In this episode, Dr. Geo sits down with Yale’s Dr. Preston Sprenkle to explore cutting-edge organ-sparing treatments—like IRE, cryoablation, and Tulsa Pro—that precisely target cancer while preserving urinary and sexual function. Learn how focal therapy is transforming prostate cancer care, who it’s best for, and what happens if it doesn’t work.
Focal Therapy in Prostate Cancer: Insights from Dr Preston Sprinkle and Dr Gio Espinosa
Introduction
Focal therapy has emerged as an appealing middle ground between active surveillance and whole-gland treatments for prostate cancer, promising cancer control with fewer side effects. In a recent Dr Gio Prostate Podcast, Dr Preston Sprinkle—urologic oncologist at Yale—outlined when, why, and how focal approaches can fit into modern care.
The Rise of Integrative & Holistic Urology
Twenty years ago, nutrition, exercise, and complementary practices were marginalized in urologic circles, yet today they are routinely blended with conventional management to support overall prostate health. Regular resistance exercise, for example, can counteract muscle loss from androgen-deprivation therapy and may exert anti-cancer effects through myokine release.
Active Surveillance for Low-Risk Disease
· Pure Gleason 6 (Grade Group 1) cancer rarely metastasizes, making surveillance the preferred initial strategy.
· Genomic assays can reveal higher-risk biology in some Gleason 6 tumors, prompting closer MRI-guided biopsy scheduling—often at 12 months instead of 24 months—while still deferring intervention [1].
· Missing scheduled PSA, MRI, or biopsy visits remains the chief danger; delayed follow-up may allow indolent lesions to progress unnoticed [1].
Selecting Intermediate-Risk Patients
· Gleason 7 (3 + 4 or 4 + 3) cancers are prime candidates for focal ablation when disease is organ-confined and away from critical structures [1].
· A 1 cm treatment margin around MRI-visible lesions lowers in-field recurrence without materially increasing functional harm, especially when only one neurovascular bundle is exposed [1].
· Patient priorities—continence, sexual function, and future salvage options—should guide the choice between hemi-ablation and larger “extended focal” templates [1].
Controversy in High-Risk Disease
· Guidelines discourage focal therapy for Gleason ≥ 8 cancers because occult micrometastases reach ~20 % even when PSMA-PET is negative [1].
· Dr Sprinkle counsels most young, high-risk patients toward radical prostatectomy with extended pelvic lymph-node dissection or combined-modality radiation and hormones, reserving ablation for select, low-volume cases within research protocols .
Technology Platforms
Platform | Energy Source | Best Anatomic Niche | Key Functional Advantages | Citation |
Irreversible Electroporation (IRE / NanoKnife) | Electrical pulses | Posterolateral peripheral lesions or lesions spanning urethra | Non-thermal; preserves collagenous frameworks and may allow nerve regeneration | |
Cryoablation | Argon-based freezing | Anterior prostate or peripheral zone when away from rectum | Real-time ice-ball visualization; >80 % potency when one bundle spared | |
Transurethral Ultrasound Ablation (TULSA-PRO) | MRI-guided directional HIFU | Whole-gland or multi-focal disease, including anterior tumors | Real-time thermometry, automated feedback, CPT-1 reimbursement expected 2026 | |
Transrectal HIFU | Focused ultrasound via rectum | Posterior lesions within 2–3 cm of probe | Outpatient procedure; long track record abroad |
Imaging & Planning
MRI fusion targeting has improved biopsy accuracy, yet inconspicuous satellite lesions remain possible, so most experts favor treating at least a hemi-gland rather than a “spot-weld” alone . Real-time MRI thermometry during TULSA offers the tightest temperature control, whereas ultrasound-guided IRE relies on cognitive or software fusion for needle placement .
Salvage Options After Ablation
Repeat focal ablation can address in-gland recurrence with minimal added morbidity, while radical prostatectomy remains feasible with continence outcomes comparable to primary surgery, though erectile recovery is modestly lower due to peri-neural fibrosis .
Quality-of-Life Trade-offs
· All prostate interventions risk transient or permanent erectile dysfunction and reduced ejaculate volume, yet focal techniques typically halve incontinence rates relative to whole-gland radiation or surgery [1].
· Shared decision-making, second opinions, and clarity about personal goals are essential before committing to any therapy [1].
Future Directions
Ongoing trials are testing focal therapy in selected high-risk tumors, integrating PSMA-PET for staging, and exploring multimodal combinations such as ablation followed by early salvage radiation if needed . Long-term data beyond ten years will ultimately define how these approaches influence metastasis-free and overall survival [1].
Conclusion
Focal therapy sits at the crossroads of oncologic control and functional preservation, and—as emphasized by Dr Sprinkle—it should be tailored to tumor biology, anatomy, and patient values rather than enthusiasm for any single device [1].
Dr. Sprenkle and Dr. Geo explore:
* When focal therapy (including IRE, cryoablation, Tulsa Pro) is the best option
* How to decide between surgery, radiation, and focal treatment
* What Gleason scores (6, 7, 8, 9+) actually mean for your treatment plan
* How PSMA PET scans and genomic testing guide smarter decisions
* What happens if focal therapy doesn’t work—and what your options are
* The future of prostate cancer care and why holistic urology is here to stay
Whether you're on active surveillance or exploring options after a diagnosis, this is a must-watch episode for any man serious about preserving quality of life while effectively treating prostate cancer.
Chapters
00:00 Introduction to the Dr. Geo Prostate Podcast
02:00 A Walk Down Memory Lane: Dr. Geo and Dr. Sprinkle's History
02:51 The Evolution of Holistic and Integrative Urology
04:24 The Importance of Physical Exercise in Prostate Cancer Care
05:40 Trust Issues and the Role of Urologists
07:17 Patient-Centered Approach to Prostate Cancer Treatment
11:49 Understanding Gleason Scores and Genomic Testing
18:57 Intermediate and High-Risk Prostate Cancer Treatments
19:09 Sponsor Message: Lynx DX Prostate Cancer Screening
20:25 Ablation Therapy for Intermediate and High-Risk Patients
24:56 Current Guidelines on Ablation Therapies
25:36 Challenges and Considerations in Ablation
26:23 Surgical Options Post-Ablation
27:08 Comparing Ablation to Radiation
28:21 Salvage Therapies After Ablation
30:08 Types of Focal Therapies
31:10 Technologies and Tools in Ablation
31:41 IRE and Its Benefits
35:58 Tulsa Pro: A New Frontier
38:44 Patient Considerations and Decision Making
48:16 The Future of Focal Ablation Therapies
49:10 Final Thoughts and Resources
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