Focal therapy vs radical prostatectomy for localized prostate cancer: a systematic review, meta-analysis, bayesian...

Prostate cancer is a prevalent malignancy with procedural treatment strategies. These treatments are associated with significant quality of life impact, including erectile dysfunction and urinary incontinence. Focal therapy (FT) has emerged as an option that may minimize treatment-related side effects. Its efficacy in cancer control compared to standard strategies, such as radical prostatectomy (RP), remains controversial. This systematic review and meta-analysis sought to compare the oncologic and functional outcomes of focal therapy versus radical prostatectomy (RP) for localized prostate cancer.

A comprehensive systematic search was conducted across PubMed, EMBASE, Scopus, and Google Scholar in October 2025. The study followed PRISMA guidelines and included prospective and retrospective observational studies comparing RP with FT. Eleven studies met inclusion criteria providing a total of 8399 patients of which 4498 underwent RP and 3901 underwent FT. The coprimary endpoints were salvage treatment-free survival and failure-free survival, with secondary endpoints including continence, erectile function, and complication rate.

Oncologic outcomes revealed a statistically significant overall difference in salvage treatment-free survival and failure-free survival between FT and RP, with a HR of 2.05 (95% Cl 1.29-3.26, p=0.002) and 2.68 (95% CI 1.04-6.93, p=0.04), respectively. Differences in overall survival were not statistically significant HR 1.71 (95% CI 0.75-3.90, p = 0.20). Subgroup analyses showed varied results across different focal therapy approaches, with cryotherapy and combined approaches demonstrating higher treatment failure rates. Functional outcomes strongly favored FT, with significantly higher rates of continence and erectile function across all measured time intervals. At 12 months post-treatment, FT patients demonstrated substantially better continence (OR 3.45, p<0.00001) and erectile function preservation (OR 6.43, p<0.00001) compared to RP.

FT offers substantial quality of life benefits, particularly within the first 12 postoperative months, compared to RARP, however, at the cost of decreased oncologic treatment effectiveness. Differences in oncologic outcomes become attenuated in propensity-matched studies and trial sequential analysis yielded inconclusive results. Careful patient selection is paramount, and patients should be thoroughly counseled about potentially reduced oncologic control effectiveness and increased post-ablation monitoring.