SoCal Focal socalfocal.com ·
Clinical Decision Support · V1.0

PROSTATE Score

Nephrometry-style scoring system to guide modality selection in prostate cancer focal therapy, based on tumor anatomy, zonal location, proximity to critical structures, and treatment zone feasibility.

ProFocal · © 2026
Decision aid — not medical advice
This tool is a structured decision aid intended to support clinician-patient discussion and inform referral pathways. It does not directly or explicitly provide medical advice, does not establish a clinician-patient relationship, and does not replace individualized assessment by a qualified urologist or interventional oncologist. Outputs are guidance only — final treatment decisions must be made through multidisciplinary review and informed shared decision-making with a treating clinician.
About Focal Therapy & Shared Decision Making
Modality overview · Treatment tradeoffs · Evidence base
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⚖ Shared Decision Making — Understanding Your Options

For localized prostate cancer, robotic-assisted radical prostatectomy (RARP) and radiotherapy (EBRT / brachytherapy) remain the gold standard treatments with the longest evidence base for oncologic control. Both offer well-established cure rates and are endorsed by all major guidelines (EAU, AUA, NCCN).

Focal therapy is an emerging, minimally invasive alternative that targets only the index lesion rather than the whole gland. It aims to achieve oncologic control whilst preserving urinary continence, erectile function, and quality of life to a greater degree than whole-gland treatments. However, it is not yet a guideline-endorsed standard of care and patients must understand the following tradeoffs before proceeding.

✓ Potential Advantages
· Preservation of erectile function and continence
· Shorter recovery time, often day-case procedure
· Retreatment possible if cancer recurs
· Radical therapy (surgery/radiation) remains available
· Reduced impact on quality of life
⚠ Tradeoffs & Limitations
· More intensive surveillance required post-treatment
· PSA monitoring, repeat MRI, and follow-up biopsies
· Risk of residual or recurrent cancer in untreated areas
· Potential need for further therapy in future
· Less long-term outcome data than surgery/radiation
· Requires specialist center with MRI fusion capability
Focal Therapy Modalities
HIFU procedure
HIFU
High Intensity Focused Ultrasound
A transrectal probe focuses high-energy ultrasound waves to a precise focal point within the prostate, generating temperatures exceeding 80°C and causing coagulative necrosis. The Focal One® and Sonablate® devices allow real-time MRI-ultrasound fusion targeting. Treatment is performed under general or spinal anaesthesia as a day-case procedure.
Thermal Transrectal Day-case No ionizing radiation Retreatable
Cryotherapy procedure
Cryotherapy
Cryoablation / Partial Gland Ablation
Argon gas–cooled cryoneedles are placed transperineally under ultrasound guidance into the target zone. Repeated freeze-thaw cycles to −40°C destroy tissue through ice crystal formation and vascular disruption. The iceball is monitored in real time. Urethral warming is used to protect the urethra during treatment.
Cryo-ablation Transperineal Ultrasound-guided Argon gas Retreatable
TULSA-PRO procedure
TULSA-PRO
Transurethral Ultrasound Ablation
A directional ultrasound applicator is placed within the prostatic urethra and rotated to deliver precisely shaped thermal ablation outward from the center of the gland. Treatment is performed entirely within the MRI bore, allowing real-time MR thermometry to guide and confirm ablation boundaries. The ECD (endorectal cooling device) protects the rectal wall.
Thermal Transurethral MRI-guided Real-time thermometry MR suite required
IRE NanoKnife procedure
IRE
Irreversible Electroporation (NanoKnife®)
Multiple transperineal electrodes deliver high-voltage, ultra-short electrical pulses that permanently disrupt cell membrane integrity, causing non-thermal cell death. Because the mechanism is electrical rather than thermal, critical structures including the neurovascular bundles, urethra, and rectum are relatively preserved. Requires general anaesthesia with full neuromuscular blockade.
Non-thermal Transperineal NVB-sparing GA + paralysis Retreatable
📈 Evidence: Focal Therapy vs Surveillance — Freedom from Radical Therapy
Martin SC, Gonzalez S, Kwan L et al. · J Urol 2025;214(2):177–187 · Senior author: Leonard S. Marks MD, UCLA
0.0 0.2 0.4 0.5 0.6 0.8 1.0 RP/RT-free Survival Probability 0 1 2 3 4 5 6 7 8 9 10 11 Years from Focal Therapy Eligibility FT No FT *P <0.01 At risk 271 125 71 29 8 4 99 55 23 11 1 0 Focal Therapy (FT, n=99) No Focal Therapy (n=271) RP/RT-FREE SURVIVAL — RECONSTRUCTED FROM MARTIN ET AL. / MARKS, J UROL 2025 NoFT FT
SVG reconstruction based on published figure — not a reproduction. For exact data refer to the original article (PMID 40257918).
Key Findings
~71%
of focal therapy patients remained RP/RT-free at 11 years
~39%
of surveillance-only patients remained RP/RT-free at 11 years
P <0.01
Log-rank test. Median survival of No FT group crossed 0.5 at ~3.5 years (dashed line)
Study Context
Single-center UCLA cohort. FT group n=99; No FT group n=271. All patients had baseline MRI-guided biopsy showing low- to intermediate-risk prostate cancer. Focal therapy offered from 2016 for higher-risk or progressing cancers. Authors note specialist-center limitation.
0
/ 50 pts
—
HIFU
—
Cryo
—
TULSA-PRO
—
IRE
—
Interactive Anatomic Map
Click to place tumor location(s) · Auto-populates T & O scores
▼
Click on the prostate to mark tumor location(s) · Drop a T2 axial DICOM below
T2 Axial MRI
W:— C:—
Axial View — Mid-Gland · Click to Place Tumors
ANTERIOR POSTERIOR Urethra NVB NVB Rectum PZ TZ TZ R L APICAL PLANE d EUS <5mm +3 5–10 +2 >10mm +1 EUS — External Urethral Sphincter AXIAL · MID-GLAND · CLICK TO PLACE
🔬 Pathology Core Map — 12-Core Systematic + Targeted
▶
Enter each core result. Positive cores will appear on both axial and sagittal maps.
Neg = Negative   GG1–5 = Grade Group of that core
Left
Right
Base Lateral
Base Medial
Mid Lateral
Mid Medial
Apex Lateral
Apex Medial
Targeted (MRI-Fusion) Cores
Sagittal View — Click to Set Craniocaudal Location
SAGITTAL · LEFT PARAMEDIAN · CLICK TO PLACE Bladder Seminal Vesicle Urethra ANT POST Base Apex BASE MID APEX EUS dEUS <5 5-10 >10 Rectum NVB PZ TZ
Peripheral Zone (PZ)
Transition Zone (TZ)
Prostatic Urethra
Neurovascular Bundle (NVB)
External Urethral Sphincter (EUS) — dEUS measured from inferior lesion margin to proximal sphincter border on sagittal MRI
Ant / Post Equator
Seminal Vesicle (SV)
Axial view is a schematic cross-section at mid-gland level. NVBs depicted at posterolateral 5 & 7 o'clock positions. Sagittal view shows left paramedian plane rotated so base is left, apex is right. Not to scale.
⊙
Imaging Characterization
mpMRI visibility · PI-RADS assessment
—
▼
Imaging characterization is a clinical pre-requisite for focal therapy and does not contribute to the anatomical complexity score. Findings here inform eligibility, targeting confidence, and disease extent — and generate clinical flag alerts.
mpMRI — Lesion Visibility
MRI should be obtained prior to focal therapy. While an MRI visible lesion is not a pre-requisite for focal therapy it can assist the clinician in treatment planning.
Yes — MRI-visible lesion confirmed
PI-RADS ≥ 3 lesion identified on mpMRI · Target defined for fusion biopsy and treatment planning
✓
No — No MRI-visible lesion
Lesion not visible on mpMRI · Focal therapy may still be feasible based on biopsy mapping and clinical context · Discuss treatment planning at MDT
✕
Not yet performed / pending
mpMRI not yet available · Recommended prior to focal therapy planning to assist with target definition and treatment design
—
⚡
◎
Treatment Margin Planning
Ablation margin · Modality-specific margin feasibility
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▼
Treatment margin is the additional tissue ablated beyond the visible tumor boundary to account for microscopic extension and targeting uncertainty. A wider margin improves oncologic control but increases collateral injury risk to the urethra, NVBs, EUS, and rectum. Margin selection must be reconciled against the proximity scores in the P+S and R domains above.
Intended Ablation Margin Beyond Index Lesion
Select the planned isotropic margin around the visible MRI lesion. Margin should be chosen before considering proximity constraints — the P+S and R scores then indicate where full margin delivery is compromised.
Margin not yet defined
Treatment planning not initiated · Margin to be determined at MDT or pre-procedure planning session
—
Targeted / Zero margin — Lesion boundary only
Ablation confined to visible MRI lesion · Highest functional preservation · Highest risk of marginal miss · Typically reserved for lesions immediately adjacent to critical structures
0 mm
Narrow margin — 5 mm
Standard minimum margin for focal ablation · Balances oncologic safety with functional preservation · May be appropriate near NVB, urethra, or EUS
5 mm
Standard margin — 10 mm
Preferred oncologic margin for intermediate-risk disease · Greater confidence in microscopic extension coverage · Increased proximity risk near critical structures
10 mm
Wide margin — 15 mm or hemi-gland
Extended coverage for higher-risk lesions, multifocal disease, or unfavorable intermediate risk · Approaches hemi-gland ablation territory · Significant proximity implications for urethra and contralateral NVB
15 mm+
T
Tumor Zone, Side & Size
Prostate zone · Laterality · Lesion diameter
0 pts
▼
Prostate Zone (affects heat/cold delivery)
Peripheral Zone
+2
Transition Zone
+3
Tumor Laterality
Unilateral
+1
Bilateral
+2
Lesion Diameter (largest dimension on mpMRI)
Maximum index lesion diameter on T2-weighted or DCE mpMRI. Larger lesions raise marginal-miss risk and disadvantage focal therapy in a modality-specific way: Cryotherapy and TULSA-PRO handle larger volumes relatively well; HIFU treatment time scales with size; IRE electrode geometry degrades with larger targets.
≤ 5 mm — Very small lesion
Maximally favorable for focal therapy · Reliable margin coverage achievable across all modalities · Minimal marginal-miss risk
+0
5–10 mm — Small lesion
Favorable for focal therapy across all modalities · Adequate margins readily achievable
+1
10–15 mm — Moderate lesion
Typical PI-RADS 4 territory · Modest disadvantage to all modalities · Plan ablation margins carefully
+2
> 15 mm — Large lesion
PI-RADS 5 territory · Focal therapy is questionable but not excluded · Cryo / TULSA preferred · Consider hemi-gland or whole-gland alternatives at MDT
+3
O
Tumor Orientation
Anterior vs posterior · Craniocaudal location
0 pts
▼
Anterior vs Posterior
Posterior
+1
Anterior
+2
Vertical Location (Craniocaudal)
Base / Mid
+1
Apex
+2
Spanning Base–Apex
+3
P+S
Proximity to Critical Structures
EUS · NVB
0 pts
▼
Distance to External Urethral Sphincter (EUS) — Apex to Sphincter
dEUS is measured on sagittal MRI from the inferior margin of the index lesion (or ablation zone far edge) to the proximal border of the striated urethral sphincter. See Anatomic Reference Map above for diagram. Sphincter injury risks permanent stress urinary incontinence — the most feared functional complication of apical focal therapy.
> 10 mm — Safe distance
Full margin delivery achievable at apex · Sphincter preservation expected · See green zone on diagram
+1
5–10 mm — Borderline
Margin must be trimmed at apex · TULSA periurethral thermal effect critical · Intraoperative US monitoring mandatory · See amber zone on diagram
+2
< 5 mm — High risk
Sphincter in ablation field · SUI risk high · Zero-margin or ablation modification essential · Consider alternative approach · See red zone on diagram
+3
Neurovascular Bundle (NVB) Proximity
> 5 mm
+1
≤ 5 mm
+2
Abutting / Involving NVB
+3
Rectal Wall Proximity (posterior margin)
Distance from posterior tumor margin to anterior rectal wall on axial mpMRI. Recto-urethral or recto-prostatic fistula is the most catastrophic complication of focal therapy — risk rises sharply with proximity, particularly for thermal modalities (HIFU, Cryo, TULSA). IRE preserves rectal architecture due to its non-thermal mechanism.
> 10 mm — Safe distance
Generous posterior margin · All modalities feasible · Rectal injury risk minimal
+1
4–10 mm — Borderline
Margin trimming required · Endorectal cooling mandatory for thermal modalities · Cryo posterior iceball must be limited
+2
< 4 mm — High fistula risk
Fistula risk substantial for thermal modalities · Cryo penalized heavily · IRE strongly preferred for non-thermal preservation of rectal wall
+3
R
Radius from Urethra
Minimum distance from prostatic urethra
0 pts
▼
Minimum Distance from Prostatic Urethra
> 10 mm
+1
5–10 mm
+2
< 5 mm or Periurethral
+3
GG
Gleason Grade Group
Index lesion grade · Positive cores · % Pattern 4
0 pts
▼
Grade Group (Index / Dominant Lesion)
Grade Group 1 Gleason 3+3=6
Low risk · Ideal focal candidate
+1
Grade Group 2 Gleason 3+4=7
Favorable intermediate risk · Established focal indication
+2
Grade Group 3 Gleason 4+3=7
Unfavorable intermediate risk · Focal with caution
+3
Grade Group 4 Gleason 4+5 / 5+4=9
High risk · Selective focal, MDT required
+4
Grade Group 5 Gleason 5+5=10
Very high risk · Focal therapy generally not indicated
+5
AE
Anatomic Extent
Gland volume · Extracapsular extension / SVI
0 pts
▼
Prostate Gland Volume (mpMRI volumetry)
Whole-gland volume measured on T2-weighted MRI (ellipsoid formula or planimetry). Gland size affects modality selection in opposite directions: small glands favor HIFU (optimal focal depth); large glands favor Cryotherapy and TULSA-PRO (more parenchymal depth, BPH co-management option). For glands >60cc, adjunctive TURP is a documented mitigation strategy — see flag panel.
< 40 cc — Small gland
Optimal for HIFU · Focal depth feasibility maximized · All modalities feasible
+1
40–60 cc — Moderate gland
Acceptable for all modalities · TULSA / Cryo modest advantage · HIFU still feasible if focal depth <40mm
+2
> 60 cc — Large gland
Disadvantages HIFU (focal depth) · Modest IRE penalty · Cryo / TULSA preferred · Consider adjunctive TURP for HIFU/Cryo planning
+3
Extracapsular Extension / Seminal Vesicle Invasion
Assessment of capsular contact, ECE (T3a), and seminal vesicle invasion (T3b) on mpMRI and pathology. Confirmed SVI is generally a contraindication to focal therapy. Suspected ECE requires expanded margin planning and increases recurrence risk.
Organ-confined — No ECE
No capsular bulge or breach on MRI · Tumor confined within prostate capsule · Standard focal therapy candidate
+1
Suspected ECE (T3a)
Capsular abutment / bulge / focal breach on MRI · Wider ablation margin required · Discuss oncologic risk · Cribriform pattern check important
+2
Confirmed SVI (T3b)
Seminal vesicle invasion · Focal therapy generally NOT indicated · Whole-gland or systemic therapy at MDT review
+3
Cx
Access & Complexity Modifiers
Urethral architecture · HIFU focal depth · Pubic arch · Calcifications/seeds
0 pts
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Urethral Architecture
Status of the prostatic urethra. Stricture or prior TURP precludes TULSA-PRO (compromised applicator placement and altered MR thermometry baseline). Mild deviation from BPH or cysts is informational only.
Normal — Intact urethral architecture
No prior instrumentation · Standard urethral anatomy · All modalities feasible
0
Deviated — BPH / cyst distortion
Median lobe / cyst / BPH adenoma deflecting urethra · Informational · TULSA still feasible with adjusted planning
+1
Stricture / Prior TURP
Compromised urethral architecture · TULSA-PRO contraindicated · HIFU/Cryo/IRE remain feasible
+2
HIFU Focal Depth (rectum-to-far-margin distance)
Measured on sagittal mpMRI from the rectal mucosa to the far edge of the planned ablation zone. The Focal One / Sonablate device focal beam is limited to 40 mm — distances beyond this cannot be ablated by HIFU and trigger a hard exclusion. This field affects HIFU only.
< 30 mm — Comfortable depth
Well within focal beam range · No HIFU penalty
0
30–35 mm — Borderline
Approaching focal depth limit · HIFU treatment planning needs careful margin trim
+1
35–40 mm — Near limit
Severe HIFU penalty · Marginal coverage at risk · Consider alternative modality
+2
> 40 mm — Beyond focal beam
HARD EXCLUSION for HIFU · HIFU score forced to zero · Use Cryo / TULSA / IRE
+3
Pubic Arch Interference (transperineal access)
Pubic arch interference assesses the angle and depth of the pubic symphysis relative to the prostate apex. Significant interference impairs transperineal needle / probe access for HIFU, Cryotherapy, and TULSA-PRO. IRE is comparatively unaffected (can adjust electrode positioning). Assess on axial mpMRI at apex level.
None — Wide pelvic outlet
No access concerns · Standard procedural planning
0
Mild — Minor interference
Anterior apex slightly obscured · Minor adjustment to needle / probe trajectory
+1
Moderate — Significant interference
Anterior apex coverage compromised for HIFU / Cryo / TULSA · IRE positioning advantage
+2
Severe — Major access blockade
Anterior apex inaccessible · IRE strongly preferred · HIFU / Cryo / TULSA may be unable to deliver adequate margin
+3
Intraprostatic Calcifications / Brachytherapy Seeds
Calcifications and brachytherapy seeds reflect ultrasound (HIFU acoustic shadowing) and disrupt MR thermometry (TULSA-PRO). Cryotherapy is mildly affected at high burden. IRE (non-thermal electrical field) is unaffected and is the preferred modality at high calcification or seed density.
None — Clean parenchyma
No calcifications or seeds · All modalities feasible
0
Scattered — Few foci
Modest HIFU acoustic shadow · Mild TULSA thermometry disruption · Cryo / IRE unaffected
+1
Moderate — Multifocal calcifications
Significant HIFU and TULSA penalties · Cryo modestly affected · IRE preferred if dense in target zone
+2
Dense — Confluent calcifications or seed-bearing
HIFU and TULSA functionally impaired · IRE strongly preferred (unaffected by calcifications/seeds)
+3
Important Disclaimer This tool is intended as a clinical decision support aid only and does not replace individualized patient assessment, multidisciplinary team review, or the clinical judgment of an experienced urologist or interventional oncologist. Modality selection must incorporate PSA, biopsy grade, MRI quality, patient comorbidities, and institutional expertise. Score thresholds are based on expert consensus principles analogous to the RENAL nephrometry framework and should be validated prospectively before use in clinical protocols.
Want to learn more about focal therapy?
SoCal Focal · Educational resource on prostate cancer focal therapy
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