Review Article

Which technology to select for primary focal treatment of prostate cancer?—European Section of Urotechnology (ESUT) position statement




With growing interest in focal therapy (FT) of prostate cancer (PCa) there is an increasing armamentarium of treatment modalities including high-intensity focused ultrasound (HIFU), cryotherapy, focal laser ablation (FLA), irreversible electroporation (IRE), vascular targeted photodynamic therapy (VTP), focal brachytherapy (FBT) and stereotactic ablative radiotherapy (SABR). Currently there are no clear recommendations as to which of these technologies are appropriate for individual patient characteristics. Our intention was to review the literature for special aspects of the different technologies that might be of advantage depending on individual patient and tumour characteristics.


The current literature on FT was screened for the following factors: morbidity, repeatability, tumour risk category, tumour location, tumour size and prostate volume and anatomical issues. The ESUT expert panel arrived at consensus regarding a position statement on a structured pathway for available FT technologies based on a combination of the literature and expert opinion.


Side effects were low across different studies and FT modalities with urinary continence rates of 90–100% and erectile dysfunction between 5 and 52%. Short to medium cancer control based on post-treatment biopsies were variable between ablative modalities. Expert consensus suggested that posterior lesions are better amenable to FT using HIFU. Cryotherapy provides best possible outcomes for anterior tumours. Apical lesions, when treated with FBT, may yield the least urethral morbidity.


Further prospective trials are required to assess medium to long term disease control of different ablative modalities for FT. Amongst different available FT modalities our ESUT expert consensus suggests that some may be better for diffe`rent tumour locations. Tumour risk, tumour size, tumour location, and prostate volume are all important factors to consider and might aid in designing future FT trials.

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Author notes

  1. These authors contributed equally: Roman Ganzer, Vinodh Kumar Adithyaa Arthanareeswaran.


  1. Department of Urology, Asklepios Hospital Bad Tölz, Bad Tölz, Germany

    • Roman Ganzer
    • , Vinodh Kumar Adithyaa Arthanareeswaran
    •  & Jens-Uwe Stolzenburg
  2. Division of Surgery, Department of Surgery and Cancer, Imperial College London, London, UK

    • Hashim U. Ahmed
  3. Department of Urology, Imperial College Healthcare NHS Trust, London, UK

    • Hashim U. Ahmed
  4. Department of Urology, Advanced Urotechnology Center, IRCCS Istituto Auxologico Italiano, Milan, Italy

    • Andrea Cestari
  5. Department of Urology, Rangueil University Hospital, Toulouse, France

    • Pascal Rischmann
  6. Martini Clinic, Prostate Cancer Center, Hamburg, Germany

    • Georg Salomon
  7. Department of Urology, University of Heidelberg, Heidelberg, Germany

    • Dogu Teber
  8. Department of Urology, University of Patras, Patras, Greece

    • Evangelos Liatsikos
  9. Department of Urology, Institut Montsouris, Paris, France

    • Eric Barret


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RM: protocol development, data collection and management, manuscript writing/editing. VKAA: protocol development, data collection and management, manuscript writing/editing. HUA: data collection and management. AC: data collection and management. PR: data collection and management. GS: data collection and management. DT: data collection and management. EL: data collection and management. J-US: data collection and management. EB: protocol development, data collection and management, manuscript writing/editing

Conflict of interest

PR is a consultant for EDAP-TMS, Vaulx-en-Velin, France and stock owner of EDAP TMS shares; HUA receives funding from SonaCare Medical (previously USHIFU) for clinical trials and has received funding from SonaCare Medical for travel to conferences. RG, VKAA, AC, GS, DT, EL, J-US and EB declare that they have no conflict of interest.

Corresponding author

Correspondence to Roman Ganzer.