Prostate Cancer: Fusion Biopsy and Focal Therapy

When PSA comes back elevated or an MRI shows a lesion, the next step does not have to be a blind biopsy or treatment of the entire prostate. A fusion biopsy finds the exact spot — and if the cancer is localized and you are a candidate, that area alone can be treated.

Image-guided diagnosis · Office-based, local anesthesia

Targeted, not blind

For years the prostate biopsy was taken by random sampling, and treating localized cancer meant operating on or irradiating the whole gland — even when the tumor occupied a small area. That exposes a man to risks of incontinence and erectile dysfunction that, in selected cases, can now be reduced.

Dr. Edward Gheiler, MD, FACS works with transperineal MRI/ultrasound fusion biopsy and with office-based focal ablation under local anesthesia. He is a co-author of published studies on both techniques, with reported follow-up at one and five years — references below.

The basics, in two minutes

How common is it?

Prostate cancer is one of the most common cancers in men. Risk rises with age and is higher with a family history or for men of African or Afro-Caribbean descent. Common does not mean aggressive: many cases are found localized and grow slowly.

Does it cause symptoms early?

Usually not. Early prostate cancer is typically silent, which is why it is found with PSA and examination rather than by how it feels. Urinary symptoms — weak stream, getting up at night, urgency — almost always come from an enlarged prostate (BPH), a separate and benign condition. When prostate cancer does cause symptoms (bone pain, blood in the urine or semen), it is usually more advanced. Waiting for symptoms is not a way to catch it early.

And after treatment?

Follow-up is by serial PSA and, depending on the case, repeat imaging and targeted biopsy. That follow-up is not optional — it is part of the treatment, because treating one area means the rest of the prostate is still there and has to be watched. If disease appears later, focal treatment does not close the door on other options, though not all of them are left equally simple: radiation generally remains viable after a focal ablation, while radical surgery can become more technically demanding, because fibrosis in treated tissue changes the surgical planes. How much that weighs depends on the ablation modality and on your anatomy, and it is part of the conversation before you decide.

How it works: diagnosis to treatment

1. MRI — the map. A multiparametric MRI of the prostate identifies suspicious areas and builds a detailed map of the gland. It is what makes it possible to stop searching blind.
2. Transperineal fusion mapping biopsy — the confirmation. The computer overlays the MRI map onto live ultrasound and aims cores at the suspicious spot — and, in the same sitting, takes systematic cores across the rest of the gland. Both halves matter: targeting alone can miss cancer the MRI did not show, and for focal therapy the systematic cores are what establish that the rest of the prostate is clear. It is taken through the perineum — through the skin, not the rectum — under local anesthesia in the office. Pathology confirms whether there is cancer, of what grade, and exactly where.
3. Focal treatment, if you are a candidate. If the cancer is localized and meets criteria, energy is applied only to the lesion, with the intent of sparing healthy tissue, urinary continence and sexual function. It is performed in the office and the patient goes home the same day.

Who this is for

Two different questions get mixed together here, so it is worth separating them: whether you need the diagnostic pathway, and whether you are a candidate for focal treatment. Nobody is a candidate for ablation before a biopsy confirms cancer.

Come in for the diagnostic pathway (MRI → mapping biopsy) if…

Your PSA is elevated, or rising, and you have no diagnosis yet
An MRI has shown a lesion that has not been sampled
You had a negative random biopsy but your PSA keeps climbing
You prefer an office procedure under local anesthesia, without hospitalization

Focal treatment may be an option if…

Biopsy has confirmed prostate cancer — focal therapy is never offered before that
The disease is localized and low- or intermediate-risk, with the lesion well identified on MRI, matched to the targeted cores, and the systematic mapping cores showing the rest of the gland clear
You want to weigh it honestly against surveillance, surgery and radiation rather than default to one

When it does not apply: high-risk, extensive or multifocal disease generally requires treating the whole gland or another approach. If that is your situation we say so plainly and coordinate the treatment that fits.

Published research

Dr. Gheiler is a co-author of these peer-reviewed publications on fusion biopsy and focal ablation:

Bianco FJ, Martínez-Salamanca JI, López-Prieto A, Gheiler EL, Shafizadeh F, Zachareas MJ, Pike S, Kaufman AM, Kaufman D, Egui-Benatuil G, Kattan MW. Natural History of Patients Undergoing Transperineal Fusion Biopsies to Transperineal Fusion Cryoablation: 5-Year Outcomes. Journal of Endourology. 2025;39(S2):S3–S12. doi:10.1089/end.2024.0864
Maiolino G, López-Prieto A, Egui-Benatuil G, Kaufman AM, Gheiler EL, Bianco FJ. Transperineal MR Fusion Laser Ablation of Prostate Cancer in Office Setting: 1-Year Efficacy and Safety Outcomes in Intermediate-Risk Patients. Journal of Endourology. 2025;39(S2):S13–S20. doi:10.1089/end.2024.0776
Luna E, López-Prieto A, Gheiler E, Kaufman A, Shafizadeh F, Zachareas M, Bianco F. MRI/US Fusion Guided Prostate Biopsy under Local Anesthesia: Transperineal approach. Urology Video Journal. 2020. doi:10.1016/j.urolvj.2020.100057

This page is patient education and does not provide a diagnosis or an individual treatment recommendation. Focal therapy is not appropriate for every patient and results vary by case. Discuss your situation with your urologist.

Frequently asked questions

What is a fusion prostate biopsy?

It is an image-guided mapping biopsy. An MRI of the prostate is taken first, then the computer overlays that map onto live ultrasound so cores can be aimed at the suspicious spot — and systematic cores are also taken across the rest of the gland in the same sitting, because targeting alone can miss cancer the MRI did not show. It is taken through the perineum — the skin between the scrotum and the anus — under local anesthesia in the office, rather than through the rectum.

What is focal therapy for prostate cancer?

Instead of removing or irradiating the whole prostate, focal therapy applies energy only to the area where cancer was confirmed, with the intent of sparing the surrounding healthy tissue. Not everyone is a candidate: it depends on the grade, location and extent of the tumor.

Does early prostate cancer cause symptoms?

Usually not. Early prostate cancer is typically silent, which is why it is found through PSA testing and examination rather than by how it feels. Urinary symptoms — weak stream, getting up at night, urgency — almost always come from an enlarged prostate (BPH), a different and benign condition. Waiting for symptoms is not a way to catch it early.

Am I a candidate for focal therapy?

It is generally considered for men with localized low- or intermediate-risk prostate cancer whose lesion is clearly identified on MRI, confirmed on targeted cores, and whose systematic mapping cores show the rest of the gland clear. Targeted cores alone do not establish candidacy — they confirm the lesion, not the absence of disease elsewhere. High-risk, extensive or multifocal disease usually needs treatment of the whole gland or another approach. Dr. Gheiler reviews your imaging and pathology and tells you plainly which options apply.

Does insurance cover the biopsy and the treatment?

These are two different questions. MRI and prostate biopsy, when medically indicated, are established studies. Focal treatment is different: some plans still classify it as investigational, coverage varies considerably, prior authorization is often required, and in some cases it is not covered. We will not tell you it is covered until we have verified it in writing with your plan — that happens before anything is scheduled, along with what your own cost would be. Ask us to verify your plan.

Elevated PSA, or an MRI with findings?

Request a consultation to review your studies and understand your options. English · Spanish. También en español: urofeliz.com.

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