Prostate MRI is becoming more and more important in the diagnosis and management of prostate cancer. It is important, however, to interpret an MRI correctly and use the information in conjunction with other data such as your PSA and other risk factors for prostate cancer. MRI can be used in the initial diagnosis of cancer but is also used when following men with cancer who do not require treatment immediately after diagnosis ie – in active surveillance. In these men, changes in the MRI appearance of the prostate over time may indicate change or progression in their cancer which may result in a repeat biopsy or even a decision to treat the cancer sooner rather than continue with observation.
It is important to understand what the MRI scan can detect. It will not show all cancers and in fact generally only shows more aggressive, high grade tumours. This means it will not detect low grade, slow growing cancers. This is generally a good thing as it is these non- aggressive cancers that may well not require treatment soon, or in fact ever. They can generally be observed over time and treated if there is suspicion of progression.
If a suspicious lesion is identified on an MRI scan, it will be graded according to the likelihood that it represents a significant cancer. This is called the PIRADS score. A PIRADS score of 4 or 5 indicates a high suspicion of significant disease that will likely require treatment. A lesion with a score of PIRADS 3 has about a 50:50 chance of significant disease.
If a suspicious lesion is identified, it can be targeted specifically at the time of biopsy by a technique called MRI fusion biopsy. This technique fuses the MRI image with the ultrasound image used when performing biopsy to allow us to more accurately biopsy the abnormal area.
MRI also gives the Urologist information about whether or not a cancer has extended beyond the capsule of the prostate which helps to plan the surgery more carefully. This can have implications if nerve sparing surgery in being contemplated. It may also detect enlarged lymph nodes near the prostate that may indicate spread of disease.
There are several new techniques becoming available for men with enlarged prostates that cause a blockage to the flow of urine. If medical therapy fails, or is not suitable, men may need to consider surgery. Some surgical techniques cause side effects that some patients may wish to avoid, such as retrograde, or dry ejaculation.
Some of the newer techniques such as Urolift and REZUM have a reported lower risk of these side effects. They are also less invasive and often have a shorter length of stay in hospital. They do, however, benefit many men but as they are relatively new, long term outcome data is not yet readily available.
These techniques may not be suitable for all men and careful evaluation is required to determine if they would be useful in your specific situation. You should not compromise your treatment because you want something new or novel, or because your Urologist pushes you to have a procedure that is new.
Remember also that being told by a surgeon that he or she is the first to do something, or the best at something, does not necessarily mean you are getting the best treatment. You should be confident that you understand the procedure and are happy with the possible side effects and likely outcomes.
It is becoming more and more evident that not all men diagnosed with prostate cancer need treatment. There is no doubt that in the past many men were treated for cancers that would almost certainly not have killed them and may well have never caused them any problems. It is very difficult however to decide which cancers may become more aggressive and which will not.
More recently there has become a very well defined set of parameters relating to prostate cancer that would indicate a very low likelihood of any future problems associated with the cancer. Some of these indicators include a low Gleason grade of cancer as well as a low volume of the cancer detected on biopsy. These are generally the cancers that are not detected on MRI scanning which only adds somewhat to the degree of confusion about the investigations for prostate cancer.
In very general terms, low grade, low volume prostate cancers would not require treatment, and certainly not urgent treatment. In fact, there are only very few prostate cancers that ever require urgent treatment of any type and in most cases there is ample time to discuss at length various treatment options with your Urologist. If often takes men with low grade, low volume prostate cancer a long time to understand that they may not in fact require treatment despite a diagnosis of cancer. We know that prostate cancers usually do not behave like other cancers and grow very slowly. Of course there is no guarantee that a low grade, low volume cancer will not progress and careful monitoring is obviously required and again there are many programs and regimens that we use to ensure we do not miss the boat if a cancer does progress.
It seems that the more knowledge and understanding we have about prostate cancer, the more questions are raised about the best way to manage it. Many new treatments that you may read about in the press are generally not available as routine therapies but are more investigational and are being used only in the setting of a clinical trial. The main stay of treatment for prostate cancer, should it require treatment, is still surgery or radiotherapy. Active surveillance is however also being used more and more often and a man should never fell that he is being rushed into treatment.
Many patients are found to have incidental stones in their kidneys that have never caused problems and such patients may never have known that they have had stones in their kidney. There is then the dilemma of whether or not to treat these stones that may have present for years with no one being any the wiser. Of course stones left untreated may well get bigger and can be associated with bleeding or infection. The most significant issue however, is if the stone moves and causes a blockage to the flow of urine. There is generally acute pain and treatment becomes urgent if not an emergency in some situations. Of course it is entirely unpredictable as to when a stone will move and cause a problem, or if in fact it will get bigger in a relatively short or longer period of time.
With modern methods of stone treatment, patients suffer few side effects although many people who have had stones in the past will know that stents to protect the kidney can be uncomfortable. This discomfort however is usually nowhere near as severe as the pain from an acute blockage to the kidney. For patients who travel frequently, or find it very difficult to take time off work, especially at short notice, treatment of incidentally identified stones should be seriously considered. This of course depends on the size of the stone and stones less than 3-4mm can generally be watched quite safely. Should a very small stone drop into the ureter it would have a very high chance of passing spontaneously without the need for intervention. In general terms it is good to maintain a good fluid intake. There is really no correct of amount of fluid to drink but you should ensure that your urine is always a light lemon colour. Obviously the more you drink, the more urine you pass, and drinking too much fluid may well interfere with your quality of life if you are up many times at night to pass excessive amounts of urine.
Once you have been diagnosed with stones there are some basic tests you can perform to look for an underlying cause for your stone disease. Apart from maintaining a good fluid intake, a general balanced healthy diet avoiding excess intake of foods known to have a high oxalate content is reasonable. Added salt to the diet should also be kept to a minimum. If a specific abnormality is identified in the tests, more specific treatment may be necessary. All of these issues can be discussed with your urologist.
Many patients see their urologist because they have either seen blood in their urine or have been told they have microscopic levels of blood in the urine when tested by their local doctor. It is never normal to have any blood cells in the urine but of course it is extremely common and in most cases there is no treatable cause identified. Whether you see the blood or not, or whether there is only one episode or more, blood in the urine always needs to be further investigated with some simple tests to be sure that there is no sinister underlying cause. Many patients feel that they may only have seen blood once and as it does not happen again they feel whatever the cause they are no longer at risk. This is definitely not the case as a bladder cancer, for example, may bleed once but may not bleed again for some time and if the diagnosis is missed, the cancer will obviously grow and potentially be more difficult to treat in the future.
Depending on your age, even microscopic blood in the urine can indicate the presence of an underlying cancer in the bladder or the kidney and again simple tests will help to determine if this is the case. Cancer is obviously in no way the most common underlying problem and in men bleeding is often related to kidney stones or an enlarged prostate and in women it is often related to infection or stones as well. Many cases of microscopic bleeding are related to a simple leakage of red blood cells through the filters in the kidney that therefore appear in the urine.
It is always prudent to seek specialist advice if blood is found in your urine and in most cases there would probably not be a significant underlying cause.
We have been providing dedicated care to our patients at St Vincent’s and Sydney’s inner and outer west since 2000.