Focal therapy is a targeted treatment option for men with localised prostate cancer, offering an intermediate pathway between active surveillance and whole-gland treatments such as surgery or radiation. The technique specifically targets the index lesion (the largest and most aggressive tumour) while preserving surrounding healthy prostate tissue to reduce side effects.
What is focal therapy?
Localised prostate cancer means the cancer hasn’t spread beyond the prostate and nearby tissue. Focal therapy targets only the most significant tumour area, aiming to control the disease while minimising side effects. Traditional options for localised prostate cancer include:
Active surveillance: Regular testing to monitor slow-growing cancer, with treatment only if the cancer begins to spread. However, studies show 14–41% of men on active surveillance may eventually need surgery or radiation.
Surgery or radiation: These remove or destroy the entire prostate but can lead to side effects like incontinence (loss of bladder control) and impotence (difficulty maintaining erections).
Focal therapy offers a middle-ground option, targeting the most serious tumour while minimising side effects.
How does focal therapy work?
Focal therapy focuses on the index lesion that is identified through imaging and biopsy. Controlling this tumour can manage cancer with fewer side effects.
Common focal therapy techniques used include:
- Cryotherapy: Freezing the tumour.
- Laser ablation: Heating the tumour.
- High Intensity Focused Ultrasound (HIFU): Using high-intensity focused ultrasound which also generates heat to destroy cancer cells.
- NanoKnife (irreversible electroporation): Using electrical pulses to destroy cancer cells while sparing surrounding nerves and blood vessels.
Who is a candidate for focal therapy?
Focal therapy is typically recommended for patients who:
- Have low or intermediate-risk prostate cancer
- Have confirmed cancer localised to specific zones via MRI and biopsy
Prof Lawrentschuk will consider your age, health, tumour size and location, and imaging results to determine your suitability.
Focal Therapy with NanoKnife
The NanoKnife procedure is a type of focal therapy performed under general anaesthesia.
Prior to your procedure, you will be asked to complete a questionnaire. We request that you please complete this and return it to us before your NanoKnife.
It is similar to a transperineal biopsy in setup:
- 4–6 needles are inserted into the prostate using real-time ultrasound guidance.
- These deliver electrical pulses that destroy tumour cells without heating.
- A flexible cystoscopy may be performed first to confirm no blood clots in the bladder.
- The procedure takes approximately 45 minutes, after which a temporary urinary catheter is inserted.
After your NanoKnife Procedure
Medications
- Pain relief: Take paracetamol and anti-inflammatory medicine for at least a week, even if you feel fine.
- Alpha blockers: Help relax the prostate for easier urination.
- Antibiotics: Prevent infection.
Catheter Care
You'll go home with a urinary catheter and instructions for care. A follow-up visit will be scheduled to remove the catheter (called a "trial of void").
Our Nurse Specialist, Grace, generally performs the removal in the rooms at Level 1 of Epworth Freemasons Medical Centre, Victoria Parade, East Melbourne, but occasionally, it is done on the ward. It is important that your bowels are functioning properly prior to catheter removal. If your bowels have slowed down, please use prune juice or laxatives. Potential issues that may arise after catheter removal are discussed below.
Resuming Activities
After catheter removal, you can slowly return to normal activities, including driving and light exercise. Sexual activity is safe once you feel comfortable, though you might notice some blood in your semen (this will resolve).
Future Appointments
After your trial of void, an optional appointment exists at 4-6 weeks to discuss treatment and any plans and symptoms if any are present. You will be asked to return in 6 months with a new PSA blood test and an MRI scan. Following this, you will have ongoing reviews every 6 months for at least 5 years.
Please contact Professor Lawrentschuk’s rooms at 9329 1197 or attend your nearest Emergency Department if you experience severe pain that cannot be managed by medication, inability to urinate or a high fever.
Possible Risks of NanoKnife Focal Therapy
Treatment Failure
Any treatment for prostate cancer may fail. Prof Lawrentschuk will keep watching you closely with PSA tests and imaging (MRI, PSMA PET-CT) to make sure your cancer is controlled.
A repeat biopsy is generally done down the track to provide reassurance. If the treatment does not work the first time, it can be repeated or salvaged with surgery or radiation (provided the prostate has not had radiation before). The alternative to focal therapy is generally radical treatment which includes surgery or radiation.
Difficulty urinating (2%)
Swelling or bruising may temporarily block urine flow, requiring a catheter. The inability to pass urine is more likely to occur in men who had difficulty passing urine before their treatment or if previous radiation has been used.
Very rarely, a temporary catheter may be passed after a trial of void to allow the prostate to settle down further from the treatment. If urinary symptoms of burning and stinging occur, they generally resolve within 2-6 weeks and should be treated with Ural from the chemist, as well as continuing paracetamol.
Infection (1%)
Fever or urinating pain/stinging could indicate an infection. If you experience this, please contact either Prof Lawrentschuk’s rooms, your local GP or visit your closest Emergency Department.
Blood in urine
Urine may appear pink or dark red. Please drink plenty of fluids and avoid physical activities like heavy lifting and cycling, especially if you notice blood in your urine. If bleeding is heavy or persistent please visit your local Emergency Department and tell them about your recent NanoKnife procedure.
Blood in semen
Although frightening, this is a normal side effect of focal therapy and will pass in 2-12 weeks (usually only a few weeks but may persist). It is not harmful to you or your partner.
Scar tissue (2–10%)
If you have not had radiation to the prostate or pelvis, the risk of a stricture (scar tissue) in the urethra (pipe you pass urine through) is low at around 2%.
However, if you already have scar tissue or you have had radiation, the risk is around 5-10%. Scar tissue within the prostate may also occur, particularly when focal therapy is conducted after radiation, necessitating scraping away in a small number of men (5-10%).
Allergic reactions
You may have allergic reactions to medication which you have been given. These are rare but if you are aware of any allergies please tell Prof Lawrentschuk before your procedure.
Other general risks
Other general risks of having a general anaesthetic and a procedure remain but are extremely low with focal therapy, such as deep vein thrombosis (DVT), bruising, chest infection etc.
Follow-up and monitoring
You will usually have a follow-up appointment scheduled with Prof Lawrentschuk for 6 months following your procedure. You will be given an MRI Prostate and PSA test to request 1–2 weeks prior to this appointment.
At the 12-month mark, you will then be scheduled for a routine repeat prostate biopsy. Prior to this procedure, you will be asked to complete a PSMA PET and PSA test.
If you have any queries, please use the contact details below:
MONDAY to FRDAY 8:30AM–4:00PM
Call the rooms at 9329 1197
AFTER HOURS
Contact Epworth Emergency on 03 9426 6666 or Royal Melbourne Emergency on 03 9342 7000.
You can also page Prof Lawrentschuk on 03 9387 1000.
For appointments and enquiries:
CONSULTING LOCATIONS
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