Choosing salvage therapy after prostate cancer focal ablation

Among the sessions featured at the 2025 Society of Urologic Oncology Annual Meeting in Phoenix, Arizona, was a case discussion, “Recurrence after Focal Therapy and Salvage Prostatectomy.” In this video interview, Kelly L. Stratton, MD, FACS, an assistant professor of urologic oncology in the University of Oklahoma Department of Urology and an adjunct assistant professor of medical oncology at the Stephenson Cancer Center, explains that although focal therapy for prostate cancer is increasingly popular, some patients will experience persistent or recurrent cancer, making salvage treatment an important topic. The best salvage approach depends on several individualized factors:

• type of focal therapy received and extent of prostate tissue treated

• characteristics of the recurrence (location, risk category, imaging appearance)

• changes caused by the initial ablation, such as prostate shrinkage, which may affect the feasibility and complexity of salvage surgery.

Stratton emphasizes a personalized approach: evaluating imaging (including MRI and prostate-specific membrane antigen [PSMA]-PET), performing targeted biopsy to confirm recurrence, and assessing whether the disease has spread. Options may include:

• active surveillance

• repeat focal/ablative therapy

• radiation therapy

• salvage prostatectomy.

For patients undergoing salvage surgery or radiation, he notes that previous focal therapy can influence outcomes. Urinary control after salvage prostatectomy is often similar to primary surgery, but nerve preservation may be more difficult due to tissue changes from the ablation.

Stratton stresses the importance of reviewing the patient’s pre-treatment disease features, changes after ablation, and aligning treatment decisions with goals such as cancer control, quality of life, continence, and erectile function. Advances in imaging—especially PSMA-PET—help determine whether repeat focal therapy is appropriate or whether patients should transition to whole-gland treatments like surgery or radiation.