Is tissue-sparing prostate ablation a reliable treatment option?

Reliability of Tissue-Sparing Prostate Ablation

Tissue-sparing prostate ablation cannot be recommended as a reliable treatment option for most patients with prostate cancer due to insufficient high-quality evidence comparing its outcomes to standard treatments like radiation therapy, surgery, and active surveillance. 1

Current Evidence and Guidelines

For Prostate Cancer

• The American Urological Association (AUA) and American Society for Radiation Oncology (ASTRO) guidelines clearly state that patients considering prostate ablation should be informed about the lack of high-quality comparative data 1
• Ablation may only be considered in select patients with intermediate-risk prostate cancer, with clinical trial enrollment prioritized 1
• Ablation should NOT be recommended for:
  • Low-risk prostate cancer (active surveillance is preferred)
  • High-risk prostate cancer (outside of clinical trials) 1

Evidence Limitations

• A 2021 systematic review concluded there is "insufficient high-certainty evidence to endorse focal therapy as an oncologically effective and durable treatment modality" 1
• The only properly powered randomized controlled trial on prostate ablation:
  • Was limited to low-risk prostate cancer patients
  • Used photodynamic therapy (PDT), which isn't approved in the US
  • Showed that >50% of treated patients had persistent disease at 2 years
  • Demonstrated that patients experienced adverse events, pain, and transient reductions in urinary and sexual function 1

Recent Research

• A 2023 Focal Therapy Society review of whole-gland ablation (cryoablation and HIFU) reported:
  • 10-year biochemical recurrence-free survival of only 58%
  • Erectile function preservation in only 37% of cases
  • Complications including strictures (11%), urinary retention (9.5%), and urinary tract infections (8%) 2

For Benign Prostatic Hyperplasia (BPH)

For BPH, several ablative techniques exist but have specific limitations:

• Transurethral Needle Ablation (TUNA): While effective in partially relieving BPH symptoms, it requires higher analgesia/sedation/anesthesia than other minimally invasive options 1
• High-intensity focused ultrasound (HIFU): Considered investigational and should not be offered outside clinical trials 1
• Interstitial laser coagulation, water-induced thermotherapy, and PlasmaKinetic systems: Require additional data before being recommended as treatment options 1
• Balloon dilation: Not recommended as a treatment option for BPH 1

Emerging Technologies

Some newer technologies show promise but still lack robust long-term data:

• UroLift System: A minimally invasive option for moderate-to-severe BPH symptoms with prostate size <80g that preserves sexual function, but provides less improvement in maximum flow rate compared to TURP 3
• Nanoparticle-directed focal therapy: A 2024 study showed 73% of patients had successful treatment at 12 months, but this represents early-stage research 4

Clinical Decision-Making Algorithm

1. Risk Stratification:

   • Low-risk prostate cancer → Active surveillance (NOT ablation)
   • Intermediate-risk prostate cancer → Consider standard treatments first (surgery or radiation)
   • High-risk prostate cancer → Standard treatments only (NOT ablation)

2. For patients specifically interested in ablation:

   • Discuss the lack of high-quality comparative data
   • Emphasize higher rates of cancer persistence and recurrence compared to standard treatments
   • Consider clinical trial enrollment when available
   • Only consider in select intermediate-risk patients who understand the limitations

3. For BPH patients:

   • Consider standard treatments like TURP (gold standard) or medical therapy
   • For those concerned about sexual function, newer options like UroLift may be appropriate for prostates <80g
   • Avoid investigational treatments like HIFU outside of clinical trials

Pitfalls and Caveats

• Overestimating efficacy: The limited data shows significant rates of cancer persistence and recurrence after ablation
• Patient selection: Not all patients are suitable candidates; proper risk stratification is essential
• Technology limitations: Different ablative modalities have varying efficacy and safety profiles
• Follow-up requirements: Patients require careful monitoring for disease recurrence
• Evolving field: Treatment protocols are not standardized across centers

In conclusion, while tissue-sparing prostate ablation represents an appealing concept that may reduce side effects compared to radical treatments, current evidence does not support its routine use outside of carefully selected cases and clinical trials.