[Focal Therapy for Prostate Cancer in Germany: Progress or Illusion?]

Over the past two decades, focal therapy for localized prostate cancer has evolved from an experimental approach into a structured treatment option within the framework of risk-adapted prostate cancer management. The aim of this article is to provide a critical appraisal of the current role of focal therapy in light of contemporary guidelines, available evidence, and health-economic considerations. The introduction of multiparametric MRI and MRI-targeted fusion biopsy has substantially improved the accurate identification of clinically significant index lesions, thereby establishing the technical foundation for selective ablative approaches. Despite these advances, the evidence base remains heterogeneous, and large randomized comparative trials are still lacking. The largest comparative study to date (HIFI trial) demonstrated oncological non-inferiority compared with radical prostatectomy, albeit with important methodological limitations, while achieving superior functional outcomes. Initial randomized data from the FARP trial has so far been presented only in abstract format at scientific meetings, and a full peer-reviewed publication is pending. Within the contemporary therapeutic landscape, active surveillance, focal therapy, and radical treatments should not be viewed as strictly competing strategies but rather as components of a risk-adapted continuum. While active surveillance remains the standard of care for patients with low-risk disease, focal therapy may represent a suitable option for carefully selected patients with a clearly localized, biologically relevant index lesion and a strong preference for functional preservation. Optimal outcomes depend on rigorous patient selection using modern imaging, fusion biopsy techniques, and structured follow-up protocols. At the same time, considerable structural disincentives persist: pretherapeutic precision diagnostics are frequently inadequately reimbursed, and hospital reimbursement for focal procedures remains substantially lower than for radical standard treatments. In summary, focal therapy should no longer be regarded primarily as an experimental approach but as a selective component of a differentiated precision oncology concept. Its appropriate application remains indication-dependent and requires further high-quality prospective studies as well as supportive structural and economic frameworks.