Prostate cancer treatment: minimally invasive options

A diagnosis does not mean surgery

This is the first point to establish. The prostate cancer evolves most often slowly, and not all of its forms require the same treatment. Certain cancers, which are not very aggressive, warrant simple close monitoring; others require prompt management.

What distinguishes these situations is neither the PSA level alone, nor the age: it is the tumor grade, established by the analysis of prostate biopsies and expressed by the Gleason score, translated into ISUP prognostic groups from 1 to 5.

Five strategies can be discussed:

• Active surveillance close monitoring of PSA, MRI, and biopsies, without immediate treatment, for low-aggressiveness forms
• Surgery — radical prostatectomy, complete removal of the gland
• Radiotherapy — external or by brachytherapy
• Focal treatments - cryotherapy or focused ultrasound, targeting the tumor area alone
• Drug treatments - hormone therapy, in certain situations or in combination

Comparison of strategies

When treatment is indicated, three paths are discussed. None is superior on all criteria: here is what each provides, and what it costs.

Data from international literature. Each indication is individual and is decided upon through multidisciplinary consultation.

The principle of focal treatment

The logic therefore differs radically from that of whole-gland treatments. Where surgery and radiotherapy treat the entire prostate to be certain of covering the tumor, the focal approach agrees to target it, at the price of one requirement: knowing exactly where the cancer is located.

This explains why this approach was only possible from the moment when'multiparametric MRI and targeted biopsies made it possible to precisely map the disease. Inaccurate mapping would render focal treatment illusory.

Two techniques, one goal

The cryotherapy destroys tissue by cold, the high-intensity focused ultrasound by heat. Guidance is provided by imaging, without an incision.

In both cases, the objective is identical: to control the cancer while limiting the impact on continence and sexuality.

Focal cryotherapy of the prostate

The cryotherapy, or cryoablation, consists of freezing the tumor tissue using probes inserted transperineally under ultrasound guidance. The controlled cooling causes ice crystals to form inside the cells, leading to their destruction.

The course of the intervention

1. Initial assessmentMultiparametric MRI and targeted biopsies, which precisely locate the lesion and confirm its grade. Without this mapping, focal therapy cannot be considered.
2. Installation of the probesUnder anesthesia, cryogenic probes are positioned transperineally, under ultrasound guidance, into the area to be treated.
3. Freezing cyclesControlled freezing and thawing cycles are applied. The temperature and the expansion of the ice ball are monitored in real time.
4. SuitesThe procedure is most often performed on an outpatient basis or with a short hospital stay. A urinary catheter is usually left in place for a few days.

What cryotherapy provides

• A targeted approach, which spares the rest of the gland and functional structures
• A minimally invasive procedure, without incision, often performed on an outpatient basis
• Faster recovery than that of resection surgery
• A functional preservation most often obtained, regarding both continence and erection
• An option for fragile patients, for whom major surgery would be risky
• A repeatable treatment and not ruling out subsequent catch-up treatment

What you need to know before choosing

• The long-term decline remains limited compared to surgery and radiotherapy, whose oncological outcomes have been documented for decades
• Patient selection is strict not all cancers are suitable, particularly multifocal, extensive, or high-grade forms
• Close monitoring remains essential after treatment, because the preserved gland may harbor other foci
• Complications are possible : urinary disorders transient, infection, bleeding, more rarely fistula

HIFU: Focused Ultrasound

The HIFU, for High Intensity Focused Ultrasound, relies on the opposite principle of cryotherapy: it destroys tissue through heat. High-intensity ultrasound waves are focused on a precise point in the gland, where they cause a highly localized rise in temperature.

The probe is introduced rectally and the treatment is image-guided. As with cryotherapy, the procedure does not require any incisions and can often be performed in ambulatory.

Both techniques share the same indications, limitations, and level of evidence. The choice between them depends mainly on the location of the lesion within the gland, its volume, and the patient's anatomy. In practice, this decision is up to the team taking care of you, after a complete review of your file.

For which patients?

Focal therapy is intended for a specific population. Selecting it correctly determines its value.

It is argued in principle before:

• A localized cancer, without extension beyond the gland
• A single or dominant lesion, well identified on the MRI and confirmed by the biopsies
• A intermediate or low grade, typically ISUP 1 to 2, sometimes 3 depending on the situation
• A patient informed of the uncertainties and accepting close monitoring

Conversely, it is not suitable for multifocal cancers disseminated throughout the gland, high-grade forms, tumors extending beyond the capsule, or locations that make targeting difficult.

Let us finally clarify what focal therapy is not: it is neither a comfort treatment nor a default option to avoid surgery. It is a strategy in its own right, with its own follow-up requirements.

What the recommendations say

This nuance deserves to be understood rather than passed over in silence. It does not mean that these treatments are experimental or risky: it means that the medical community continues to measure their oncological effectiveness over the long term, whereas surgery and radiotherapy have several decades of hindsight.

For you, this translates into two concrete requirements: one complete information before deciding, and a organized follow-up after treatment. Preserving quality of life as much as possible must never come at the expense of cancer control.

Frequently asked questions

Have your file proofread

Send your biopsy report with the Gleason score, your prostate MRI and your latest PSA levels. We will let you know which options can be discussed in your situation.

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