The Precision Prostatectomy: an IDEAL Stage 0, 1 and 2a Study

Area of Science:

• Urology
• Oncology
• Surgical Innovation

Background:

• Focal/hemiablation of prostate cancer (CaP) is being explored as an alternative to whole-gland therapy.
• Preclinical models are crucial for evaluating novel surgical techniques.
• Conventional criteria for focal/hemiablation may leave significant residual cancer.

Purpose of the Study:

• To develop a preclinical model for evaluating focal/hemiablation (IDEAL stage 0).
• To design and assess a novel focal surgical treatment, precision prostatectomy (IDEAL stage 1/2a).
• To determine the feasibility, safety, and short-term outcomes of precision prostatectomy.

Main Methods:

• Whole-mount prostatectomy specimens from 100 men were analyzed to simulate focal/hemiablation.
• A prospective study of precision prostatectomy was conducted in 8 men meeting specific criteria (PSA ≤15 ng/mL, cT2 stage, unilateral dominant lesion Gleason ≤4+3, no contralateral Gleason ≥4, IIEF-5 ≥17).
• Feasibility, safety, urinary, sexual, and oncological outcomes were evaluated.

Main Results:

• Analysis of specimens indicated that focal ablation or hemiablation could leave significant residual cancer (up to 68% clinically significant).
• Precision prostatectomy in 8 men showed feasibility and excellent short-term functional recovery (urinary and sexual).
• At 24-30 months, median PSA was 0.2 ng/mL, with 2 men having low-grade residual cancer managed with active surveillance; none required secondary treatment.

Conclusions:

• Conventional focal/hemiablation criteria may result in significant residual prostate cancer.
• Precision prostatectomy is technically feasible and offers excellent functional recovery.
• A risk-stratified approach like precision prostatectomy may avoid whole-gland therapy and preserve erectile function in men with intermediate-risk CaP.