Sexual function outcomes in men undergoing minimal invasive ablative techniques for prostate cancer: a ESRU/YAU urotech systematic review and pooled analysis

INTRODUCTION: In the latest years the advent of minimally invasive focal treatment for prostate cancer (PCa) has gained a wide diffusion. Different platforms and sources of energy have been developed (HIFU, cryotherapy, focal brachytherapy...) and reported to be able to effectively treat PCa with minimal impact on sexual function. The aim of this systematic review is to summarize, evaluate and compare the impact of these focal therapies on the sexual function (erectile and ejaculatory function) of men harboring low to intermediate risk PCa. EVIDENCE ACQUISTION: A systematic literature search was conducted in October 2022 and updated in August 2024 using Medline (via PubMed), Embase (via Ovid), Scopus, and Web of Science (registered on PROSPERO as CRD42022370237). The search strategy used PICO criteria and article selection was conducted following the PRISMA guidelines. The risk of bias and the quality of the articles included were assessed. A dedicated data extraction form was used to collect the data of interest. EVIDENCE SYNTHESIS: Overall, our electronic search identified 4465 papers, 96 of which ultimately met the inclusion criteria and thus were included in the analysis. Among them, 87 were single arm studies, eight were comparative studies, whilst only 1 was a randomized prospective study. Overall, 6244 patients were evaluated (2318 HIFU, 2034 focal cryoablation, 1194 irreversible electroporation [IRE], 346 focal laser ablation [FLA], 147 high-dose brachytherapy [HDB], 247 Vascular photodynamic therapy [VPT], 21 focal microwave ablation [FMA], 151 low-dose brachytherapy [LDB], 10 focal bipolar radiofrequency ablation [FBRA] and 22 trans-urethral ultrasound ablation [TULSA]). The most reported measure of sexual function was IIEF-5, with baseline scores ranging from 16.2 (IRE) to 22.35 (VPT). At 12 months post-treatment, VPT and high-dose brachytherapy had the highest IIEF-5 scores (20.01 and 19.90, respectively), while cryotherapy, low-dose brachytherapy, and HIFU had the lowest (14.08, 14.94, and 15.40, respectively). Ejacula-tory function was underreported, with only two studies assessing its preservation after HIFU. Safety analysis showed an overall complication rate of 21%, with major complications occurring in 1.4% of cases. CONCLUSIONS: FT offers a promising balance between oncologic control and functional preservation in low-to inter-mediate-risk PCa. However, significant variability in FT modalities, ablation strategies (focal vs. hemigland vs. zonal), and outcome assessment methods limits direct comparisons. Future prospective studies with standardized protocols and long-term follow-up are essential to optimize patient selection and improve functional outcomes.