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Imaging in focal therapy: advanced ultrasound imaging and mpMRI—a comprehensive review

Prostate Cancer and Prostatic Diseases (2025)Cite this article

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Standard therapeutic options for localized prostate cancer (PCa) include whole gland treatment such as radical prostatectomy (RP) or radiation, administered according to various protocols. These treatments may result in erectile and urinary dysfunction in 50% or more of patients. Active surveillance (AS) does not affect functional outcomes and should be offered to patients presenting with low-risk and favorable intermediate-risk PCa. Due to improved risk stratification and increasing use of multiparametric Magnetic Resonance Imaging (mpMRI) in PCa follow-up, the cancer survival of patients on AS is not affected if appropriate follow-up is done. Focal therapy (FT) represents an alternative between radical therapies and observation. Regretfully, it is not recommended in many guidelines despite its good safety profile and the demonstrated superiority of post treatment erectile and urinary functions rates. This reflects the lack of randomized trials and limited data on long term oncologic outcomes [1, 2].

Many energy sources have been used including high-intensity focused ultrasound, cryoablation (CA), laser ablation (LA), irreversible electroporation, microwave focal ablation, focal brachytherapy (BT), and MR-guided transurethral US ablation (TULSA). Two approaches have evolved, either half/whole gland treatment, or selective destruction of identified clinically significant PCa (CsPCa). The latter should induce fewer complications or side effects and better spare erectile and sphincter function, whereas limited prostate volume ablation may lead to a higher recurrence rate [3]. Few randomized trials have been conducted comparing FT techniques. FT should be proposed only in expert centers after appropriate patient information is provided. Clinical trials and well-designed registries should be supported where possible [1].

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Fig. 1: Under staging of PCa when the diagnostic strategy is limited to MRI findings: the additional value of mpUS for the detection of CsPCa missed at MRI.
Fig. 2: Focal therapy with laser ablation of a prostate cancer using transrectal approach and MR thermometry (Courtesy Dr. Jurgen Fütterer, Radboudumc and Pierre Bour, Certis Therapeutics).
Fig. 3: Focal therapy with laser ablation of a prostate cancer using real-time MR thermometry (Courtesy Dr. Jurgen Fütterer, Radboudumc and Pierre Bour, Certis Therapeutics).
Fig. 4: The critical role of mpMRI and PRECISE score.
Fig. 5: mpUS can improve PCa identification and staging. 67-year-old patient with two renal transplantations in 1991 (right iliac fossa) and in 2002 (left iliac fossa), with moderate chronic renal dysfunction in 2024, presenting with a slow PSA increase up to 6.1 ng/mL.

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Authors and Affiliations

  1. Department of Adult Radiology, Necker Universty Hospital, APHP centre, Paris, France

    Jean-Michel Correas

  2. Paris Cité Medical University, Paris, France

    Charles Dariane

  3. Department of Urology, Georges-Pompidou European Hospital, Paris, France

    Charles Dariane

  4. Service d’imageries Spécialisées et des Urgences (SISU). APHP, Hôpital Pitié-Salpêtrière, Paris, France

    Raphaele Renard Penna

  5. Department of Medical Imaging, Mount Sinai Hospital, Women’s College Hospital, Toronto, Canada

    Sangeet Ghai

  6. Department of Urology, CHU de Bordeaux Université de Bordeaux, Bordeaux, France

    Franck Bladou

  7. Département d’Urologie, Institut Mutualiste Montsouris, Université Paris Cité, Paris, France

    Xavier Cathelineau

  8. Department of Urology, University of Texas MD Anderson Cancer Center, Houston, USA

    John F. Ward

  9. Department of Urology, University College London Hospital, London, UK

    Mark Emberton

  10. International School of Medicine, Istanbul Medipol University, Istanbul, Türkiye

    Pilar Laguna & Jean de la Rosette

  11. Department of Surgery, The Chinese University of Hong Kong, Ma Liu Shui, Hong Kong

    Peter Chiu

  12. Unit of Urology, Sant’Andrea Hospital, Sapienza University, Rome, Italy

    Cosimo de Nunzio

  13. Division of Urology, Sunnybrook Health Sciences Center, Toronto, Canada

    Laurence Klotz

  14. Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands

    Jurgen Futterer

  15. Bashkir State Medical University, Ufa, Russia

    Jean de la Rosette

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Contributions

JMC, CD, and RRP were responsible for the writing of the manuscript and the literature. JF and JdlR were involved in the review of the article, improving the manuscript and selecting the figures. SG, FB, XC, JFW, ME, PL, PC, CdN, and LK participated in the final review of the manuscript, the improvement of the language, the update of the reference list.

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Correspondence to Jean-Michel Correas.

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CdN is Editor of Prostate Cancer and Prostatic Diseases.

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Correas, JM., Dariane, C., Renard Penna, R. et al. Imaging in focal therapy: advanced ultrasound imaging and mpMRI—a comprehensive review. Prostate Cancer Prostatic Dis (2025). https://doi.org/10.1038/s41391-025-01017-z

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