Focal Therapy?

Perhaps the most important question in this entire guide is not:

“Does focal therapy work?”

It is:

“Am I suitable for focal therapy?”

The answer depends entirely on your individual cancer.

Not every man with prostate cancer is a candidate for focal therapy.

Likewise, not every man needs robotic surgery or radiotherapy.

Modern prostate cancer treatment is becoming increasingly personalised.

The aim is no longer simply to remove or treat every prostate.

Instead, it is to choose the treatment that offers the best balance between:

long-term cancer control
urinary continence
preservation of erectile function
recovery time
and quality of life.

Determining whether focal therapy is appropriate requires careful assessment of both the cancer and the individual.

Who Is Most Likely to Benefit?

Although every patient is different, focal therapy is generally best suited to men who have:

A single area of clinically significant prostate cancer

The ideal candidate has one clearly defined index lesion visible on MRI.

This tumour should be:

clearly identifiable
accurately mapped
confirmed by targeted biopsy
technically accessible for treatment.

Small areas of low-grade cancer elsewhere in the prostate do not necessarily exclude focal therapy, provided they are unlikely to influence long-term outcome.

Intermediate-risk prostate cancer

Most men suitable for focal therapy have:

Grade Group 2 (Gleason 3+4) disease

or, in carefully selected cases,

Grade Group 3 (Gleason 4+3) disease.

These cancers usually require active treatment but may still be suitable for a tissue-preserving approach.

Every case should be assessed individually.

Cancer confined to the prostate

Focal therapy is designed to treat localised prostate cancer.

It is generally suitable only when:

MRI shows no significant extracapsular extension
there is no evidence of lymph node involvement
there are no distant metastases.

If cancer has spread beyond the prostate, whole-gland treatment or additional therapies are often more appropriate.

A tumour that can be safely targeted

Location matters.

Some tumours are ideally positioned for focal treatment.

Others lie too close to:

the urinary sphincter
the urethra
both neurovascular bundles
or occupy such a large proportion of the prostate that treating only part of the gland would not be appropriate.

Modern MRI allows us to assess these relationships in remarkable detail before recommending treatment.

Good overall health

Focal therapy is usually recommended for men expected to benefit from curative treatment.

Factors considered include:

age
general fitness
other medical conditions
life expectancy
personal priorities.

Chronological age alone rarely determines suitability.

Many healthy men in their seventies remain excellent candidates for curative treatment.

Consultant’s Perspective

One of the most common misconceptions I encounter is that focal therapy is suitable simply because a patient wants a less invasive treatment.

Unfortunately, it doesn’t work like that.

The biology of the cancer always comes first.

If I believe robotic surgery or radiotherapy offers a better chance of long-term cure, that is the recommendation I will make—even if focal therapy initially seems more attractive.

Who Is Less Likely to Be Suitable?

Equally important is recognising when focal therapy is unlikely to offer the best long-term outcome.

Generally, focal therapy is not recommended for men with:

Extensive prostate cancer

If MRI and biopsy show:

multiple significant tumours
cancer affecting both sides of the prostate
diffuse high-grade disease

whole-gland treatment is usually more appropriate.

High-risk prostate cancer

Men with:

Grade Group 4
Grade Group 5
Gleason 8–10 disease

often require more comprehensive treatment.

Although every patient is different, focal therapy is less likely to provide adequate cancer control in these situations.

Cancer extending beyond the prostate

If imaging demonstrates:

extracapsular extension
seminal vesicle invasion
lymph node involvement

treatment usually needs to address disease beyond the prostate itself.

Tumours that cannot be accurately identified

Focal therapy depends entirely on knowing exactly where the cancer is.

If MRI cannot define the lesion clearly—or biopsy findings do not match the imaging—then treating only part of the prostate becomes much less reliable.

What About Gleason 6 Prostate Cancer?

This surprises many patients.

Men often assume that because focal therapy is less invasive than surgery, it must be the ideal treatment for Gleason 3+3 (Grade Group 1) prostate cancer.

In fact, the opposite is usually true.

Most men with low-risk prostate cancer are best managed with active surveillance.

This involves:

regular PSA tests
repeat MRI scans
clinical review
and, where appropriate, repeat biopsy.

The aim is to avoid unnecessary treatment while still identifying the small number of cancers that become more aggressive over time.

For many men, active surveillance provides excellent long-term outcomes without exposing them to treatment-related side effects.

Suitability Is About Much More Than Your PSA

Patients often ask:

“My PSA is 5.8. Can I have focal therapy?”

The answer is:

Your PSA alone cannot determine the best treatment.

During assessment, we consider:

PSA level
PSA density
PSA trend over time
MRI findings
PI-RADS score
Gleason Grade Group
number of positive biopsy cores
percentage of cancer within each core
tumour volume
tumour location
prostate size
urinary symptoms
erectile function
age
general health
personal priorities.

Every one of these factors contributes to deciding whether focal therapy is likely to provide the best outcome.

More Than One Treatment May Be Appropriate

One of the most reassuring things I tell patients is this:

There is often more than one good treatment option.

For example, a healthy 62-year-old man with a single MRI-visible Grade Group 2 prostate cancer may reasonably choose:

focal therapy
robotic radical prostatectomy
radiotherapy
or, in selected circumstances, active surveillance.

Each option has different advantages.

Each also has different trade-offs.

There is rarely a universally “correct” answer.

Instead, treatment should reflect:

the biology of the cancer
the available evidence
and what matters most to the individual patient.

Questions I Encourage Every Patient to Ask

Before deciding whether focal therapy is right for you, I recommend asking your specialist:

Am I genuinely a suitable candidate for focal therapy?
Why do you recommend this treatment rather than surgery or radiotherapy?
What are the chances I will need additional treatment?
How will this treatment affect my continence and erections?
If this were your family member, what would you recommend?

These questions often lead to the most valuable part of the consultation.

At a Glance

You may be a suitable candidate for focal therapy if:

✓ You have a single MRI-visible clinically significant prostate cancer.

✓ The cancer is confined to the prostate.

✓ Biopsy confirms intermediate-risk disease.

✓ The tumour can be safely treated while preserving healthy tissue.

✓ You understand and accept the need for long-term PSA, MRI and biopsy follow-up.

✓ Preserving urinary continence and erectile function is an important priority.

Key Points

Focal therapy is designed for carefully selected men with localised prostate cancer.
The ideal candidate has a clearly defined, MRI-visible, clinically significant tumour confirmed by targeted biopsy.
Patient selection is the single most important factor influencing successful outcomes.
Many men have more than one appropriate treatment option, and the final decision should balance cancer control with quality of life.
The goal is not to choose the least invasive treatment—it is to choose the treatment that is most appropriate for your individual cancer.

Focal Therapy vs Robotic Surgery vs Radiotherapy

Sooner or later, almost every man diagnosed with localised prostate cancer asks the same question:

“Which treatment is best?”

It is one of the most important questions in modern prostate cancer care.

It is also one of the most difficult to answer.

Many patients hope there is a single “best” treatment that offers the highest cure rate, the fewest side effects and the quickest recovery.

Unfortunately, medicine is rarely that simple.

The reality is that every treatment involves trade-offs.

Some treatments provide greater certainty that all cancer has been treated.

Others offer better preservation of urinary continence and erectile function.

Some involve a single operation.

Others require several weeks of treatment.

The challenge is not finding the treatment that is best in general.

It is finding the treatment that is best for your cancer and your priorities.

There Is No Universal “Best” Treatment

This is perhaps the single most important message in this guide.

Patients often ask me:

“If you were in my position, what would you choose?”

My answer is always the same.

I would first want to know:

What does the MRI show?
What is the Gleason Grade Group?
Is the cancer confined to the prostate?
How old am I?
What is my general health?
How important is preserving erections?
How important is avoiding urinary leakage?
Would I find regular surveillance reassuring or stressful?

Only after answering those questions can the most appropriate treatment be recommended.

That is why two men with apparently similar prostate cancers may make completely different—and equally appropriate—treatment decisions.

Comparing the Main Treatment Options

	Focal Therapy	Robotic Radical Prostatectomy	External Beam Radiotherapy
Treatment target	Clinically significant tumour only	Entire prostate gland	Entire prostate gland
Hospital stay	Usually day case	Usually one night	Outpatient treatment
Anaesthetic	General anaesthetic	General anaesthetic	No anaesthetic required
Catheter	Usually 3–7 days	Usually 7–14 days	Not usually required
Return to normal activities	1–2 weeks	4–6 weeks	Usually during or shortly after treatment
PSA after treatment	Falls but remains detectable	Should become undetectable	Falls gradually over months
Urinary continence	Usually very well preserved	Excellent in most men, but recovery takes time	Usually preserved initially
Erectile function	Often better preserved	Depends on nerve-sparing and baseline function	Often declines gradually over time
Need for long-term surveillance	Essential	Routine PSA follow-up	Routine PSA follow-up
Likelihood of further prostate treatment	Higher	Lower	Lower
Length of published evidence	Strong medium-term evidence	Excellent long-term evidence	Excellent long-term evidence

The table provides a useful overview, but it does not tell the whole story.

Understanding why these differences exist is much more important than memorising them.

Why Some Men Choose Focal Therapy

The principal advantage of focal therapy is preservation of quality of life.

Because only the clinically significant tumour is treated, much of the prostate remains untouched.

For carefully selected men, this may result in:

a lower risk of urinary incontinence
better preservation of erectile function
a quicker return to normal activities
a shorter recovery
avoidance of whole-gland treatment.

For many patients, these are compelling advantages.

However, they come with an important trade-off.

The prostate remains in place.

That means:

PSA does not fall to zero
long-term surveillance is essential
MRI remains important
repeat biopsy may be recommended
some men will require additional treatment in the future.

Choosing focal therapy therefore means accepting ongoing monitoring as part of the treatment pathway.

Why Some Men Choose Robotic Radical Prostatectomy

Robotic surgery remains one of the most established treatments for localised prostate cancer.

Its greatest strength is certainty.

Removing the prostate allows the pathologist to examine the entire gland under the microscope.

We learn:

the exact size of the tumour
whether cancer has started to extend beyond the prostate
whether surgical margins are clear
whether additional treatment might be beneficial.

After successful surgery, PSA should become undetectable.

For many men, this provides considerable reassurance.

Modern robotic surgery also allows excellent visualisation of the delicate nerves responsible for erections, enabling nerve-sparing techniques whenever it is oncologically safe.

Nevertheless, surgery remains a major treatment.

Recovery takes longer than focal therapy, and urinary continence and erectile function recover at different rates depending on the individual, the extent of surgery and baseline function.

Why Some Men Choose Radiotherapy

Radiotherapy is an excellent treatment for localised prostate cancer.

Long-term cancer control is comparable with surgery for many patients.

It avoids an operation and may be particularly attractive for men who wish to avoid surgery or who have medical conditions that increase surgical risk.

Modern radiotherapy techniques have become remarkably precise.

Nevertheless, because the whole prostate is treated, urinary, bowel and sexual side effects may develop either during treatment or gradually over subsequent years.

Unlike surgery, PSA falls slowly rather than immediately becoming undetectable.

Consultant’s Perspective

One of the most rewarding parts of my job is helping patients understand that there is rarely a single “correct” treatment.

A man who values preserving erectile function above everything else may reasonably choose focal therapy.

Another who values the reassurance of removing the entire prostate may reasonably choose robotic surgery.

Both decisions can be entirely appropriate.

My role is not to persuade someone towards one treatment.

It is to help them understand the advantages and limitations of each option before making an informed decision.

Which Treatment Would I Recommend?

Patients often ask me:

“What would you recommend for your own family?”

It is an understandable question.

The answer is that I would recommend the treatment that offers the best balance between cancer control and quality of life for that individual’s cancer.

Sometimes that is focal therapy.

Sometimes it is robotic radical prostatectomy.

Sometimes it is radiotherapy.

Sometimes it is active surveillance.

The recommendation depends entirely on the biology of the cancer and the goals of the patient.

No responsible specialist should recommend the same treatment for every man.

Can I Still Have Surgery If Focal Therapy Doesn’t Work?

Yes—in many cases.

This is one of the most common concerns patients have.

If follow-up identifies persistent or recurrent clinically significant cancer, several options may remain available, including:

repeat focal therapy
robotic radical prostatectomy
radiotherapy
continued active surveillance in selected situations.

Although surgery after focal therapy can be technically more demanding, it remains feasible in experienced hands.

This is one reason why careful follow-up is such an important part of focal therapy.

How Should You Decide?

When patients leave my clinic, I hope they understand one important principle.

The question is not:

“Which treatment has the fewest side effects?”

Nor is it:

“Which treatment is the newest?”

The question is:

“Which treatment offers the best balance between long-term cancer control and the quality of life that matters most to me?”

That answer is different for every patient.

It should only be reached after careful review of your MRI, biopsy, PSA history and personal priorities.

At a Glance

Focal Therapy

✔ Preserves more healthy prostate tissue

✔ Lower risk of urinary incontinence

✔ Better preservation of erections in suitable men

✔ Faster recovery

✔ Requires long-term surveillance

✔ Higher likelihood of needing additional treatment

Robotic Radical Prostatectomy

✔ Removes the entire prostate

✔ Complete pathological analysis

✔ PSA should become undetectable

✔ Excellent long-term evidence

✔ Longer recovery

✔ Greater risk of urinary and sexual side effects than focal therapy

Radiotherapy

✔ No operation required

✔ Excellent long-term cancer control

✔ Suitable for many men who wish to avoid surgery

✔ PSA falls gradually

✔ Urinary, bowel and sexual side effects may develop over time

Key Points

There is no single “best” treatment for localised prostate cancer.
Focal therapy, robotic surgery and radiotherapy all have important advantages and limitations.
The right treatment depends on the biology of the cancer and the priorities of the individual patient.
Treatment decisions should be made after a balanced discussion of all appropriate options.
The aim is not simply to treat the cancer—it is to achieve the best possible long-term outcome for the individual patient.

What Are the Side Effects of Focal Therapy?

For many men, the greatest attraction of focal therapy is not simply treating the cancer.

It is the possibility of doing so while preserving quality of life.

For decades, the side effects of prostate cancer treatment have understandably been one of patients’ greatest concerns.

Many men worry just as much about urinary leakage, erectile dysfunction and recovery as they do about the cancer itself.

These concerns are entirely understandable.

The good news is that, for carefully selected patients, focal therapy generally causes fewer long-term functional side effects than whole-gland treatment.

However, no treatment is completely free of risks.

Understanding both the benefits and the limitations is essential before making a decision.

Why Are Side Effects Usually Less Common?

The answer lies in what is being treated.

During robotic radical prostatectomy, the entire prostate gland is removed.

During radiotherapy, the whole prostate receives treatment.

Focal therapy is different.

Only the area containing the clinically significant cancer is treated.

Much of the healthy prostate remains untouched.

Importantly, this often allows preservation of structures that are essential for normal urinary and sexual function, including:

the external urinary sphincter
much of the normal prostate
one or both neurovascular bundles responsible for erections
surrounding pelvic tissues.

This is why many men recover more quickly and experience fewer long-term side effects.

What Should I Expect Immediately After Treatment?

Most focal therapy procedures are performed as day-case surgery.

After a short period of recovery, most patients return home the same day.

It is entirely normal to experience some temporary symptoms while the prostate heals.

These commonly include:

mild discomfort between the legs (the perineum)
slight burning when passing urine
increased urinary frequency
urinary urgency
a small amount of blood in the urine
blood in the semen
mild pelvic aching
temporary tiredness.

These symptoms are usually short-lived and gradually improve over the following days or weeks.

Simple pain relief is normally all that is required.

Will I Need a Catheter?

Yes—most men do.

Because the treated area swells after focal therapy, a urinary catheter is usually inserted before you wake from the anaesthetic.

For most patients it remains in place for around three to seven days, although the exact duration depends on:

the amount of prostate treated
the focal therapy technique used
how quickly the swelling settles.

Removing the catheter is usually straightforward and can often be arranged as an outpatient appointment.

Will I Become Incontinent?

This is almost always the first question patients ask.

Fortunately, the answer is reassuring.

Significant long-term urinary incontinence is uncommon after focal therapy.

The reason is that the urinary sphincter—the muscle responsible for maintaining continence—usually lies outside the treatment area and can therefore be preserved.

Many men remain completely dry throughout their recovery.

Others experience:

mild urinary urgency
temporary frequency
occasional leakage during the healing phase.

These symptoms generally improve as inflammation settles.

Although no treatment can completely eliminate the risk of urinary problems, the likelihood of severe long-term incontinence following focal therapy is considerably lower than after whole-gland treatment in appropriately selected men.

Consultant’s Perspective

One of the most rewarding conversations I have in clinic is with men who are understandably frightened that prostate cancer treatment will inevitably leave them incontinent.

Modern prostate cancer care has changed enormously over the past two decades.

For carefully selected patients undergoing focal therapy, long-term urinary control is usually excellent.

Nevertheless, every patient is different, and I believe it is important to discuss both the likely benefits and the potential risks honestly before treatment.

Will Focal Therapy Affect My Erections?

This is often the question men worry about most.

The nerves responsible for erections run immediately alongside the prostate.

If these nerves can be preserved, erectile function is much more likely to recover.

Because focal therapy treats only part of the prostate, one or both neurovascular bundles can often be left untouched.

Many men therefore maintain good erectile function after treatment, particularly when:

erections were good before treatment
the tumour lies away from the erectile nerves
only a relatively small area of prostate requires treatment.

However, no treatment can guarantee preservation of erections.

Recovery depends on many factors, including:

age
baseline erectile function
diabetes
cardiovascular health
smoking
the location of the tumour
the amount of prostate treated.

Some men notice a temporary reduction in erections during the healing phase before gradually improving over the following months.

Others require medication such as phosphodiesterase-5 inhibitors to assist recovery.

What Happens to Ejaculation?

Unlike radical prostatectomy, focal therapy usually preserves ejaculation.

However, many men notice changes.

These may include:

a smaller volume of semen
blood in the semen for several weeks
changes in the force of ejaculation
temporary discomfort during ejaculation.

The degree of change depends on how much of the prostate has been treated.

Complete loss of ejaculation is much less common than after radical prostatectomy because much of the prostate and seminal pathway remain intact.

How Long Does Recovery Take?

One of the major advantages of focal therapy is the relatively rapid recovery.

Although everyone heals differently, most men can expect something similar to the following timeline.

The first few days

Rest at home.
Catheter remains in place.
Mild discomfort.
Blood in urine or semen.
Light walking encouraged.

One week

Most men:

have had the catheter removed
are walking comfortably
require little or no pain relief.

Two weeks

Many patients have returned to:

office-based work
driving
normal household activities.

Four to six weeks

Most men can resume:

golf
cycling
swimming
gym exercise
sexual activity,

provided recovery has progressed normally.

Heavy manual work may require a little longer.

What Complications Can Occur?

Serious complications are uncommon but, as with any medical procedure, they can occur.

Potential complications include:

urinary tract infection
urinary retention
prolonged urinary frequency
prolonged urgency
urethral stricture (narrowing of the water pipe)
epididymitis
persistent blood in the urine.

Rare complications include injury to surrounding structures or the development of a urinary fistula.

Fortunately, these are uncommon when treatment is performed in experienced specialist centres.

Are There Any Long-Term Side Effects?

For most men, the principal long-term consequence of focal therapy is not a physical side effect.

It is the need for ongoing surveillance.

Unlike robotic surgery, the prostate remains in place.

That means:

PSA remains detectable
regular PSA tests continue
MRI scans remain important
repeat biopsy may be recommended.

Some men are very comfortable with this approach.

Others prefer the certainty of removing the entire prostate and achieving an undetectable PSA.

Neither perspective is right or wrong.

The decision depends on what matters most to the individual.

Balancing Cancer Control and Quality of Life

Every prostate cancer treatment involves a balance.

Focal therapy aims to preserve quality of life by treating only the clinically significant tumour.

For carefully selected men, this can provide:

excellent urinary continence
excellent preservation of erectile function
rapid recovery
effective cancer control.

The trade-off is accepting careful long-term follow-up and recognising that additional treatment may occasionally be required.

Understanding that balance is one of the most important parts of deciding whether focal therapy is right for you.

At a Glance

Most men undergoing focal therapy can expect:

✓ Day-case treatment

✓ Catheter for approximately 3–7 days

✓ Mild discomfort for a few days

✓ Excellent long-term urinary continence in carefully selected patients

✓ Better preservation of erectile function than whole-gland treatment for many suitable men

✓ Return to desk-based work within 1–2 weeks

✓ Return to most normal activities within 4–6 weeks

✓ Ongoing PSA, MRI and follow-up surveillance

Key Points

The principal advantage of focal therapy is preserving quality of life while effectively treating clinically significant prostate cancer.
Long-term urinary continence is usually excellent because the urinary sphincter is typically preserved.
Erectile function is often better preserved than after whole-gland treatment, although outcomes vary between individuals.
Most men return home the same day and resume normal activities within a few weeks.
Long-term follow-up remains an essential part of treatment because healthy prostate tissue is intentionally preserved.

PSA After Focal Therapy: What Should You Expect?

One of the biggest differences between focal therapy and whole-gland treatment is how we monitor your PSA afterwards.

Understanding this before treatment is extremely important because it helps prevent unnecessary anxiety during follow-up.

Many men have friends or relatives who have undergone robotic radical prostatectomy.

They know that after surgery the PSA should become undetectable, and naturally assume the same should happen after focal therapy.

It doesn’t.

In fact, if your PSA fell to zero after focal therapy, that would be unexpected because healthy prostate tissue has intentionally been left behind.

Why Doesn’t PSA Fall to Zero?

The answer is actually quite simple.

PSA is produced by normal prostate cells as well as prostate cancer cells.

After robotic radical prostatectomy, the entire prostate gland has been removed.

There are therefore very few prostate cells left to produce PSA.

Following successful surgery, PSA should become undetectable.

Focal therapy is completely different.

Because much of the healthy prostate remains in place, those normal cells continue to produce PSA.

This means:

PSA falls after successful treatment
PSA usually remains detectable
A detectable PSA is entirely expected
A detectable PSA does not mean the cancer has returned.

This is probably the single most important concept to understand before choosing focal therapy.

There Is No Single “Normal” PSA After Focal Therapy

Patients often ask:

“What should my PSA be after treatment?”

Unfortunately, there is no single number.

Unlike robotic surgery, where we hope PSA becomes undetectable, PSA after focal therapy varies considerably between individuals.

It depends on factors including:

how much prostate tissue remains
the size of the prostate before treatment
the amount of tissue treated
whether benign enlargement of the prostate is present
your PSA before treatment.

For this reason, comparing your PSA with somebody else’s is rarely helpful.

Consultant’s Perspective

One of the commonest reasons patients become worried after focal therapy is because they compare their PSA with someone who has had robotic surgery.

These are completely different treatments with completely different expectations.

After focal therapy, I am far more interested in how your PSA behaves over time than in any single number.

What Matters Most Is the Trend

Perhaps the most important message in this section is this:

We treat PSA as a trend—not as an isolated blood test.

A single PSA result tells us relatively little.

Instead, we look at the pattern over months and years.

Questions we ask include:

Has PSA fallen as expected?
Is it remaining stable?
Is it gradually increasing?
Has there been a sudden unexpected rise?
Does the PSA change match what we see on MRI?

Looking at the overall pattern provides far more useful information than reacting to one individual result.

PSA Is Only One Part of Follow-Up

Another important difference between focal therapy and robotic surgery is that PSA is not the only test we rely on.

Follow-up combines several different sources of information.

These usually include:

PSA blood tests

Monitoring trends over time.

Multiparametric MRI (mpMRI)

Looking for any suspicious residual or recurrent cancer.

Clinical review

Discussing urinary symptoms, sexual function and general recovery.

Repeat biopsy

Many specialist centres recommend a repeat targeted biopsy of the treated area, even when MRI appears reassuring.

Although MRI has transformed prostate cancer diagnosis, it cannot detect every area of clinically significant cancer.

Biopsy therefore remains an important part of careful long-term surveillance.

What Does Follow-Up Usually Involve?

Follow-up schedules vary between hospitals and clinical trials.

A typical programme may include:

PSA every three to six months during the first two years
repeat mpMRI at approximately twelve months
repeat biopsy when appropriate
annual review thereafter.

Your own follow-up schedule will depend on:

the focal therapy technique used
MRI findings
PSA behaviour
biopsy results
your treating specialist’s protocol.

Does a Rising PSA Mean the Cancer Has Returned?

Not necessarily.

PSA naturally fluctuates.

It may increase temporarily because of:

benign enlargement of the prostate
inflammation
urinary infection
recent ejaculation
urinary retention
instrumentation of the urinary tract.

For this reason, one slightly higher PSA result rarely changes management.

Instead, we look for consistent changes over time.

If PSA behaves unexpectedly, this usually prompts further investigation rather than immediate treatment.

What Happens If We Are Concerned?

If PSA, MRI or biopsy suggests persistent or recurrent clinically significant prostate cancer, further assessment is usually straightforward.

This may include:

repeat PSA testing
repeat MRI
targeted biopsy
multidisciplinary team discussion.

Only after combining all of this information can we decide whether further treatment is necessary.

What Are the Options If Cancer Returns?

One of the strengths of focal therapy is that several treatment options often remain available.

Depending on the individual situation, these may include:

repeat focal therapy
robotic radical prostatectomy
external beam radiotherapy
active surveillance in carefully selected circumstances.

The appropriate option depends on:

where the cancer is located
how aggressive it appears
previous treatment
and your overall health.

Importantly, recurrence after focal therapy does not automatically mean that curative treatment is no longer possible.

Living With PSA After Focal Therapy

Choosing focal therapy means accepting a different relationship with PSA.

Some men find regular PSA monitoring reassuring.

Others find it a source of anxiety.

This is one reason why treatment choice is so personal.

Patients who value the reassurance of an undetectable PSA often prefer robotic surgery.

Others are comfortable accepting ongoing monitoring in exchange for preserving urinary continence and erectile function.

Neither approach is better.

They simply reflect different priorities.

At a Glance

After successful focal therapy you should expect:

✓ PSA to fall but remain detectable

✓ Regular PSA blood tests

✓ Repeat MRI

✓ Ongoing specialist follow-up

✓ Possible repeat biopsy

✓ Monitoring of PSA trends rather than a single PSA value

Questions Patients Commonly Ask

Should my PSA be zero after focal therapy?

No. Because healthy prostate tissue remains, PSA usually remains detectable.

Is a detectable PSA a sign the treatment has failed?

No. This is entirely expected after focal therapy.

What is more important than my PSA level?

The overall PSA trend, together with MRI findings and, where appropriate, repeat biopsy.

Can PSA fluctuate naturally?

Yes. Temporary rises are common and do not necessarily indicate recurrent cancer.

Can further treatment still cure recurrent disease?

Often, yes. Many men remain suitable for repeat focal therapy, robotic surgery or radiotherapy if clinically significant recurrence is detected.

Key Points

Unlike robotic surgery, PSA should not fall to zero after focal therapy because healthy prostate tissue remains.
A detectable PSA is expected and does not indicate treatment failure.
The trend in PSA over time is much more informative than any individual blood test.
Follow-up combines PSA testing, MRI, clinical assessment and, in many men, repeat biopsy.
Careful long-term surveillance is an integral part of successful focal therapy, allowing any recurrent clinically significant cancer to be identified and treated at an early stage.

How Successful Is Focal Therapy?

One of the first questions patients ask is:

“What are the success rates?”

It is an entirely reasonable question.

However, before we can answer it, we need to agree on what we mean by success.

For some men, success means:

“Has every cancer cell been removed?”

For others, success means:

“Can I be treated without becoming incontinent or losing my erections?”

Both perspectives are important.

Modern prostate cancer treatment is no longer judged solely by cancer control.

Today, we also measure:

quality of life
urinary continence
erectile function
return to normal activities
the need for further treatment
and long-term survival.

The best treatment is one that balances all of these outcomes.

Does Focal Therapy Work?

The short answer is:

Yes—for carefully selected patients.

Over the past fifteen years, an increasing number of studies from specialist centres around the world have shown that focal therapy can provide excellent medium-term cancer control while preserving urinary continence and erectile function better than many forms of whole-gland treatment.

This is why focal therapy has become an increasingly important option for selected men with localised prostate cancer.

It is no longer regarded as simply an experimental idea.

Instead, it has become an established treatment option within specialist prostate cancer centres for carefully selected patients.

How Do Doctors Measure Success?

Success after focal therapy is assessed in several different ways.

Cancer control

The most important question is whether clinically significant prostate cancer has been successfully treated.

Doctors assess this using:

PSA trends
MRI
repeat biopsy where appropriate
long-term clinical follow-up.

Preservation of urinary continence

One of the principal goals of focal therapy is preserving urinary control.

For carefully selected men, long-term continence outcomes are excellent.

Preservation of erectile function

Maintaining erectile function is another major reason many men consider focal therapy.

Published studies consistently demonstrate better preservation of erections than is generally seen following whole-gland treatment, although individual outcomes vary considerably.

Freedom from additional treatment

Another important outcome is how many men require further treatment.

Some patients remain treatment-free for many years.

Others require:

repeat focal therapy
robotic surgery
radiotherapy

during long-term follow-up.

Quality of life

Perhaps the greatest strength of focal therapy is that many men recover quickly while maintaining an excellent quality of life.

This has become an increasingly important outcome in modern prostate cancer research.

Does Focal Therapy Cure Prostate Cancer?

This is probably the question I hear most often.

The honest answer is:

Focal therapy can provide durable long-term cancer control, but no treatment can guarantee a cure.

That statement is true whether a patient chooses:

robotic surgery
radiotherapy
or focal therapy.

Every treatment has the potential for recurrence.

The aim of focal therapy is to eradicate the clinically significant tumour while preserving as much healthy tissue as possible.

Many men never require further treatment.

Others do.

That possibility should be discussed before treatment begins.

Consultant’s Perspective

I think one of the biggest mistakes patients make is comparing treatments using a single headline success rate.

Medicine is rarely that simple.

A treatment that offers slightly greater certainty may also have a greater impact on urinary continence or erectile function.

Another treatment may preserve quality of life better but require closer follow-up.

The question should never be:

“Which treatment has the highest percentage?”

It should be:

“Which treatment gives me the best overall outcome?”

Why Are Retreatment Rates Higher?

This is an important point to understand.

Following robotic radical prostatectomy, the entire prostate has been removed.

Following radiotherapy, the whole gland has been treated.

Focal therapy deliberately leaves healthy prostate tissue behind.

This has advantages.

It also means:

new clinically significant cancers can occasionally develop elsewhere in the gland
small low-risk cancers may later become more significant
repeat focal treatment may occasionally be required.

This is not necessarily a failure of treatment.

It reflects the philosophy of preserving healthy tissue while continuing careful surveillance.

Many patients consider this a worthwhile trade-off.

What Happens If Further Treatment Is Needed?

One of the reassuring aspects of focal therapy is that additional treatment options usually remain available.

Depending on the situation, these may include:

repeat focal therapy
robotic radical prostatectomy
external beam radiotherapy
active surveillance in selected circumstances.

The exact recommendation depends on:

where recurrence has occurred
MRI findings
biopsy results
previous treatment
overall health.

Importantly, choosing focal therapy does not usually remove the possibility of later curative treatment.

What About Long-Term Evidence?

This is one of the few areas where focal therapy differs from robotic surgery and radiotherapy.

Robotic radical prostatectomy has:

decades of follow-up
excellent long-term cancer control data
extensive international experience.

Radiotherapy has similarly strong long-term evidence.

Focal therapy is newer.

The available evidence is now very encouraging, particularly regarding medium-term cancer control and preservation of quality of life.

However, we do not yet have the same volume of 15–20-year comparative data available for surgery or radiotherapy.

That does not mean focal therapy is inferior.

It simply reflects the fact that it is a newer treatment whose evidence continues to mature.

What Does This Mean for Patients?

When deciding between treatments, I encourage patients not to focus on one statistic.

Instead, ask yourself:

Which treatment offers the best chance of controlling my cancer?
How important is preserving urinary continence?
How important is preserving erectile function?
How do I feel about long-term surveillance?
How would I feel if further treatment became necessary in the future?

The answers to these questions are often more important than comparing isolated success rates.

At a Glance

Current evidence suggests that focal therapy provides:

✓ Excellent medium-term cancer control in carefully selected patients

✓ Excellent preservation of urinary continence

✓ Better preservation of erectile function than many forms of whole-gland treatment

✓ Rapid recovery

✓ Higher likelihood of needing further treatment than whole-gland therapy

✓ Long-term evidence that continues to mature through ongoing clinical trials

Questions Patients Frequently Ask

Does focal therapy cure prostate cancer?

It can provide durable long-term cancer control, but no prostate cancer treatment can guarantee a cure.

Why might I need another treatment later?

Because healthy prostate tissue remains after focal therapy, new clinically significant cancer can occasionally develop elsewhere in the gland or previously insignificant disease may progress over time.

Does needing another treatment mean focal therapy has failed?

Not necessarily.

Additional treatment is a recognised part of the focal therapy pathway for some patients and reflects the decision to preserve healthy prostate tissue rather than remove the entire gland.

Can I still have robotic surgery afterwards?

In many cases, yes.

Although surgery after focal therapy can be technically more demanding, it remains an important option when required.

Key Points

Focal therapy provides excellent medium-term cancer control for carefully selected men with localised prostate cancer.
Success should be judged not only by cancer control, but also by urinary continence, erectile function and quality of life.
Because healthy prostate tissue remains, some men will require further treatment during long-term follow-up.
Choosing focal therapy does not usually prevent later robotic surgery or radiotherapy if these become necessary.
Long-term evidence continues to mature, and ongoing clinical trials will help define the future role of focal therapy.

What Does the Latest Research Tell Us?

Patients often ask me:

“If focal therapy is so promising, why isn’t every man with prostate cancer offered it?”

It is an excellent question.

The answer lies not in whether focal therapy works—it clearly can—but in how medical evidence develops over time.

Every major advance in medicine follows a similar journey.

A new treatment is introduced.

Early clinical experience suggests it is safe.

Specialist centres begin reporting encouraging results.

Larger studies follow.

Finally, carefully designed clinical trials compare the new treatment with the current standard of care.

Only then can we truly understand where that treatment fits.

Focal therapy has now reached an exciting stage in that journey.

What Do We Know So Far?

Over the past fifteen years, evidence supporting focal therapy has grown rapidly.

Studies from leading prostate cancer centres in the UK, Europe and North America have consistently shown that, in carefully selected men:

clinically significant prostate cancer can often be effectively controlled
urinary continence is preserved in the vast majority of patients
erectile function is maintained more frequently than after whole-gland treatment
serious complications are uncommon
recovery is generally rapid
patient satisfaction is high.

Importantly, these findings have been reported across multiple specialist centres using different focal therapy technologies.

Taken together, they provide reassuring evidence that focal therapy is an effective treatment option for selected patients.

What Questions Still Need Answering?

Although the results are encouraging, medicine is not based on enthusiasm alone.

We also need to know:

How does focal therapy compare directly with robotic surgery?
How does it compare with radiotherapy?
Which patients benefit the most?
Which patients should avoid focal therapy?
How durable are the results after ten, fifteen or twenty years?
Which focal therapy technology offers the best outcomes for different tumour locations?

These are exactly the questions current research is trying to answer.

Trials such as the CHRONOS study have been designed to address the lack of high-quality comparative evidence between focal ablation and radical whole-gland treatment for localised clinically significant prostate cancer.

Consultant’s Perspective

One of the things I enjoy most about working in prostate cancer is seeing how quickly the field continues to evolve.

When I became a consultant, focal therapy was still considered an emerging concept.

Today it has become an established treatment option in specialist centres, supported by an expanding body of evidence.

At the same time, I believe we must remain honest about the questions that have not yet been fully answered.

Patients deserve balanced advice—not enthusiasm unsupported by evidence.

Why Are Clinical Trials So Important?

Clinical trials are the reason modern prostate cancer treatment has become so successful.

Without them, we would never know whether one treatment genuinely performs better than another.

Well-designed clinical trials help answer questions such as:

Does focal therapy control cancer as effectively as whole-gland treatment?
Which patients achieve the greatest benefit?
How often is further treatment required?
What happens ten or twenty years after treatment?
Which treatment provides the best quality of life?

These questions cannot be answered by individual experience alone.

They require carefully conducted research involving large numbers of patients.

What Do Current Guidelines Say?

Professional organisations such as NICE recognise focal therapy as an important treatment option for carefully selected men.

At the same time, they also emphasise:

careful patient selection
multidisciplinary decision-making
experienced treatment centres
structured follow-up
ongoing data collection.

This reflects the current state of the evidence.

Focal therapy is no longer viewed simply as an experimental concept.

Instead, it has become an increasingly accepted part of modern prostate cancer care, while continuing to benefit from ongoing research and long-term follow-up.

Why Long-Term Evidence Matters

Patients sometimes ask:

“If the results are already good, why do we still need more studies?”

The answer is simple.

Prostate cancer often progresses slowly.

Some men live for twenty or thirty years after treatment.

Understanding which treatment provides the best outcomes over those decades naturally takes time.

Robotic radical prostatectomy and radiotherapy have accumulated many years of follow-up.

Focal therapy is gradually building the same level of evidence.

That should not be viewed as a weakness.

It is simply the natural evolution of a newer treatment.

The Future of Focal Therapy

The next decade is likely to be one of the most exciting periods in prostate cancer research.

Several developments are already beginning to influence clinical practice.

These include:

improvements in multiparametric MRI
artificial intelligence to assist MRI interpretation
advances in PSMA PET imaging
genomic testing
molecular risk prediction
increasingly personalised treatment planning.

As these technologies continue to develop, our ability to identify the men who are most likely to benefit from focal therapy should improve further.

The result is likely to be more personalised prostate cancer care, with treatment increasingly tailored to the biology of each individual’s cancer rather than following a one-size-fits-all approach.

What Does This Mean for Patients Today?

The most important message is that focal therapy should neither be dismissed because it is newer nor chosen simply because it is less invasive.

Instead, treatment decisions should be based on:

the biology of your cancer
your MRI findings
your biopsy results
your PSA history
your general health
your personal priorities
and the best available scientific evidence.

That is the approach I take with every patient I see.

At a Glance

Current research shows that focal therapy:

✓ Provides encouraging medium-term cancer control in carefully selected men.

✓ Preserves urinary continence and erectile function better than many forms of whole-gland treatment.

✓ Continues to accumulate long-term evidence through international research.

✓ Is being evaluated in major UK clinical trials such as IP2-ATLANTA.

✓ Should be offered within experienced specialist services with structured follow-up.

Frequently Asked Questions

Is focal therapy experimental?

No.

It is an established treatment offered in specialist centres for carefully selected patients, although research continues to refine exactly which men benefit most.

Why are clinical trials still needed?

Because they provide the highest-quality evidence for comparing different treatments fairly and help improve care for future patients.

Does being involved in research improve patient care?

Clinical research helps ensure that treatment decisions are informed by the latest evidence and contributes to improving care for future patients.

Will focal therapy replace robotic surgery?

Almost certainly not.

The future is unlikely to be one treatment replacing another.

Instead, we are moving towards increasingly personalised treatment, where focal therapy, robotic surgery, radiotherapy and active surveillance each have an important role depending on the characteristics of the cancer and the priorities of the patient.

Key Points

Current evidence supports focal therapy as an effective treatment for carefully selected men with localised prostate cancer.
Medium-term cancer control and quality-of-life outcomes are encouraging, while long-term comparative evidence continues to mature.
Clinical trials such as IP2-ATLANTA are helping define where focal therapy fits alongside robotic surgery and radiotherapy.
The future of prostate cancer care is increasingly personalised, with treatment tailored to the individual rather than applying the same approach to every patient.
Treatment decisions should always be based on the best available evidence, careful patient selection and a balanced discussion of all appropriate options.

Is Focal Therapy Available on the NHS and Privately?

Once patients understand what focal therapy is and who it may be suitable for, the next question is usually a practical one:

“How can I actually access this treatment?”

The answer depends on several factors, including:

where you live
the characteristics of your prostate cancer
the focal therapy technique being considered
and whether treatment is being provided through the NHS or privately.

Unlike robotic radical prostatectomy or radiotherapy, focal therapy is not available in every hospital.

This is because successful focal therapy requires:

specialist imaging
experienced prostate radiologists
MRI-targeted biopsy
multidisciplinary assessment
dedicated treatment equipment
structured long-term follow-up.

For this reason, focal therapy is generally concentrated within specialist centres with expertise in prostate cancer diagnosis and treatment.

Can I Have Focal Therapy on the NHS?

Yes.

Focal therapy is available within the NHS at a number of specialist centres across the UK.

However, availability varies between regions.

Whether treatment is appropriate depends on:

the findings of your MRI
your biopsy results
the characteristics of your cancer
and the recommendations of your multidisciplinary team (MDT).

Some NHS centres provide focal therapy as part of established clinical services.

Others may offer treatment within prospective registries or clinical trials designed to improve the evidence base.

If focal therapy is not available locally, your consultant may discuss referral to a specialist centre if appropriate.

Can I Have Focal Therapy Privately?

Yes.

Several private hospitals across the UK offer focal therapy through experienced specialist teams.

Private treatment may offer:

earlier assessment
greater flexibility in appointment times
access to specialist imaging and diagnostics
rapid treatment where appropriate.

However, the most important point is this:

Private treatment should never determine the recommendation.

The decision should always begin with the question:

“Is focal therapy actually the best treatment for this cancer?”

Only once that has been answered should practical arrangements be discussed.

Consultant’s Perspective

Patients sometimes assume that because focal therapy is available privately, it must automatically be the treatment I recommend.

That is never my approach.

My responsibility is first to determine which treatment offers the best balance between cancer control and quality of life.

Sometimes that is focal therapy.

Sometimes it is robotic surgery.

Sometimes it is radiotherapy.

Occasionally, the best treatment is no immediate treatment at all and active surveillance is the safest option.

The recommendation should always be driven by the cancer—not by where treatment happens.

Will My Private Medical Insurance Cover Focal Therapy?

This is a question I am asked frequently.

The answer is:

It depends on your insurer and your individual policy.

Insurance approval may vary according to:

the type of focal therapy
the indication for treatment
whether pre-authorisation has been obtained
the terms of your policy.

If you have private medical insurance, it is sensible to contact your insurer before making arrangements for treatment.

Most insurers will ask for:

your diagnosis
procedure codes
consultant details
and confirmation that treatment has been recommended.

Your consultant’s secretary can usually help provide the necessary information.

Do I Need a GP Referral?

Not always.

Many patients are referred by:

their GP
another urologist
an oncologist
or another consultant.

However, many private hospitals also accept self-referrals, allowing you to arrange an initial consultation directly.

If you already have:

PSA results
MRI scans
biopsy reports
pathology results
clinic letters

bringing these to your appointment can be extremely helpful.

Reviewing existing investigations often avoids unnecessary repeat tests and allows a more informed discussion during your first consultation.

Should I Seek a Second Opinion?

I believe it is entirely reasonable to seek a second opinion before making a decision about prostate cancer treatment.

Choosing between active surveillance, focal therapy, robotic surgery and radiotherapy is one of the most important healthcare decisions many men will ever make.

A second opinion can provide:

reassurance that the diagnosis is correct
confirmation that all treatment options have been considered
an independent interpretation of MRI and biopsy findings
greater confidence in your final decision.

Good specialists should welcome informed questions and understand why patients sometimes wish to hear another expert perspective.

What Happens During a Focal Therapy Consultation?

The purpose of the consultation is not simply to decide whether focal therapy can be performed.

It is to determine whether it should be performed.

During your appointment, the urology team will usually review:

your PSA history
multiparametric MRI (mpMRI)
biopsy pathology
Gleason Grade Group
the location and extent of the cancer
urinary symptoms
erectile function
previous treatments
other medical conditions
your personal priorities.

They will then discuss all appropriate treatment options, including:

active surveillance
focal therapy
robotic radical prostatectomy
radiotherapy.

The aim is for you to leave with a clear understanding of:

the advantages of each treatment
the disadvantages of each treatment
the uncertainties that remain
and which option is most appropriate for your individual circumstances.

What Should I Bring to My Appointment?

If possible, bring copies of:

your PSA results
MRI report
MRI images (if performed elsewhere)
biopsy report
clinic letters
details of previous prostate treatments
a list of your medications.

It is also worth bringing a partner, family member or close friend.

Many patients find it helpful to have another person present when discussing treatment options, as it can be difficult to remember every detail after the consultation.

Preparing Questions Before Your Appointment

One of the best ways to get the most from your consultation is to prepare a list of questions in advance.

These might include:

Am I genuinely suitable for focal therapy?
Why are you recommending this treatment rather than surgery or radiotherapy?
What are the chances I will need further treatment?
How will treatment affect my continence?
How will treatment affect my erections?
How many similar procedures have you performed?
What follow-up will I need?
What would you recommend if I were a member of your own family?

There are no “wrong” questions.

The more you understand your options, the more confident you are likely to feel about your final decision.

Making Your Decision

Many men worry about making the “wrong” choice.

In reality, there is often more than one appropriate treatment.

The goal is not to identify a universally perfect option.

Instead, it is to choose the treatment that best reflects:

the biology of your cancer
the available scientific evidence
your lifestyle
your priorities
and your attitude towards risk and long-term follow-up.

Taking time to consider your options, discuss them with your family and ask questions is rarely a mistake.

An informed decision is almost always a better decision.

At a Glance

Accessing focal therapy

✓ Available within selected NHS specialist centres.

✓ Available privately in experienced prostate cancer units.

✓ Availability varies according to location and patient suitability.

✓ Insurance cover depends on the individual policy.

✓ A second opinion is entirely reasonable before deciding on treatment.

✓ Your consultation should focus on choosing the right treatment—not simply arranging focal therapy.

Key Points

Focal therapy is available within selected NHS centres and in the private sector.
Careful assessment is essential before deciding whether it is the most appropriate treatment.
Private medical insurance may cover focal therapy depending on your policy and the clinical indication.
Seeking a second opinion is appropriate and often helpful when several treatment options are available.
The purpose of your consultation is not simply to discuss focal therapy, but to determine which treatment offers the best balance between cancer control and quality of life for your individual cancer.

How Should You Decide Whether Focal Therapy Is Right for You?

By the time you reach this point, you will probably have realised something important.

There is no single treatment that is right for every man with prostate cancer.

Focal therapy can be an excellent option.

So can robotic radical prostatectomy.

So can radiotherapy.

For many men, active surveillance remains the safest and most appropriate approach.

The challenge is not deciding which treatment is “best.”

It is deciding which treatment is best for you.

That decision should be based on:

the biology of your cancer
the evidence supporting each treatment
your overall health
and the things that matter most to you.

The Biology of the Cancer Comes First

Whenever I meet a man newly diagnosed with prostate cancer, I start with the cancer—not the treatment.

Before discussing HIFU, NanoKnife®, robotic surgery or radiotherapy, I first want to understand:

Where is the cancer?
How aggressive is it?
Is it confined to the prostate?
Is there one significant tumour or several?
Is treatment actually necessary?

Only once those questions have been answered can we have a meaningful discussion about treatment options.

This is one of the reasons why two men with apparently similar PSA levels may receive completely different recommendations.

The biology of the cancer is far more important than any single blood test.

What Matters Most to You?

Once we understand the cancer, we can begin talking about your priorities.

Every patient is different.

Some men tell me:

“I want the treatment with the highest possible certainty of removing the cancer.”

Others say:

“My biggest concern is preserving my continence and sexual function.”

Others simply want to avoid treatment unless it is genuinely necessary.

None of these priorities are right or wrong.

They are personal.

Modern prostate cancer care is about matching the treatment to both the cancer and the individual.

When Focal Therapy May Be the Best Choice

Focal therapy may be particularly attractive if:

your cancer is confined to a clearly defined area of the prostate
preserving urinary continence is a high priority
maintaining erectile function is important to you
you are comfortable with regular follow-up using PSA, MRI and, where appropriate, repeat biopsy
you understand that additional treatment may occasionally be required in the future.

For these men, focal therapy may provide an excellent balance between effective cancer treatment and quality of life.

When Robotic Surgery May Be the Better Option

For other men, robotic radical prostatectomy may provide greater reassurance.

It is often recommended when:

the cancer is more extensive
there are multiple areas of clinically significant disease
complete pathological assessment of the prostate is important
the patient prefers the reassurance of removing the entire gland
long-term surveillance would cause considerable anxiety.

Following successful surgery, PSA should become undetectable, which many men find psychologically reassuring.

When Radiotherapy May Be Most Appropriate

Radiotherapy is another highly effective treatment.

It may be particularly suitable for men who:

wish to avoid surgery
have medical conditions that increase surgical risk
are happy to attend several weeks of treatment
prefer a non-surgical approach.

Modern radiotherapy has excellent long-term outcomes and remains one of the cornerstones of prostate cancer treatment.

When Active Surveillance Is the Right Decision

One of the biggest changes in prostate cancer care over the past two decades has been recognising that not every prostate cancer needs immediate treatment.

Many low-risk cancers grow so slowly that careful monitoring provides excellent long-term outcomes while avoiding unnecessary side effects.

For suitable men, active surveillance is not “doing nothing.”

It is an active treatment strategy involving:

regular PSA testing
repeat MRI
clinical review
and, when appropriate, repeat biopsy.

Many men remain on surveillance for years without ever requiring active treatment.

Consultant’s Perspective

One of the most satisfying consultations I have is when a patient leaves feeling confident about why a particular treatment has been recommended.

Sometimes that recommendation is focal therapy.

Sometimes it is robotic surgery.

Sometimes it is radiotherapy or active surveillance.

My goal is never to persuade someone towards a particular procedure.

It is to help them understand the evidence, the likely outcomes and the trade-offs, so that together we can choose the treatment that is most appropriate for their individual cancer.

Questions I Encourage Every Patient to Ask

Before deciding on treatment, I encourage patients to ask questions such as:

Why do you believe this treatment is the best option for me?
What are the realistic chances of controlling my cancer?
How will treatment affect my continence?
How will treatment affect my erections?
What happens if the cancer comes back?
What follow-up will I need?
What uncertainties still exist?
If I were your family member, what would you recommend?

Good specialists welcome these discussions.

They are an important part of shared decision-making.

There Is Rarely Only One Reasonable Option

One of the most reassuring things I tell patients is this:

It is common for more than one treatment to be appropriate.

For example, a healthy man with a single Grade Group 2 tumour may reasonably choose:

focal therapy
robotic radical prostatectomy
radiotherapy.

Each treatment offers different advantages.

Each has different trade-offs.

The decision is not simply about statistics.

It is about choosing the treatment that best reflects your priorities.

Taking Time to Decide

Unless your cancer requires urgent treatment, there is usually time to consider your options carefully.

Many patients find it helpful to:

discuss the diagnosis with their partner or family
seek a second opinion
read reliable patient information
speak to specialist nurses
write down questions before clinic appointments.

Feeling informed and confident about your decision is just as important as choosing the treatment itself.

At a Glance

The best treatment depends on:

✓ The location and extent of your cancer.

✓ Your MRI and biopsy findings.

✓ Your age and overall health.

✓ Your attitude to long-term surveillance.

✓ How important preserving continence and erectile function is to you.

✓ Your own values and priorities.

Key Points

There is no universally “best” treatment for localised prostate cancer.
The biology of the cancer should always guide treatment recommendations.
More than one treatment may be appropriate for many men.
Shared decision-making is essential, with careful discussion of the benefits and limitations of every suitable option.
The best treatment is the one that offers the right balance between cancer control, quality of life and your personal priorities.

Frequently Asked Questions About Focal Therapy for Prostate Cancer

What is focal therapy?

Focal therapy is a treatment for localised prostate cancer that destroys only the clinically significant area of cancer rather than treating or removing the entire prostate gland. The aim is to achieve effective cancer control while preserving as much healthy prostate tissue as possible, reducing the risk of urinary incontinence and erectile dysfunction in appropriately selected men.

Is focal therapy a cure for prostate cancer?

Focal therapy can provide durable long-term cancer control for carefully selected men with localised prostate cancer, but no prostate cancer treatment can guarantee a cure.
The aim is to eradicate the clinically significant tumour while preserving quality of life. Long-term follow-up remains an essential part of treatment because healthy prostate tissue is intentionally left behind.

Is focal therapy available in the UK?

Yes.
Focal therapy is available in selected NHS specialist centres and in a number of private hospitals throughout the UK.
Availability varies depending on the treatment technology, local expertise and individual patient suitability.

Who is the ideal candidate for focal therapy?

The best candidates are usually men with:
localised prostate cancer
a clearly defined MRI-visible tumour
intermediate-risk disease
cancer confined to one area of the prostate
biopsy confirmation of clinically significant disease.
Suitability should always be assessed by an experienced prostate cancer specialist.

Can I have focal therapy if I have Gleason 6 prostate cancer?

Most men with Grade Group 1 (Gleason 3+3) prostate cancer are better managed with active surveillance because many of these cancers grow so slowly that immediate treatment offers little benefit.

Can Gleason 7 prostate cancer be treated with focal therapy?

Yes.
Many men with Grade Group 2 (Gleason 3+4) prostate cancer—and selected men with Grade Group 3 (Gleason 4+3) disease—may be suitable, depending on the MRI findings, biopsy results and location of the tumour.

Does my age matter?

Age alone is rarely the deciding factor.
Overall health, life expectancy, tumour characteristics and your personal priorities are usually much more important than chronological age.
Many healthy men in their seventies remain excellent candidates for curative treatment.

Can I have focal therapy if I have more than one tumour?

Sometimes.
Small areas of low-grade prostate cancer elsewhere in the prostate do not automatically prevent focal therapy.
However, men with multiple clinically significant tumours affecting different parts of the prostate are often better treated with whole-gland therapy.

How is focal therapy performed?

The exact technique depends on whether HIFU, cryotherapy or NanoKnife® is being used.
Most procedures are performed under general anaesthetic as a day case.
Treatment is carefully directed at the tumour identified on MRI and confirmed by biopsy.

How long does the procedure take?

Most focal therapy procedures take between one and two hours, although this varies depending on the treatment technology and the amount of prostate requiring treatment.

Will I need an overnight stay?

Usually not.
Most men return home on the same day once they have recovered from the anaesthetic and are comfortable.

Will I have a catheter?

Yes.
Most men have a urinary catheter for around three to seven days while swelling settles.
Your treating team will advise when it can be removed.

Is focal therapy painful?

Most men experience only mild discomfort after treatment.
Common symptoms include temporary burning when passing urine, mild pelvic discomfort and a small amount of blood in the urine or semen.
Simple pain relief is usually sufficient.

When can I return to work?

Many men return to desk-based work within one to two weeks.
Recovery may take longer if your job involves heavy physical activity.

When can I drive?

You can usually drive once:
the catheter has been removed
you are comfortable performing an emergency stop
you are no longer taking strong pain medication.
Always follow the advice of your treating team.

When can I play golf or exercise?

Light walking is encouraged almost immediately.
Golf, cycling, swimming and gym exercise can usually be resumed after four to six weeks, depending on your recovery.

Will I become incontinent?

Long-term urinary incontinence is uncommon after focal therapy because the urinary sphincter is usually preserved.
Some men experience temporary urgency or mild leakage while the prostate heals.

Will focal therapy affect my erections?

Many men maintain good erectile function after focal therapy, particularly if erections were good before treatment and the tumour lies away from the erectile nerves.
However, no treatment can guarantee preservation of erectile function.

Will I still ejaculate?

Usually yes.
Unlike radical prostatectomy, focal therapy generally preserves ejaculation, although semen volume and ejaculation may change.

Can I father children afterwards?

Fertility is more likely to be preserved than after radical prostatectomy, but it cannot be guaranteed.
If future fertility is important, discuss sperm banking before treatment.

Should my PSA become undetectable?

No.
Healthy prostate tissue remains after focal therapy, so PSA usually remains detectable.
This is entirely expected.

What is more important than my PSA number?

The trend over time.
Doctors interpret PSA alongside MRI findings, clinical review and, where appropriate, repeat biopsy.

How often will I need follow-up?

Most men undergo:
regular PSA testing
repeat MRI
clinical review
and, in many cases, repeat biopsy.
Your follow-up schedule will be tailored to your individual circumstances.

What happens if my PSA rises?

A rising PSA does not automatically mean the cancer has returned.
Your specialist may recommend repeat PSA testing, MRI or biopsy before deciding whether further treatment is required.

Can focal therapy be repeated?

Yes.
If a new area of clinically significant cancer develops or the original tumour is not fully controlled, repeat focal therapy may be appropriate in selected patients.

Can I still have robotic surgery afterwards?

Yes.
Although surgery after focal therapy can be technically more challenging, it remains an important treatment option when required.

Can I still have radiotherapy?

In many cases, yes.
The choice depends on your previous treatment, MRI findings and biopsy results.

Does needing another treatment mean focal therapy failed?

Not necessarily.
Because healthy prostate tissue remains, some men develop new clinically significant cancer elsewhere in the prostate over time.
This reflects the philosophy of preserving healthy tissue rather than removing the whole gland.

Is focal therapy better than robotic surgery?

Neither treatment is universally better.
Focal therapy generally offers better preservation of urinary continence and erectile function for suitable patients, while robotic surgery provides complete removal of the prostate and decades of long-term outcome data.
The best treatment depends on the characteristics of your cancer and your personal priorities.

Is focal therapy better than radiotherapy?

Again, there is no universal answer.
Both are effective treatments for selected men.
The choice depends on tumour characteristics, overall health, expected side effects and individual preferences.

What would you recommend?

Every recommendation should begin with a careful review of your MRI, biopsy and PSA history.
The aim is not to recommend the same treatment for every patient, but to identify the treatment that offers the best balance between cancer control and quality of life for your individual circumstances.

Is HIFU better than NanoKnife®?

This is one of the commonest questions patients ask, but there is no simple answer.
HIFU and NanoKnife® destroy prostate cancer in different ways.
HIFU uses focused ultrasound to generate heat and destroy cancer cells.
NanoKnife® (Irreversible Electroporation) uses carefully controlled electrical pulses to disrupt cancer cell membranes without relying primarily on heat or freezing.
Neither technology has been shown to be universally superior.
The choice depends on several factors, including:
the size of the tumour
its location within the prostate
its relationship to the urethra and erectile nerves
the experience of the treating team.
For most patients, selecting the right treatment strategy is far more important than selecting a particular machine.

Is cryotherapy better than HIFU?

Both treatments are well-established focal therapy techniques.
Cryotherapy destroys cancer by freezing it, whereas HIFU destroys cancer using heat generated by focused ultrasound.
Some tumours are technically better suited to one treatment than the other.
Rather than asking which treatment is “better”, it is usually more helpful to ask:
“Which treatment is most appropriate for my individual cancer?”

Which focal therapy has the best evidence?

At present, HIFU has the largest body of published clinical experience in the UK and Europe.
Cryotherapy also has substantial published evidence.
NanoKnife® has produced encouraging early and medium-term results, although long-term comparative evidence continues to evolve.
Current research aims to determine which technologies provide the best outcomes for different tumour characteristics.

Does the type of machine determine the outcome?

Usually not.
The most important factors influencing success are:
careful patient selection
high-quality MRI
accurate biopsy
appropriate treatment planning
experience of the treating team
structured follow-up.
Technology is only one part of the overall treatment pathway.

When can I have sex after focal therapy?

Most men can resume sexual activity approximately four to six weeks after treatment, provided recovery is progressing normally and any discomfort has settled.
There is no advantage in rushing recovery.
Listen to your body and follow your consultant’s advice.

Conclusion

My Advice to Patients

If there is one message I hope you take away from this guide, it is this:

Don’t focus on finding the newest treatment or the treatment with the most impressive headline.

Instead, focus on finding the treatment that is most appropriate for:

your cancer
your health
your priorities
and your future quality of life.

Modern prostate cancer care is increasingly personalised.

For some men, focal therapy provides the ideal balance between cancer control and preserving quality of life.

For others, robotic surgery, radiotherapy or active surveillance will be the better choice.

The most important decision is not choosing a particular technology.

It is choosing the treatment that gives you the best opportunity for a long, healthy life while preserving the things that matter most.

Medical Disclaimer

The information in this article is intended to provide general educational guidance about focal therapy and other treatments for localised prostate cancer. It is designed to help patients understand the condition, the investigations that may be required and the treatment options that are currently available.

Every prostate cancer is different. Decisions about treatment should always be based on an individual assessment of your medical history, PSA results, MRI findings, biopsy results, general health and personal priorities. Information contained within this guide should not be used as a substitute for consultation with a suitably qualified healthcare professional.

Although every effort has been made to ensure that the information in this article is accurate and reflects current UK clinical practice at the time of publication, medical knowledge and clinical guidelines continue to evolve. Individual treatment recommendations may therefore differ according to new evidence, advances in technology and the specific circumstances of each patient.

This article does not establish a doctor–patient relationship and should not be relied upon as personal medical advice. If you have symptoms suggestive of prostate cancer, have been diagnosed with prostate cancer, or have concerns about your PSA or treatment options, you should seek advice from your GP or a Consultant Urological Surgeon.

If you would like an independent specialist opinion regarding your diagnosis or treatment options, including active surveillance, focal therapy, robotic radical prostatectomy or radiotherapy, you are welcome to arrange a consultation with Mr Neil Haldar.

Independent guidance and research

Mr Neil Haldar

Mr Neil Haldar is a UK Consultant Urological Surgeon specialising in prostate cancer, robotic surgery, uro-oncology and paediatric urology. He offers expert diagnosis, treatment and second opinions for complex urological conditions.