The role of focal therapy for localized prostate cancer: From diagnosis to ablation.

[INTRODUCTION] Focal therapy (FT) has emerged as an intermediate therapeutic strategy between active surveillance (AS) and radical treatments for the management of localized prostate cancer (PCa) in patients with clinically significant disease and a well-defined index lesion (IL). The development of ablative and imaging techniques has enabled the selective treatment of the IL, preserving healthy tissue and reducing adverse effects.

[OBJECTIVES] o review the current evidence on FT in localized PCa, including technological modalities, selection criteria, diagnostic tools, post-treatment surveillance strategies, and barriers to its clinical implementation in the Spanish healthcare setting.

[MATERIALS AND METHODS] A structured narrative review was conducted through a search in PubMed, Scopus, and Web of Science, including studies published up to April 2025. Original articles, reviews, clinical guidelines, and meta-analyses focusing on FT for localized PCa were selected. Prospective and comparative studies addressing oncological and functional outcomes, as well as associated technologies such as fusion biopsy, multiparametric magnetic resonance imaging (mpMRI), prostate-specific membrane antigen positron emission tomography (PSMA-PET), and artificial intelligence (AI), were prioritized.

[RESULTS] FT offers encouraging short- and medium-term oncological outcomes, with notable functional preservation. Modalities such as high-intensity focused ultrasound (HIFU) and cryotherapy are currently the most widely used and have the longest clinical trajectory, while irreversible electroporation (IRE) stands out among emerging techniques with results. Surveillance after FT should be multifactorial and include serial PSA monitoring, systematic and targeted biopsies, as well as imaging techniques such as mpMRI. Specific tools such as PI-FAB (Prostate Imaging after Focal Ablation) and TARGET (Transatlantic Recommendations for MRI Evaluation after Focal Therapy) systems allow for standardized interpretation of mpMRI after FT. In Spain, its adoption remains limited, reinforcing the need for specific guidelines and multicenter registries.