Directional compression improves procedural efficiency during focal therapy with high-intensity focused ultrasound for localized prostate cancer

Objectives High-intensity focused ultrasound (HIFU) has emerged as an important modality for focal therapy in localized prostate cancer (PC). However, intraoperative prostate swelling and displacement during HIFU can compromise the millimeter-level precision required for focal therapy. Therefore, we evaluated the clinical utility of a novel directional compression (DC) technique using a simple attachment designed to achieve efficient prostate-directed compression during transrectal HIFU. Methods A retrospective matched-cohort study of 120 patients who underwent focal therapy with HIFU for localized PC between 2022 and 2025 was conducted. Sixty consecutive patients treated with DC technique were matched 1:1 with patients treated with conventional compression based on prostate-specific antigen (PSA) level, Gleason score, T stage, and prostate volume. Procedural outcomes, magnetic resonance imaging (MRI) findings, PSA kinetics, and complications were compared between the groups. Results Baseline characteristics, PSA reduction , and nadir values were comparable in the groups. In contrast, the DC group showed significantly reduced treatment preparation time (3 vs. 5 min, p<0.001), initial water volume (31 vs. 100 mL, p<0.001), additional intraoperative water adjustments (9 vs. 40 mL, p<0.001), HIFU ablation time (16 vs. 19 min, p<0.001), total procedural time (20 vs. 28 min, p<0.001), and treatment interruptions caused by rectal gas release (0 vs 1, p<0.001) compared to that in the conventional group. Contrast-enhanced MRI revealed complete perfusion loss within the target area in all cases without rectal injury. Complication rates were low; urethral stricture occurred in 1.7% of patients in both groups, whereas transient external hemorrhoids were observed only with conventional compression. Conclusions DC technique significantly improves procedural efficiency and reduces technical complexity during focal therapy using HIFU without compromising oncological efficacy or safety. This technique may represent a practical adjunct for improving reproducibility and precision in focal therapy with HIFU for localized PC.