Tailoring Treatment in Localized Prostate Cancer: Comparative Effectiveness of HIFU, Cryoablation, and Robot-Assisted Radical Prostatectomy at 2-Year Follow-Up: Insights from Prospective Institutional Cohort.

In the evolving landscape of localized prostate cancer management, focal therapies such as high-intensity focused ultrasound (HIFU) and prostate gland cryoablation (PGC) have emerged as organ-sparing alternatives for patients with low- to intermediate-risk disease. While these strategies aim to preserve functional outcomes, comparative data against robot-assisted radical prostatectomy (RARP) remain scarce and heterogeneous. We conducted a prospective, single-center study evaluating oncologic and functional outcomes in patients with organ-confined prostate cancer (Grade Group ≤ 2) treated with HIFU ( = 49), PGC ( = 114), or RARP ( = 109). Outcomes were assessed using standardized definitions at a median follow-up of 22 months. Treatment failure was defined according to EAU guidelines, and Kaplan-Meier analysis was applied to time-to-event outcomes. Focal therapy patients were older, more comorbid, and had lower baseline erectile function (each < 0.001). RARP was associated with the longest operative time but yielded the lowest complication rate (2.75% vs. 20.4% for HIFU and 31.5% for PGC; < 0.001). Catheter-related morbidity was disproportionately higher in the PGC group. RARP conferred a longer time to treatment failure ( < 0.001), although continence and potency recovery at follow-up were comparable across groups. Notably, erectile function returned earlier among HIFU patients. While focal therapies offer promising early functional results with minimal perioperative risk, they are associated with earlier treatment failure and higher catheter-related morbidity, particularly after cryoablation. These findings underscore the need for individualized treatment strategies guided by standardized, comparative outcome frameworks.