Achieving cancer control while preserving urinary continence and erectile function—the “trifecta”—remains the principal therapeutic goal in localized prostate cancer treatment. Focal therapy (FT) aims to minimize functional compromise relative to radical prostatectomy (RP), but comparative outcomes remain uncertain. This study evaluates oncologic and functional outcomes of RP and FT in a contemporary cohort.
A total of 767 men treated between 2018–2024 with RP (n = 672) or FT (n = 95) were retrospectively analyzed. We assessed functional outcomes using the Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP). The trifecta was defined as treatment-failure–free survival (TFFS) with both continence (0-1 pads/day) and potency (erections sufficient for sexual activity). TFFS was estimated using Kaplan–Meier analysis and compared with the log-rank test. Multivariable Cox proportional hazards modeling was adjusted for magnetic resonance imaging (MRI) extraprostatic extension (EPE), grade group, clinical T stage, pre-treatment prostate-specific antigen (PSA), and diabetes mellitus (DM).
nt, FT was independently associated with increased hazard of failure (hazard ratio [HR] 2.40, 95% confidence interval [CI] 1.20–5.10, p=0.014). MRI EPE (HR 1.54, p=0.0016), grade group ≥ 3 (HR ≥ 2.4, p<0.05), and higher PSA (p<0.001) were adverse predictors of TFFS. Continence recovery occurred in 75% of RP vs 78% of FT patients; potency recovery in 77% vs 87%, respectively. The trifecta was achieved in 616 of 765 patients (80.5%), including 563 of 671 RP (83.9%) and 53 of 94 FT (56.4%) (p<0.001). Conclusions: At 36 months, RP achieved significantly higher trifecta rates driven by superior oncologic control, despite lower functional recovery. FT demonstrated better preservation of continence and erectile function but was associated with higher treatment failure risk. These findings highlight the balance between cancer control and functional outcomes and underscore the importance of individualized treatment selection and close post-FT monitoring.
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