Focal therapy versus radical prostatectomy: a propensity score-matched comparison of failure-free survival

Abstract Introduction Focal therapy aims to treat clinically significant localized prostate cancer while preserving uninvolved tissue and adjacent structures, but direct comparisons with radical prostatectomy remain limited. The objective of this study was to compare failure-free survival (FFS) between patients undergoing focal cryotherapy or irreversible electroporation and those undergoing radical prostatectomy. Materials and Methods We retrospectively identified 274 focal-therapy and 2,000 prostatectomy patients treated in 2014–2026. Maximum-cardinality 1:1 matching used exact grade-group, calendar-period, and magnetic-resonance-imaging-stage strata plus propensity-score caliper, age, and balance restrictions. Among prespecified covariates, the maximum absolute standardized mean difference was 0.083 in 207 pairs. FFS was time to active treatment outside the index strategy or metastatic progression. Any adjuvant or salvage treatment after prostatectomy counted as failure; repeat focal ablation did not. Kaplan-Meier and pair-clustered robust Cox models were used. Results Median follow-up was 38.1 months (IQR 14.2–69.0) after focal therapy and 32.6 months (IQR 13.7–60.0) after prostatectomy. There were 39 versus 17 failures, including 37 versus 16 active post-index treatments and 2 versus 1 metastatic progression before treatment. Three-year FFS was 89% versus 92%; 5-year FFS was 79% versus 88%, (95% confidence interval [CI] − 19 to 0.2). The primary model favored prostatectomy (HR 1.99, 95% CI 1.13–3.51; p = 0.017). Conclusions Focal therapy had a higher rate of failure in the primary analysis. Nevertheless, approximately four in five focal-therapy patients remained free of radical treatment or metastasis at 5 years.