Hemigland cryoablation versus high-intensity focused ultrasound for localized prostate cancer: a propensity-weighted comparison of functional and oncologic outcomes.

BACKGROUND: Whether cryoablation and high-intensity focused ultrasound (HIFU) provide distinct advantages in hemigland ablation for localized prostate cancer (PCa) is unresolved. METHODS: A prospective FT-PCa registry (2021–2025) was analysed, identifying 258 men treated with hemigland ablation (cryoablation n = 179; HIFU n = 79). Baseline differences were addressed through inverse-probability-of-treatment weighting based on age, PSA, PSA density, ISUP, PI-RADS, lesion size, % of positive cores and prostate volume. Weighted Kaplan–Meier estimators, log-rank tests and Cox models were used for time-to-event outcomes; perioperative and functional variables were compared using design-based t-tests and Rao–Scott χ² tests. Primary endpoints were failure-free survival (FFS) and biochemical failure-free survival (BFS). A subgroup analysis excluding low-risk disease was additionally performed. RESULTS: Weighting achieved excellent covariate balance (all standardized mean differences < 0.10). Perioperative outcomes were similar, including operative time (p = 0.41) and complications (p = 0.49). At 12 months, continence (97.9% vs. 97.7%; p = 0.94), spontaneous potency (41.2% vs. 36.5%; p = 0.41), overall potency (49.4% vs. 45.4%; p = 0.48), IIEF-5 (p = 0.48) and preservation indices (p > 0.7) were comparable. IPSS scores showed no significant difference after weighting (p = 0.54). At 24 months, FFS (89.3% vs. 87.8%; weighted log-rank p = 0.66) and BFS (87.9% vs. 85.6%; weighted log-rank p = 0.79) showed no significant differences, and Cox models revealed no independent hazard signal. Cancer-specific, metastasis-free and overall survival each exceeded 95% (all p > 0.7). Findings were unchanged after excluding low-risk patients. CONCLUSIONS: In this propensity-weighted comparison of hemigland FT, cryoablation and HIFU yielded comparable outcomes. When case-mix is balanced, energy modality exerts minimal influence on short-term cancer control or functional recovery.