Editorial Comment.

Abstract

The advent of magnetic resonance imaging (MRI) guided biopsy has led to increased finding of intermediate risk prostate cancers; more than half of all cancers diagnosed with the new method are of ISUP Groups 2 and 3 (see figure). Because men with intermediate risk cancers are most suitable for partial gland ablation (PGA), the candidate pool for such treatment is growing. When considering options, one question PGA candidates frequently ask is, “if focal therapy fails, can I still get safe and effective surgery later on?” The present work by Ribeiro and associates helps answer the question in the affirmative. In Ribeiro et al’s large retrospective analysis, salvage prostatectomy after PGA (95 patients) was much better tolerated than after radiation therapy (90). Therefore, the favorable results after focal therapy (only 5% complication rate in first 30 days and 83% continence rate at 1 year) will provide some reassurance that a reasonable fallback option exists. The poor results following radiation-salvage surgery have become well known; thus, surgery after failed radiation is no longer a routine option. For that reason, a more relevant comparison, de novo surgery vs post-PGA surgery, would provide the kind of information that focal therapy candidates seek. The limited studies currently available suggest results may be comparable. Despite lack of prospective, clinical trial data, adoption of PGA is increasing rapidly, at least partly because patients with prostate cancer generally prioritize quality of life in making treatment decisions. However, PGA may fail to ablate clinically significant cancer in 20% of cases. Thus, evaluation of PGA-salvage treatments will become an important research mandate in the near future.