Identifying the ideal candidate for irreversible electroporation in localized prostate cancer: a comprehensive narrative review from the EAU Section of Endourology

Vollständiger Abstract

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Background and Objective Irreversible electroporation (IRE) is an emerging non‐thermal focal therapy for localized prostate cancer (PCa), offering tissue‐selective ablation with functional preservation. This review aimed to delineate the ‘ideal’ candidate for primary IRE and provide practical guidance. Methods A narrative review (2014–2025) of primary IRE for localized PCa was conducted, including prospective series, multicentre registries, comparative studies, and systematic reviews. We synthesized baseline characteristics, lesion features, ablation strategy, oncologic/functional outcomes, and complications, focusing on cancer control and safety. Results The best outcomes were reported in men with magnetic resonance imaging–visible, organ‐confined intermediate‐risk (International Society for Urological Pathology [ISUP] 2–3) PCa, typically presenting a single dominant unilateral index lesion characterized by multiparametric MRI and biopsy. Contemporary series show in‐field ablation of clinically significant cancer in ~80–90% with high functional preservation. The main limitation is out‐of‐field recurrence (~15–25% of failures), reflecting PCa multifocality. In‐field persistence at 12 months was ~16% in the PRESERVE trial. Lesion size is a key practical constraint; current evidence and electrode geometry favour targets generally ≤20 mm. Limited comparative evidence, largely from a single study, suggests better oncologic control with hemi‐gland IRE (clinically significant PCa persistence 8.6%) versus focal ablation (25%), whereas focal IRE better preserves erectile function. Conclusions and Clinical Implications Primary IRE appears safe and effective in selected localized PCa. The ideal candidate has unilateral MRI‐visible, organ‐confined ISUP 2–3 disease, prostate‐specific antigen density