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Letter to the Editor


Reply to Runqiang Yuan and Hongxing Huang’s Letter

to the Editor re: Ernesto R. Cordeiro Feijoo,

Arjun Sivaraman, Eric Barret, et al. Focal High-intensity

Focused Ultrasound Targeted Hemiablation for

Unilateral Prostate Cancer: A Prospective

Evaluation of Oncologic and Functional Outcomes.

Eur Urol 2016;69:214–



We thank Drs. Yuan and Huang for their interest in our

study on high-intensity focused ultrasound (HIFU) hemi-

ablation for prostate cancer


. While the authors have

raised some thoughtful questions, we feel the dynamics in

the concept of this novel treatment should be appreciated.

Focal therapy or partial gland ablation (PGA) is currently a

novel approach with the intent of providing curative

treatment in selected patients with localized prostate



. Within a short time span, we have seen

significant changes in many aspects of PGA, such as patient

selection criteria, the role of magnetic resonance imaging

(MRI), and improvements in image guidance technology

and surveillance strategies


. As evident from the

literature and focal therapy consensus statements, there is a

clear shift in the target population for PGA from patients

eligible for active surveillance to selected patients with

intermediate-risk cancer. Our prospective study (2009) was

designed at the time when the first consensus statement on

focal therapy was published, and a 33% positive core cutoff

was a proposed recommendation for patient selection from

the consensus meeting


. This was based on the report by

Kestin et al


demonstrating that percentage positive

cores can be a powerful predictor of biochemical and

clinical outcome for prostate cancer. We performed at

least two sets of transrectal ultrasound biopsies before

focal therapy, which amounted to 20 or more biopsy

cores. However, with the current routine use of MRI

fusion biopsy, the biopsy criteria for selecting patients for

PGA are vastly different. The PGA selection criteria we

currently use are:

(1) Life expectancy


10 yr.

(2) Gleason score 7 (4 + 3).

(3) Prostate-specific antigen (PSA) 15 ng/ml.

(4) Biopsy proven concordant with the dominant region of

interest on MRI.

(5) No imaging evidence of extraprostatic extension,

seminal vesicle invasion, or lymph node involvement.

(6) In patients with a negative MRI finding, biopsy

positivity within one lobe of the prostate in the

contiguous segments is considered eligible.

(7) Presence of multifocal Gleason score 6 (3 + 3) disease

outside the index lesion is considered eligible.

We completely understand that prostate is a symmetric

organ, but there is an ascertainment bias as patients are

carefully selected based on biopsy and MRI characteristics

and consent for the procedure. If all consecutive patients

with prostate cancer were treated with PGA and a sufficient

sample size was attained, the symmetric distribution of

cancer could be observed. We believe that the highest rate

of tumor at the base is because thermal-based ablative

procedures (cryotherapy/HIFU) may not be an ideal energy

option for apical tumours. In accordance with our institu-

tional guidelines, we follow an ‘‘a` la carte’’ model to decide

the type of energy used for ablation on the basis of the

topographic location of the cancer within the prostate



Measuring patient-reported outcomes following PGA is

vital, and one of the limitations of our study at the time of

publication was the unavailability of 12-mo data. However,

the follow-up for functional outcomes in our cohort was very

similar to results reported in the literature

[1] .

To update the

functional outcomes, all patients were continent at 12 mo.

The mean International Prostate Symptom Score returned

almost to baseline, and potency was noted in 80% of

previously potent men. However, the mean age of this cohort

was 70.2 yr, and only 21/71 men had potency. Although

most men recovered their baseline International Index of

Erectile Function score at 12 mo, it is difficult to reach

conclusions because of the ‘‘poor’’ sexual activity of the

patients in this group. The adverse functional outcomes

observed after PGA are noted in the initial few months, with

a gradual return to baseline. A possible reason for this

observation is resulting prostatic inflammation and oedema.

Conflicts of interest:

The authors have nothing to disclose.

E U R O P E A N U R O L O G Y 7 1 ( 2 0 1 7 ) e 1 4 8 – e 1 4 9

available at


journal homepage:

DOIs of original articles: ,




2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.