What are the advantages of prostate ablation over prostatectomy (prostate surgery)?

From the Guidelines

Prostate ablation is not definitively better than surgery for all patients, and the choice between these treatments should be based on individual factors, including cancer stage, prostate size, overall health, and personal preferences, as stated in the most recent guideline by the AUA/ASTRO 1.

Key Considerations

• The AUA/ASTRO guideline recommends that ablation may be considered in select, appropriately informed patients with intermediate-risk prostate cancer, but not for those with high-risk disease outside of a clinical trial 1.
• A systematic review of focal ablative therapy for clinically localized prostate cancer found that the evidence in support of focal therapy as a feasible alternative to either active surveillance or radical interventions for localized prostate cancer is limited, with mixed and inconsistent data regarding oncological effectiveness compared to standard options 1.
• The review also noted that focal therapy had transiently worse functional and quality of life outcomes compared to active surveillance, but better functional outcomes than radical prostatectomy, although the certainty of the evidence was low 1.

Treatment Options

• Radical prostatectomy or radiotherapy plus androgen deprivation therapy (ADT) are recommended as standard treatment options for patients with high-risk localized prostate cancer, according to the AUA/ASTRO guideline 1.
• Active surveillance is the preferred approach for patients with low-risk prostate cancer, as stated in the AUA/ASTRO guideline 1.
• Focal ablative therapy may be considered for patients with intermediate-risk prostate cancer, but the evidence is limited, and more research is needed to define its role in the management of clinically localized prostate cancer 1.

Patient Factors

• Patients should discuss all treatment options with their urologist to determine the most appropriate treatment for their specific situation, taking into account individual factors such as cancer stage, prostate size, overall health, and personal preferences.
• The goal of treatment should be to balance the risks and benefits of each option, prioritizing morbidity, mortality, and quality of life outcomes.

Current Research

• Ongoing and anticipated randomized trials are expected to provide more definitive evidence on the role of ablative therapy in the management of clinically localized prostate cancer 1.
• The AUA/ASTRO guideline recommends that clinicians should not recommend whole gland or focal ablation for patients with high-risk prostate cancer outside of a clinical trial 1.

From the Research

Comparison of Prostate Ablation and Surgery

• Prostate ablation has been shown to have better functional outcomes compared to surgery, with faster recovery of urinary continence and lower risk of de novo erectile dysfunction 2, 3.
• A study comparing high-intensity focused ultrasound (HIFU) hemiablation to robot-assisted laparoscopic prostatectomy (RALP) found that HIFU was associated with better and faster recovery of continence, with most men showing no signs of urinary incontinence even right after surgery 2.
• Another study found that HIFU partial gland ablation was associated with improved recovery in terms of urinary incontinence and sexual function, particularly during the early to mid-term postoperative period, compared to robot-assisted radical prostatectomy (RARP) 3.

Oncological Outcomes

• There is no significant difference in the need for salvage therapies between prostate ablation and surgery, with one study finding that 7/55 men underwent salvage therapy in the HIFU group versus 6/55 in the RALP group (p = 0.76) 2.
• A meta-analysis found that there were no notable disparities in complication rates and the requirement for salvage therapy between HIFU partial gland ablation and RARP 3.

Hospital Stay and Recovery

• Patients treated with HIFU experienced a shorter hospital stay compared to those who received RARP, with a weighted mean difference of -2.78 days (95%CI -5.14, -0.43; p = 0.02) 3.
• A study found that HIFU was associated with faster recovery of urinary incontinence and adverse effects, with a lower postoperative adverse event rate compared to whole-gland ablation (37.5% vs. 66.7%, P = 0.023) 4.

Minimally Invasive Surgical Therapies

• Ablative minimally invasive surgical therapies, such as Aquablation, Rezum, and transperineal laser prostate ablation, have demonstrated excellent safety and efficacy profiles while preserving sexual function 5.
• These modalities may be particularly interesting to patients who value the preservation of their sexual function, and should be discussed with patients to ensure informed and shared decision-making 5.