What is new in the diagnosis of prostate cancer?
Prostate cancer is the most frequently diagnosed tumor in Spanish men and the number of cases is expected to increase in the coming years. One out of every six men will develop prostate cancer during his lifetime. At present there is no ideal marker for diagnosing prostate cancer. Until a few years ago we only had PSA which has the disadvantage of rising with any prostate disease (infection, inflammation, benign hyperplasia or cancer) so that many men who undergo a prostate biopsy for elevated PSA will not show cancer but may nevertheless present complications (infection, bleeding, etc.). In 2009 we were the first to use PCA3 in our institutes, which is a marker that is studied in the urine of men and which is only elevated in those with prostate cancer. This test allows us to identify patients who will need a prostate biopsy, since men with PCA3 above 35 must undergo biopsy, while those with PCA3 below 35 are less likely to have cancer. Although PCA3 is superior to PSA in identifying patients with prostate cancer, up to 20% of cases with PCA3 below 35 will show prostate cancer in the future. Since 2009 we have performed PCA3 in 175 men with PSA greater than 4 so they had to undergo prostate biopsy. In 78 cases PCA3 was higher than 35 so biopsy was indicated while in 97 cases PCA3 was lower than 35 so biopsy was delayed. In the cases in which a biopsy was performed, 64% presented cancer or a premalignant lesion. Of the 97 cases with PCA3 lower than 35, cancer was found in only 5 cases (5%). PCA3 prevented biopsy in 37% of cases with elevated PSA.
What is new in the treatment of benign prostatic hyperplasia?
The recent appearance of the 200-watt Thullium laser has been of great significance in the treatment of benign prostate and associated diseases such as bladder lithiasis. The high power of this laser makes it the ideal treatment for patients with prostates larger than 150 cc as it greatly shortens surgery time. The 200 watt Thullium laser cuts with great efficiency and has a higher hemostasis power than the Holmium laser due to its lower absorption by the liquid used during the procedure, at the same time it also has a good vaporization rate in case vaporization is necessary. This system is the most recent technological innovation in laser systems for prostate surgeries and we have been using it in our centers since January 2013. The use of the Thullium laser with a frontal fiber allows us to perform a very novel technique, the vaporization of the prostate with which tissue fragments are obtained with which a biopsy can be performed, unlike the green laser that only performs the vaporization of the tissue without being able to perform the study of the same. This laser has allowed us to treat patients with very large prostates (the largest we have treated was 436 cc) with only 24 hours of hospitalization. With open surgery this patient should have been hospitalized for 5 to 7 days with a high probability of requiring blood transfusion. Videos of the procedure can be viewed on our websites (www.urovirtual.net and www.institutoep.com). Many patients with prostatic enlargement have bladder stones. The Thullium laser makes it possible to treat these stones at the same time as the prostate treatment, thus avoiding the need for open surgery. The same procedure is used to make small cuts in tissues such as urethral stricture or the removal of a small kidney tumor laparoscopically, which greatly reduces surgical bleeding.
What is new in the treatment of prostate cancer?
It has recently been shown that surgical treatments (open, laparoscopic or robotic surgery) offer the same results in terms of cancer control and side effects (impotence and incontinence). These results depend fundamentally on the experience of the surgeon. This means that a surgeon with experience in open surgery has the same results and complications as a surgeon with experience in laparoscopic surgery and a surgeon with experience in robotic surgery. However, when the costs are analyzed, robotic surgery is much more expensive than open or laparoscopic surgery. A recent meta-analysis study by Grimm showed that in patients with localized prostate cancer (low risk) the results of treatment with Iodine 125 brachytherapy are superior (higher cure rate) than those treated with surgery (open, laparoscopic or robotic). However, in terms of side effects, brachytherapy offers a much lower incidence of erectile dysfunction and absence of urinary incontinence. Admission is 12 hours and they can resume normal activities 24-48 hours after treatment.