Marieke van Son

179 GENERAL DISCUSSION AND FUTURE PERSPECTIVES radical salvage therapy may be offered. A large cohort of patients (n=82) undergoing salvage prostatectomy after focal therapy (HIFU or cryotherapy) showed no increase in toxicity when compared to surgery in the primary treatment setting. The oncological effectiveness of salvage treatment depends on the nature of the recurrent lesion: if the recurrence is within the previously treated field, the oncological prognosis seems to be worse as these lesions seem to harbor more aggressive disease(18). Which patients should be offered primary focal therapy remains subject of debate. Due to the difficulty of accurately localizing significant cancer within the prostate gland, tissue-sparing techniques have been difficult to develop. The wide-spread adoption of mp-MRI has largely improved our radiological assessment, and mapping biopsy tech- niques are available to overcome remaining uncertainties. Together, imaging and pa- thology characteristics are vital in determining the significance of prostate cancer being found. In a histological study of 100 consecutive radical prostatectomy specimens, primary tumors were often multifocal (78%) and bilateral (86%), but satellite foci (small- er lesions besides the “index lesion”), were mostly <0.5 cm 3 (87%), usually with ISUP grade 1 (99.4%), indicating non-aggressive disease which may be left untreated(19). Translation into clinic The current position of the EAU is that the lack of high-level evidence does not allow the use of primary focal therapy outside the context of clinical trials(20). In the Neth- erlands, this is currently limited to three clinical centers (st. Antonius, Amsterdam UMC and Radboud) investigating focal IRE or FLA. In terms of patient selection, focal therapy is not an alternative to active surveillance in low ‐ risk men. It should be offered to men with localized, clinically significant cancer without high-risk disease characteristics such as PSA >20 ng/ml or ISUP grade 4-5. Awaiting long-term oncological effective- ness data, it now seems most suitable to men who place greater value on maintaining genitourinary function than certainty over long ‐ term disease control. 10