Description
Dr Miñana, from Spain, talks about Focal Therapy, but more specilfically , the importance of fusion system and MRI images in the treatment of Prostate Cancer.
Let's talk about:
The hot topics in prostate care
The advantages of focal therapies
The impact of MRI images in the treatment of prostate cancer
Hosted by Ausha. See ausha.co/privacy-policy for more information.
Transcription
This podcast is created by Coelis.
The thing is to understand that prostate cancer was the only solid cancer not visible until MRI came to our clinics. Systematically, we can see where the tumor is. And when you know where your enemy is, you can provide different ways to fight against it. Prostate Health.
Dear prostate enthusiasts, welcome to another riveting episode of Prostate Talk, where today we are diving deep, well beyond the surface, pierce the levels, into one of the most talked about journeys in male health, from the moment of diagnosis to the complexity of treatment for prostate cancer. And who better to help us navigate this medical labyrinth than someone who brings both expertise and a Mediterranean touch of forms? Join me today is Dr. Mignena, a renowned Spanish urologist who knows exactly how to deliver toast news, smart treatment plans, and most importantly, hope, with a side of tapas of course. So sit back, relax, but maybe cross your legs gently, because we are about to unpack prostate cancer from diagnosis to treatment, and discover why knowledge, compassion, and precision medicine might just be the best prescription of all. Hello, Dr. Mignana. Welcome to Prostatalk. I'm really happy to be here with you during the EAU Congress in Madrid. First of all, how are you and how the Congress is going?
Yes, I'm fine, thanks. I'm very happy to be here with you and to participate in this podcast. Yes, I'm enjoying this Congress, this EAU Congress. Let's see if I can help you.
So before to start this interview, could you please present yourself to our listeners to tell us who is Dr. Mignana?
Well, I'm a Spanish urologist. After being working in the public systems for almost all my life since 2017, I was appointed as director, head of department of urology of the Clínica Universidad de Navarra. It's a renowned and private hospital in Spain that depends of the University of Navarra.
quite close from the EAU conferences, I think, because I drive away this morning to come here.
Yes, yes. Our institution has two headquarters, one in Pamplona and the other one here in Madrid, very close to here. We have 50 years doing advanced urology in Spain. So it's well known in the Spain center.
Thank you. And I have heard that you are a director of the Prostate Center. Could you explain to us what is it, the Prostate Center?
Yes, it's one of the first prostate centers that has been developed in the world. It's specifically centered in diagnosis and treating prostate diseases from a multidisciplinary comprehensive approach. We have, from the very beginning, we are committed to have the cut-edge in technologies. both from diagnosis and treatment and with a lot of experience because technology with other experience means nothing. We totally agree. Yes, we treat patients from all over the world and we are committed not only for treating patients but diagnosis and treating patients but also in basic and clinical research and in the different undergraduates and postgraduate. programs.
And why did you choose specifically prostate?
There's a lot of myths, I think, that used to say we have an organ, the prostate, that after 50 is almost an useless organ that give us the problems, bring us to men a lot of problems, both benign and malignant.
And we can remind to our listener that one man out of eight will suffer of a prostate cancer in his life, right?
Yes. at the time of your birthday. But if you are 50, the numbers are higher. The risk of developing prostate cancer is a risk that is increasing through your lifespan and can reach 70% at 80 years. So if you live enough that it looks like this good idea, most of us are going to suffer. prostate disease.
We are talking about prostates. First of all, after a few days of EAU Congress, could you please tell us what are the hot topics in the urologic field, please?
I think there are a lot of stuff arising in a huge Congress like this. But to be concrete, I would like to talk about the impact of PSMA-PIT scans in all stages of prostate cancer from the very beginning, or the diagnosis, prognostic, and helping making decisions in both localized, locally advanced, and metastatic prostate cancer. We are familiar with this technique since 2019. We faced with some problems. We were working out of guidelines because nobody had previously opened a door like this. And I'm happy to be that it's going to change a lot of treatments and approaches for the patients, avoiding over-treatment and permitting more personalized treatment.
A lot of stunning things to come. So let's now get started. to the heart of the matter. I have heard that you are a fervent advocate of focal therapy. Could you explain to us what focal therapy consists and for example, since how long do you perform focal therapy?
Yes, yes. I performed my first focal therapy in 2014 with IRE, with irreversible electroporation. And focal therapy means to treat the prostate cancer inside the prostate while preserving the normal tissue. It's limited the treatment only to the tumor with a security margin. So it's been developed for avoiding side effects that are usually accompany whole gland treatments. So it's a kind of limited treatment. It has its advantages and its disadvantages.
You mentioned the side effects, could you tell us... What can it be, those effects?
Yes, the side effects of whole gland treatments are related with continence, urinary incontinence, because prostate is very close to the urinary sphincter. And the erectile dysfunction due to the nerves and vessels that contributes to the menormal erections are run very close to the prostate. So when you perform a whole gland treatment, you are compromising. compromising. integrity of these structures and then the refusion, the related functional results. That's why in the average performance of whole-gland treatment, a significant number of patients suffer from erectile dysfunction and urinary incontinence due to the whole-gland treatment. So that's why different approaches of such active surveillance or focal therapy arose. try to avoid this.
And would you say that focal therapy is for all prostate cancer or there are some criterias?
No, no, no, no, no. The best thing is to understand that prostate cancer was the only solid cancer not visible until MRI came to our clinics. Systematically, we can see where the tumor is and when you know where your enemy is. is you can provide different ways to fight against it. And nowadays we have a lot of experience with focal therapy, but I am a robotic surgeon. I perform more robotic surgeries than focal therapies. But nowadays, around 10% of our patients are very good candidates because they had to be highly selected patients. The tumor has to be visible on MRI. you have to perform an MRI ultrasound fusion biopsy in order to see that the lesion you are seeing in MRI is really the tumor and the remaining prostate is free from any tumor. And then you have to be skilled enough to access with different technologies and destroy to apply this tumor with enough security margin.
And why do you believe in focal therapy when it's a divisive subject? What are the goals of a good focal therapy?
The main goal of the focal therapy is the same of any whole-gland therapy, is to control the tumor, to cure the patients, or at least to modify its natural history, to allow patients or to help patients to live without a cancer, or at least live with the cancer with no metastasis and not dying for the cancer. This is the goal of all treatments, but So there's no difference with the others. But the most important characteristic of focal therapy is, as we commented before, that we can avoid the side effects. And you said that this is still focal therapies, some controversies. And let me see a little bit controversial in this. I think it's a divisive subject issue right now because urologists have some prejudices. If you let me explain, I think I'm going to be a little bit controversial. But we have two types of urologists. Those who have no very good results with their prostatectomy. So in the average, in their hands or in their institutions, their rates of urinary incontinence and erectile dysfunction are unacceptable. And that's why they advocate more for active surveillance and even focal therapy. So they're biased, but they are right because the results are there. In the other extreme, you have very skilled surgeons. with very low side effects in their hands, on their high volume institutions. And they think, why to do a focal therapy? Because in my hands this has no side effects. And they have the argument that breast cancer usually is multifocal. So if you are treating a tumor, maybe you are leaving another tumor untreated and they are right as well. So the solution to these crepenses of course, has to be not to be biased. And that is what's happened with us. We have no preferences. We are very skilled surgeons with very good results in terms not only oncological, but functional. And we are very skilled doing focal therapy. So we have no preferences. We are in the middle of those extremes. So if you think all three types. are right. And that's, in my opinion, the most important source of these discrepancies.
It's an interesting point of view and thank you for sharing with us your vision. In practical terms, how does focal treatment work in your practice? Do you follow your patient from diagnosis to treatment or do you only deal with treatment?
No, of course, of course, we accompany the patient from the very beginning from the high PSA, which is a normal way to go to the urologist. A doctor have a high PSA when they discuss to perform an MRI afterwards. MRI leads you to a biopsy or not. If you have a normal MRI, you can avoid a biopsy. when then when we have an abnormal MRI, we proceed to a fusion ultrasound MRI fusion biopsy and then with the result discuss with the patients, look this is where the tumor is, the tumor is located here, the tumor has this aggressiveness because we are taking course, we are taking samples from the very center of the tumors and discuss with the patients in a shared making decision process what's the different approaches that can help him. in getting free from his tumor.
Perfect. And if we are really talking logistic, do you need several systems, machines to cover the entire patient care pathway? I mean, to make diagnosis, to make treatment, to make robotic surgery, do you need many systems or do you have like one system for making of the patient journey?
Well, this is a very interesting question. Of course, the most important is because Everything right now relies on information coming from MRI. The most important, in my opinion, is to have a very good MRI ultrasound fusion systems because the information coming from this process, these systems, depends on all. And you can discuss with your patient if you perform a robotic surgery. I think robotic surgery has allowed us surgeons to be reliable. It's the surgeon. In the volume of surgeries he performs, who gives you the results, who leads you to be a surgeon with very few side effects, is the number and your abilities, your capabilities, your skills. But robotic surgery has allowed us to be more reliable. Today, we can almost assume in a young man under 60 with a tumor. located in the prostate, we can almost assume continence and a very high probability and around 90% of the semi-potency due to the help that the robotic surgery, the precision has given us to the surgeons. And regarding focal therapy, in my opinion, you don't need a lot of technologies because it wouldn't be affordable to maybe in a public system. You need always a very good system for making so proceeding with the MRI fusion system. And then robotic is important in one or two sources, maybe one of focal therapies.
Thank you. And Dr. Mignogna, a question comes to my mind. To perform focal therapy, which approach is the best? Transrectal, Transparenal, and why?
Yes, it depends. It depends on the... In my opinion, there's no difference with the sources of energy. If you are good at a source of energy, for example, HIFU, then proceed with HIFU. You're good at cryo or fiery. Of course, if you are going to do Haifu, you have to do it. to have a transectal approach. I'm more happy with a transparent approach because it allows you to access any part of the prostate and treat only the lesion, what we call the index lesion, is that one that is visible on MRI with a security margin and preserving to treat a large amount of prostate.
Thanks for this clarification. I have another question. You mentioned MRI. Does it essential for performing focal therapies?
Of course, this isn't all of our treatments relies on information coming from MRI. Of course, you can see more suspicious areas using other technologies like micro ultrasound, but the information coming from MRI, 3D information, putting the lesion where it is and permits to translate this information to the OR is not provided by any other diagnostic tool.
So would you say that prostate care tomorrow cannot do without MRI?
Of course, because you have to take into account, in my opinion, that AI with information coming from the images, even more precise, and radiomics is including images with genes, the information coming from the expression of different genes, there's a lot of information that AI in the future are going to get together and give you not only information about what is happening in the prostate right now, this kind of picture, but what is happening in this tissue in the future. So, of course, any development of where the prostate cancer is and how to manage it is In my opinion, it will be always relying on MRI.
Thanks a lot, Dr. Mignogna, for your answers. Let's see a little further now. What projects are you working on and what are your plans for the coming months?
Oh, this is a personal question. Well, I told you before I'm working, I'm happy and honored to direct a HAP volume center which are involved in many, many basic and clinically. research progress in the educational programs, both for students in the undergraduate and postgraduate. Yesterday, we have a workshop with people coming from all over the world to see how we work. I'm very happy with this. But today, my most important goal in the short terms is we are developing an information system. It's a recruiting information from nurses, doctors from clinical registries to get, in my opinion, if we are lucky enough, in a couple of months, we will be able to get information real time of the results of our practice. This is something I've been dreaming of all my life, and I'm very close to get to this goal.
We can't wait to see the advancements. Well, Dr. Mignogna, this is the end of our interview. Before to get back to the Congress, I like to finish my interview in music. So I would like to ask a last question. What is your favorite song of all time?
My favorite? Oh, that's a very good question. My favorite song of all time. Well, of course, it has to be with mainly three great artists. A song of David Bowie, maybe Leonard Cohen. To say maybe Neil Young, I can't select one of them. You can imagine they are great, but they have to be one of ten. Did you think maybe one space holiday because I'm used to seeing this song a lot with my children since they were very, very little today. They are adults and we still sing that song together. Maybe one of the main favorites one.
Perfect. Thank you so much. Eric, an excellent choice by the way. Thanks again for your time and I hope you like the exercise and let's go back to the Congress.
Okay. Thank you very much. Been a pleasure.
Huge thanks to our dedicated listeners. If you enjoyed the podcast, make sure to subscribe for more captivating content. Your support means the world. If you found this informative, quick favor, please drop up a five-star review. Your feedback helps us grow and deliver quality insight. Have topics you'd love us to cover? Share your ideas in the comments or connect with us on social media. Your input guides the... future of Prostatalk. Thanks for being a crucial part of our community. For more urology insights, visit Curlies.com. Stay tuned and see you next time.
Description
Dr Miñana, from Spain, talks about Focal Therapy, but more specilfically , the importance of fusion system and MRI images in the treatment of Prostate Cancer.
Let's talk about:
The hot topics in prostate care
The advantages of focal therapies
The impact of MRI images in the treatment of prostate cancer
Hosted by Ausha. See ausha.co/privacy-policy for more information.
Transcription
This podcast is created by Coelis.
The thing is to understand that prostate cancer was the only solid cancer not visible until MRI came to our clinics. Systematically, we can see where the tumor is. And when you know where your enemy is, you can provide different ways to fight against it. Prostate Health.
Dear prostate enthusiasts, welcome to another riveting episode of Prostate Talk, where today we are diving deep, well beyond the surface, pierce the levels, into one of the most talked about journeys in male health, from the moment of diagnosis to the complexity of treatment for prostate cancer. And who better to help us navigate this medical labyrinth than someone who brings both expertise and a Mediterranean touch of forms? Join me today is Dr. Mignena, a renowned Spanish urologist who knows exactly how to deliver toast news, smart treatment plans, and most importantly, hope, with a side of tapas of course. So sit back, relax, but maybe cross your legs gently, because we are about to unpack prostate cancer from diagnosis to treatment, and discover why knowledge, compassion, and precision medicine might just be the best prescription of all. Hello, Dr. Mignana. Welcome to Prostatalk. I'm really happy to be here with you during the EAU Congress in Madrid. First of all, how are you and how the Congress is going?
Yes, I'm fine, thanks. I'm very happy to be here with you and to participate in this podcast. Yes, I'm enjoying this Congress, this EAU Congress. Let's see if I can help you.
So before to start this interview, could you please present yourself to our listeners to tell us who is Dr. Mignana?
Well, I'm a Spanish urologist. After being working in the public systems for almost all my life since 2017, I was appointed as director, head of department of urology of the Clínica Universidad de Navarra. It's a renowned and private hospital in Spain that depends of the University of Navarra.
quite close from the EAU conferences, I think, because I drive away this morning to come here.
Yes, yes. Our institution has two headquarters, one in Pamplona and the other one here in Madrid, very close to here. We have 50 years doing advanced urology in Spain. So it's well known in the Spain center.
Thank you. And I have heard that you are a director of the Prostate Center. Could you explain to us what is it, the Prostate Center?
Yes, it's one of the first prostate centers that has been developed in the world. It's specifically centered in diagnosis and treating prostate diseases from a multidisciplinary comprehensive approach. We have, from the very beginning, we are committed to have the cut-edge in technologies. both from diagnosis and treatment and with a lot of experience because technology with other experience means nothing. We totally agree. Yes, we treat patients from all over the world and we are committed not only for treating patients but diagnosis and treating patients but also in basic and clinical research and in the different undergraduates and postgraduate. programs.
And why did you choose specifically prostate?
There's a lot of myths, I think, that used to say we have an organ, the prostate, that after 50 is almost an useless organ that give us the problems, bring us to men a lot of problems, both benign and malignant.
And we can remind to our listener that one man out of eight will suffer of a prostate cancer in his life, right?
Yes. at the time of your birthday. But if you are 50, the numbers are higher. The risk of developing prostate cancer is a risk that is increasing through your lifespan and can reach 70% at 80 years. So if you live enough that it looks like this good idea, most of us are going to suffer. prostate disease.
We are talking about prostates. First of all, after a few days of EAU Congress, could you please tell us what are the hot topics in the urologic field, please?
I think there are a lot of stuff arising in a huge Congress like this. But to be concrete, I would like to talk about the impact of PSMA-PIT scans in all stages of prostate cancer from the very beginning, or the diagnosis, prognostic, and helping making decisions in both localized, locally advanced, and metastatic prostate cancer. We are familiar with this technique since 2019. We faced with some problems. We were working out of guidelines because nobody had previously opened a door like this. And I'm happy to be that it's going to change a lot of treatments and approaches for the patients, avoiding over-treatment and permitting more personalized treatment.
A lot of stunning things to come. So let's now get started. to the heart of the matter. I have heard that you are a fervent advocate of focal therapy. Could you explain to us what focal therapy consists and for example, since how long do you perform focal therapy?
Yes, yes. I performed my first focal therapy in 2014 with IRE, with irreversible electroporation. And focal therapy means to treat the prostate cancer inside the prostate while preserving the normal tissue. It's limited the treatment only to the tumor with a security margin. So it's been developed for avoiding side effects that are usually accompany whole gland treatments. So it's a kind of limited treatment. It has its advantages and its disadvantages.
You mentioned the side effects, could you tell us... What can it be, those effects?
Yes, the side effects of whole gland treatments are related with continence, urinary incontinence, because prostate is very close to the urinary sphincter. And the erectile dysfunction due to the nerves and vessels that contributes to the menormal erections are run very close to the prostate. So when you perform a whole gland treatment, you are compromising. compromising. integrity of these structures and then the refusion, the related functional results. That's why in the average performance of whole-gland treatment, a significant number of patients suffer from erectile dysfunction and urinary incontinence due to the whole-gland treatment. So that's why different approaches of such active surveillance or focal therapy arose. try to avoid this.
And would you say that focal therapy is for all prostate cancer or there are some criterias?
No, no, no, no, no. The best thing is to understand that prostate cancer was the only solid cancer not visible until MRI came to our clinics. Systematically, we can see where the tumor is and when you know where your enemy is. is you can provide different ways to fight against it. And nowadays we have a lot of experience with focal therapy, but I am a robotic surgeon. I perform more robotic surgeries than focal therapies. But nowadays, around 10% of our patients are very good candidates because they had to be highly selected patients. The tumor has to be visible on MRI. you have to perform an MRI ultrasound fusion biopsy in order to see that the lesion you are seeing in MRI is really the tumor and the remaining prostate is free from any tumor. And then you have to be skilled enough to access with different technologies and destroy to apply this tumor with enough security margin.
And why do you believe in focal therapy when it's a divisive subject? What are the goals of a good focal therapy?
The main goal of the focal therapy is the same of any whole-gland therapy, is to control the tumor, to cure the patients, or at least to modify its natural history, to allow patients or to help patients to live without a cancer, or at least live with the cancer with no metastasis and not dying for the cancer. This is the goal of all treatments, but So there's no difference with the others. But the most important characteristic of focal therapy is, as we commented before, that we can avoid the side effects. And you said that this is still focal therapies, some controversies. And let me see a little bit controversial in this. I think it's a divisive subject issue right now because urologists have some prejudices. If you let me explain, I think I'm going to be a little bit controversial. But we have two types of urologists. Those who have no very good results with their prostatectomy. So in the average, in their hands or in their institutions, their rates of urinary incontinence and erectile dysfunction are unacceptable. And that's why they advocate more for active surveillance and even focal therapy. So they're biased, but they are right because the results are there. In the other extreme, you have very skilled surgeons. with very low side effects in their hands, on their high volume institutions. And they think, why to do a focal therapy? Because in my hands this has no side effects. And they have the argument that breast cancer usually is multifocal. So if you are treating a tumor, maybe you are leaving another tumor untreated and they are right as well. So the solution to these crepenses of course, has to be not to be biased. And that is what's happened with us. We have no preferences. We are very skilled surgeons with very good results in terms not only oncological, but functional. And we are very skilled doing focal therapy. So we have no preferences. We are in the middle of those extremes. So if you think all three types. are right. And that's, in my opinion, the most important source of these discrepancies.
It's an interesting point of view and thank you for sharing with us your vision. In practical terms, how does focal treatment work in your practice? Do you follow your patient from diagnosis to treatment or do you only deal with treatment?
No, of course, of course, we accompany the patient from the very beginning from the high PSA, which is a normal way to go to the urologist. A doctor have a high PSA when they discuss to perform an MRI afterwards. MRI leads you to a biopsy or not. If you have a normal MRI, you can avoid a biopsy. when then when we have an abnormal MRI, we proceed to a fusion ultrasound MRI fusion biopsy and then with the result discuss with the patients, look this is where the tumor is, the tumor is located here, the tumor has this aggressiveness because we are taking course, we are taking samples from the very center of the tumors and discuss with the patients in a shared making decision process what's the different approaches that can help him. in getting free from his tumor.
Perfect. And if we are really talking logistic, do you need several systems, machines to cover the entire patient care pathway? I mean, to make diagnosis, to make treatment, to make robotic surgery, do you need many systems or do you have like one system for making of the patient journey?
Well, this is a very interesting question. Of course, the most important is because Everything right now relies on information coming from MRI. The most important, in my opinion, is to have a very good MRI ultrasound fusion systems because the information coming from this process, these systems, depends on all. And you can discuss with your patient if you perform a robotic surgery. I think robotic surgery has allowed us surgeons to be reliable. It's the surgeon. In the volume of surgeries he performs, who gives you the results, who leads you to be a surgeon with very few side effects, is the number and your abilities, your capabilities, your skills. But robotic surgery has allowed us to be more reliable. Today, we can almost assume in a young man under 60 with a tumor. located in the prostate, we can almost assume continence and a very high probability and around 90% of the semi-potency due to the help that the robotic surgery, the precision has given us to the surgeons. And regarding focal therapy, in my opinion, you don't need a lot of technologies because it wouldn't be affordable to maybe in a public system. You need always a very good system for making so proceeding with the MRI fusion system. And then robotic is important in one or two sources, maybe one of focal therapies.
Thank you. And Dr. Mignogna, a question comes to my mind. To perform focal therapy, which approach is the best? Transrectal, Transparenal, and why?
Yes, it depends. It depends on the... In my opinion, there's no difference with the sources of energy. If you are good at a source of energy, for example, HIFU, then proceed with HIFU. You're good at cryo or fiery. Of course, if you are going to do Haifu, you have to do it. to have a transectal approach. I'm more happy with a transparent approach because it allows you to access any part of the prostate and treat only the lesion, what we call the index lesion, is that one that is visible on MRI with a security margin and preserving to treat a large amount of prostate.
Thanks for this clarification. I have another question. You mentioned MRI. Does it essential for performing focal therapies?
Of course, this isn't all of our treatments relies on information coming from MRI. Of course, you can see more suspicious areas using other technologies like micro ultrasound, but the information coming from MRI, 3D information, putting the lesion where it is and permits to translate this information to the OR is not provided by any other diagnostic tool.
So would you say that prostate care tomorrow cannot do without MRI?
Of course, because you have to take into account, in my opinion, that AI with information coming from the images, even more precise, and radiomics is including images with genes, the information coming from the expression of different genes, there's a lot of information that AI in the future are going to get together and give you not only information about what is happening in the prostate right now, this kind of picture, but what is happening in this tissue in the future. So, of course, any development of where the prostate cancer is and how to manage it is In my opinion, it will be always relying on MRI.
Thanks a lot, Dr. Mignogna, for your answers. Let's see a little further now. What projects are you working on and what are your plans for the coming months?
Oh, this is a personal question. Well, I told you before I'm working, I'm happy and honored to direct a HAP volume center which are involved in many, many basic and clinically. research progress in the educational programs, both for students in the undergraduate and postgraduate. Yesterday, we have a workshop with people coming from all over the world to see how we work. I'm very happy with this. But today, my most important goal in the short terms is we are developing an information system. It's a recruiting information from nurses, doctors from clinical registries to get, in my opinion, if we are lucky enough, in a couple of months, we will be able to get information real time of the results of our practice. This is something I've been dreaming of all my life, and I'm very close to get to this goal.
We can't wait to see the advancements. Well, Dr. Mignogna, this is the end of our interview. Before to get back to the Congress, I like to finish my interview in music. So I would like to ask a last question. What is your favorite song of all time?
My favorite? Oh, that's a very good question. My favorite song of all time. Well, of course, it has to be with mainly three great artists. A song of David Bowie, maybe Leonard Cohen. To say maybe Neil Young, I can't select one of them. You can imagine they are great, but they have to be one of ten. Did you think maybe one space holiday because I'm used to seeing this song a lot with my children since they were very, very little today. They are adults and we still sing that song together. Maybe one of the main favorites one.
Perfect. Thank you so much. Eric, an excellent choice by the way. Thanks again for your time and I hope you like the exercise and let's go back to the Congress.
Okay. Thank you very much. Been a pleasure.
Huge thanks to our dedicated listeners. If you enjoyed the podcast, make sure to subscribe for more captivating content. Your support means the world. If you found this informative, quick favor, please drop up a five-star review. Your feedback helps us grow and deliver quality insight. Have topics you'd love us to cover? Share your ideas in the comments or connect with us on social media. Your input guides the... future of Prostatalk. Thanks for being a crucial part of our community. For more urology insights, visit Curlies.com. Stay tuned and see you next time.
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Description
Dr Miñana, from Spain, talks about Focal Therapy, but more specilfically , the importance of fusion system and MRI images in the treatment of Prostate Cancer.
Let's talk about:
The hot topics in prostate care
The advantages of focal therapies
The impact of MRI images in the treatment of prostate cancer
Hosted by Ausha. See ausha.co/privacy-policy for more information.
Transcription
This podcast is created by Coelis.
The thing is to understand that prostate cancer was the only solid cancer not visible until MRI came to our clinics. Systematically, we can see where the tumor is. And when you know where your enemy is, you can provide different ways to fight against it. Prostate Health.
Dear prostate enthusiasts, welcome to another riveting episode of Prostate Talk, where today we are diving deep, well beyond the surface, pierce the levels, into one of the most talked about journeys in male health, from the moment of diagnosis to the complexity of treatment for prostate cancer. And who better to help us navigate this medical labyrinth than someone who brings both expertise and a Mediterranean touch of forms? Join me today is Dr. Mignena, a renowned Spanish urologist who knows exactly how to deliver toast news, smart treatment plans, and most importantly, hope, with a side of tapas of course. So sit back, relax, but maybe cross your legs gently, because we are about to unpack prostate cancer from diagnosis to treatment, and discover why knowledge, compassion, and precision medicine might just be the best prescription of all. Hello, Dr. Mignana. Welcome to Prostatalk. I'm really happy to be here with you during the EAU Congress in Madrid. First of all, how are you and how the Congress is going?
Yes, I'm fine, thanks. I'm very happy to be here with you and to participate in this podcast. Yes, I'm enjoying this Congress, this EAU Congress. Let's see if I can help you.
So before to start this interview, could you please present yourself to our listeners to tell us who is Dr. Mignana?
Well, I'm a Spanish urologist. After being working in the public systems for almost all my life since 2017, I was appointed as director, head of department of urology of the Clínica Universidad de Navarra. It's a renowned and private hospital in Spain that depends of the University of Navarra.
quite close from the EAU conferences, I think, because I drive away this morning to come here.
Yes, yes. Our institution has two headquarters, one in Pamplona and the other one here in Madrid, very close to here. We have 50 years doing advanced urology in Spain. So it's well known in the Spain center.
Thank you. And I have heard that you are a director of the Prostate Center. Could you explain to us what is it, the Prostate Center?
Yes, it's one of the first prostate centers that has been developed in the world. It's specifically centered in diagnosis and treating prostate diseases from a multidisciplinary comprehensive approach. We have, from the very beginning, we are committed to have the cut-edge in technologies. both from diagnosis and treatment and with a lot of experience because technology with other experience means nothing. We totally agree. Yes, we treat patients from all over the world and we are committed not only for treating patients but diagnosis and treating patients but also in basic and clinical research and in the different undergraduates and postgraduate. programs.
And why did you choose specifically prostate?
There's a lot of myths, I think, that used to say we have an organ, the prostate, that after 50 is almost an useless organ that give us the problems, bring us to men a lot of problems, both benign and malignant.
And we can remind to our listener that one man out of eight will suffer of a prostate cancer in his life, right?
Yes. at the time of your birthday. But if you are 50, the numbers are higher. The risk of developing prostate cancer is a risk that is increasing through your lifespan and can reach 70% at 80 years. So if you live enough that it looks like this good idea, most of us are going to suffer. prostate disease.
We are talking about prostates. First of all, after a few days of EAU Congress, could you please tell us what are the hot topics in the urologic field, please?
I think there are a lot of stuff arising in a huge Congress like this. But to be concrete, I would like to talk about the impact of PSMA-PIT scans in all stages of prostate cancer from the very beginning, or the diagnosis, prognostic, and helping making decisions in both localized, locally advanced, and metastatic prostate cancer. We are familiar with this technique since 2019. We faced with some problems. We were working out of guidelines because nobody had previously opened a door like this. And I'm happy to be that it's going to change a lot of treatments and approaches for the patients, avoiding over-treatment and permitting more personalized treatment.
A lot of stunning things to come. So let's now get started. to the heart of the matter. I have heard that you are a fervent advocate of focal therapy. Could you explain to us what focal therapy consists and for example, since how long do you perform focal therapy?
Yes, yes. I performed my first focal therapy in 2014 with IRE, with irreversible electroporation. And focal therapy means to treat the prostate cancer inside the prostate while preserving the normal tissue. It's limited the treatment only to the tumor with a security margin. So it's been developed for avoiding side effects that are usually accompany whole gland treatments. So it's a kind of limited treatment. It has its advantages and its disadvantages.
You mentioned the side effects, could you tell us... What can it be, those effects?
Yes, the side effects of whole gland treatments are related with continence, urinary incontinence, because prostate is very close to the urinary sphincter. And the erectile dysfunction due to the nerves and vessels that contributes to the menormal erections are run very close to the prostate. So when you perform a whole gland treatment, you are compromising. compromising. integrity of these structures and then the refusion, the related functional results. That's why in the average performance of whole-gland treatment, a significant number of patients suffer from erectile dysfunction and urinary incontinence due to the whole-gland treatment. So that's why different approaches of such active surveillance or focal therapy arose. try to avoid this.
And would you say that focal therapy is for all prostate cancer or there are some criterias?
No, no, no, no, no. The best thing is to understand that prostate cancer was the only solid cancer not visible until MRI came to our clinics. Systematically, we can see where the tumor is and when you know where your enemy is. is you can provide different ways to fight against it. And nowadays we have a lot of experience with focal therapy, but I am a robotic surgeon. I perform more robotic surgeries than focal therapies. But nowadays, around 10% of our patients are very good candidates because they had to be highly selected patients. The tumor has to be visible on MRI. you have to perform an MRI ultrasound fusion biopsy in order to see that the lesion you are seeing in MRI is really the tumor and the remaining prostate is free from any tumor. And then you have to be skilled enough to access with different technologies and destroy to apply this tumor with enough security margin.
And why do you believe in focal therapy when it's a divisive subject? What are the goals of a good focal therapy?
The main goal of the focal therapy is the same of any whole-gland therapy, is to control the tumor, to cure the patients, or at least to modify its natural history, to allow patients or to help patients to live without a cancer, or at least live with the cancer with no metastasis and not dying for the cancer. This is the goal of all treatments, but So there's no difference with the others. But the most important characteristic of focal therapy is, as we commented before, that we can avoid the side effects. And you said that this is still focal therapies, some controversies. And let me see a little bit controversial in this. I think it's a divisive subject issue right now because urologists have some prejudices. If you let me explain, I think I'm going to be a little bit controversial. But we have two types of urologists. Those who have no very good results with their prostatectomy. So in the average, in their hands or in their institutions, their rates of urinary incontinence and erectile dysfunction are unacceptable. And that's why they advocate more for active surveillance and even focal therapy. So they're biased, but they are right because the results are there. In the other extreme, you have very skilled surgeons. with very low side effects in their hands, on their high volume institutions. And they think, why to do a focal therapy? Because in my hands this has no side effects. And they have the argument that breast cancer usually is multifocal. So if you are treating a tumor, maybe you are leaving another tumor untreated and they are right as well. So the solution to these crepenses of course, has to be not to be biased. And that is what's happened with us. We have no preferences. We are very skilled surgeons with very good results in terms not only oncological, but functional. And we are very skilled doing focal therapy. So we have no preferences. We are in the middle of those extremes. So if you think all three types. are right. And that's, in my opinion, the most important source of these discrepancies.
It's an interesting point of view and thank you for sharing with us your vision. In practical terms, how does focal treatment work in your practice? Do you follow your patient from diagnosis to treatment or do you only deal with treatment?
No, of course, of course, we accompany the patient from the very beginning from the high PSA, which is a normal way to go to the urologist. A doctor have a high PSA when they discuss to perform an MRI afterwards. MRI leads you to a biopsy or not. If you have a normal MRI, you can avoid a biopsy. when then when we have an abnormal MRI, we proceed to a fusion ultrasound MRI fusion biopsy and then with the result discuss with the patients, look this is where the tumor is, the tumor is located here, the tumor has this aggressiveness because we are taking course, we are taking samples from the very center of the tumors and discuss with the patients in a shared making decision process what's the different approaches that can help him. in getting free from his tumor.
Perfect. And if we are really talking logistic, do you need several systems, machines to cover the entire patient care pathway? I mean, to make diagnosis, to make treatment, to make robotic surgery, do you need many systems or do you have like one system for making of the patient journey?
Well, this is a very interesting question. Of course, the most important is because Everything right now relies on information coming from MRI. The most important, in my opinion, is to have a very good MRI ultrasound fusion systems because the information coming from this process, these systems, depends on all. And you can discuss with your patient if you perform a robotic surgery. I think robotic surgery has allowed us surgeons to be reliable. It's the surgeon. In the volume of surgeries he performs, who gives you the results, who leads you to be a surgeon with very few side effects, is the number and your abilities, your capabilities, your skills. But robotic surgery has allowed us to be more reliable. Today, we can almost assume in a young man under 60 with a tumor. located in the prostate, we can almost assume continence and a very high probability and around 90% of the semi-potency due to the help that the robotic surgery, the precision has given us to the surgeons. And regarding focal therapy, in my opinion, you don't need a lot of technologies because it wouldn't be affordable to maybe in a public system. You need always a very good system for making so proceeding with the MRI fusion system. And then robotic is important in one or two sources, maybe one of focal therapies.
Thank you. And Dr. Mignogna, a question comes to my mind. To perform focal therapy, which approach is the best? Transrectal, Transparenal, and why?
Yes, it depends. It depends on the... In my opinion, there's no difference with the sources of energy. If you are good at a source of energy, for example, HIFU, then proceed with HIFU. You're good at cryo or fiery. Of course, if you are going to do Haifu, you have to do it. to have a transectal approach. I'm more happy with a transparent approach because it allows you to access any part of the prostate and treat only the lesion, what we call the index lesion, is that one that is visible on MRI with a security margin and preserving to treat a large amount of prostate.
Thanks for this clarification. I have another question. You mentioned MRI. Does it essential for performing focal therapies?
Of course, this isn't all of our treatments relies on information coming from MRI. Of course, you can see more suspicious areas using other technologies like micro ultrasound, but the information coming from MRI, 3D information, putting the lesion where it is and permits to translate this information to the OR is not provided by any other diagnostic tool.
So would you say that prostate care tomorrow cannot do without MRI?
Of course, because you have to take into account, in my opinion, that AI with information coming from the images, even more precise, and radiomics is including images with genes, the information coming from the expression of different genes, there's a lot of information that AI in the future are going to get together and give you not only information about what is happening in the prostate right now, this kind of picture, but what is happening in this tissue in the future. So, of course, any development of where the prostate cancer is and how to manage it is In my opinion, it will be always relying on MRI.
Thanks a lot, Dr. Mignogna, for your answers. Let's see a little further now. What projects are you working on and what are your plans for the coming months?
Oh, this is a personal question. Well, I told you before I'm working, I'm happy and honored to direct a HAP volume center which are involved in many, many basic and clinically. research progress in the educational programs, both for students in the undergraduate and postgraduate. Yesterday, we have a workshop with people coming from all over the world to see how we work. I'm very happy with this. But today, my most important goal in the short terms is we are developing an information system. It's a recruiting information from nurses, doctors from clinical registries to get, in my opinion, if we are lucky enough, in a couple of months, we will be able to get information real time of the results of our practice. This is something I've been dreaming of all my life, and I'm very close to get to this goal.
We can't wait to see the advancements. Well, Dr. Mignogna, this is the end of our interview. Before to get back to the Congress, I like to finish my interview in music. So I would like to ask a last question. What is your favorite song of all time?
My favorite? Oh, that's a very good question. My favorite song of all time. Well, of course, it has to be with mainly three great artists. A song of David Bowie, maybe Leonard Cohen. To say maybe Neil Young, I can't select one of them. You can imagine they are great, but they have to be one of ten. Did you think maybe one space holiday because I'm used to seeing this song a lot with my children since they were very, very little today. They are adults and we still sing that song together. Maybe one of the main favorites one.
Perfect. Thank you so much. Eric, an excellent choice by the way. Thanks again for your time and I hope you like the exercise and let's go back to the Congress.
Okay. Thank you very much. Been a pleasure.
Huge thanks to our dedicated listeners. If you enjoyed the podcast, make sure to subscribe for more captivating content. Your support means the world. If you found this informative, quick favor, please drop up a five-star review. Your feedback helps us grow and deliver quality insight. Have topics you'd love us to cover? Share your ideas in the comments or connect with us on social media. Your input guides the... future of Prostatalk. Thanks for being a crucial part of our community. For more urology insights, visit Curlies.com. Stay tuned and see you next time.
Description
Dr Miñana, from Spain, talks about Focal Therapy, but more specilfically , the importance of fusion system and MRI images in the treatment of Prostate Cancer.
Let's talk about:
The hot topics in prostate care
The advantages of focal therapies
The impact of MRI images in the treatment of prostate cancer
Hosted by Ausha. See ausha.co/privacy-policy for more information.
Transcription
This podcast is created by Coelis.
The thing is to understand that prostate cancer was the only solid cancer not visible until MRI came to our clinics. Systematically, we can see where the tumor is. And when you know where your enemy is, you can provide different ways to fight against it. Prostate Health.
Dear prostate enthusiasts, welcome to another riveting episode of Prostate Talk, where today we are diving deep, well beyond the surface, pierce the levels, into one of the most talked about journeys in male health, from the moment of diagnosis to the complexity of treatment for prostate cancer. And who better to help us navigate this medical labyrinth than someone who brings both expertise and a Mediterranean touch of forms? Join me today is Dr. Mignena, a renowned Spanish urologist who knows exactly how to deliver toast news, smart treatment plans, and most importantly, hope, with a side of tapas of course. So sit back, relax, but maybe cross your legs gently, because we are about to unpack prostate cancer from diagnosis to treatment, and discover why knowledge, compassion, and precision medicine might just be the best prescription of all. Hello, Dr. Mignana. Welcome to Prostatalk. I'm really happy to be here with you during the EAU Congress in Madrid. First of all, how are you and how the Congress is going?
Yes, I'm fine, thanks. I'm very happy to be here with you and to participate in this podcast. Yes, I'm enjoying this Congress, this EAU Congress. Let's see if I can help you.
So before to start this interview, could you please present yourself to our listeners to tell us who is Dr. Mignana?
Well, I'm a Spanish urologist. After being working in the public systems for almost all my life since 2017, I was appointed as director, head of department of urology of the Clínica Universidad de Navarra. It's a renowned and private hospital in Spain that depends of the University of Navarra.
quite close from the EAU conferences, I think, because I drive away this morning to come here.
Yes, yes. Our institution has two headquarters, one in Pamplona and the other one here in Madrid, very close to here. We have 50 years doing advanced urology in Spain. So it's well known in the Spain center.
Thank you. And I have heard that you are a director of the Prostate Center. Could you explain to us what is it, the Prostate Center?
Yes, it's one of the first prostate centers that has been developed in the world. It's specifically centered in diagnosis and treating prostate diseases from a multidisciplinary comprehensive approach. We have, from the very beginning, we are committed to have the cut-edge in technologies. both from diagnosis and treatment and with a lot of experience because technology with other experience means nothing. We totally agree. Yes, we treat patients from all over the world and we are committed not only for treating patients but diagnosis and treating patients but also in basic and clinical research and in the different undergraduates and postgraduate. programs.
And why did you choose specifically prostate?
There's a lot of myths, I think, that used to say we have an organ, the prostate, that after 50 is almost an useless organ that give us the problems, bring us to men a lot of problems, both benign and malignant.
And we can remind to our listener that one man out of eight will suffer of a prostate cancer in his life, right?
Yes. at the time of your birthday. But if you are 50, the numbers are higher. The risk of developing prostate cancer is a risk that is increasing through your lifespan and can reach 70% at 80 years. So if you live enough that it looks like this good idea, most of us are going to suffer. prostate disease.
We are talking about prostates. First of all, after a few days of EAU Congress, could you please tell us what are the hot topics in the urologic field, please?
I think there are a lot of stuff arising in a huge Congress like this. But to be concrete, I would like to talk about the impact of PSMA-PIT scans in all stages of prostate cancer from the very beginning, or the diagnosis, prognostic, and helping making decisions in both localized, locally advanced, and metastatic prostate cancer. We are familiar with this technique since 2019. We faced with some problems. We were working out of guidelines because nobody had previously opened a door like this. And I'm happy to be that it's going to change a lot of treatments and approaches for the patients, avoiding over-treatment and permitting more personalized treatment.
A lot of stunning things to come. So let's now get started. to the heart of the matter. I have heard that you are a fervent advocate of focal therapy. Could you explain to us what focal therapy consists and for example, since how long do you perform focal therapy?
Yes, yes. I performed my first focal therapy in 2014 with IRE, with irreversible electroporation. And focal therapy means to treat the prostate cancer inside the prostate while preserving the normal tissue. It's limited the treatment only to the tumor with a security margin. So it's been developed for avoiding side effects that are usually accompany whole gland treatments. So it's a kind of limited treatment. It has its advantages and its disadvantages.
You mentioned the side effects, could you tell us... What can it be, those effects?
Yes, the side effects of whole gland treatments are related with continence, urinary incontinence, because prostate is very close to the urinary sphincter. And the erectile dysfunction due to the nerves and vessels that contributes to the menormal erections are run very close to the prostate. So when you perform a whole gland treatment, you are compromising. compromising. integrity of these structures and then the refusion, the related functional results. That's why in the average performance of whole-gland treatment, a significant number of patients suffer from erectile dysfunction and urinary incontinence due to the whole-gland treatment. So that's why different approaches of such active surveillance or focal therapy arose. try to avoid this.
And would you say that focal therapy is for all prostate cancer or there are some criterias?
No, no, no, no, no. The best thing is to understand that prostate cancer was the only solid cancer not visible until MRI came to our clinics. Systematically, we can see where the tumor is and when you know where your enemy is. is you can provide different ways to fight against it. And nowadays we have a lot of experience with focal therapy, but I am a robotic surgeon. I perform more robotic surgeries than focal therapies. But nowadays, around 10% of our patients are very good candidates because they had to be highly selected patients. The tumor has to be visible on MRI. you have to perform an MRI ultrasound fusion biopsy in order to see that the lesion you are seeing in MRI is really the tumor and the remaining prostate is free from any tumor. And then you have to be skilled enough to access with different technologies and destroy to apply this tumor with enough security margin.
And why do you believe in focal therapy when it's a divisive subject? What are the goals of a good focal therapy?
The main goal of the focal therapy is the same of any whole-gland therapy, is to control the tumor, to cure the patients, or at least to modify its natural history, to allow patients or to help patients to live without a cancer, or at least live with the cancer with no metastasis and not dying for the cancer. This is the goal of all treatments, but So there's no difference with the others. But the most important characteristic of focal therapy is, as we commented before, that we can avoid the side effects. And you said that this is still focal therapies, some controversies. And let me see a little bit controversial in this. I think it's a divisive subject issue right now because urologists have some prejudices. If you let me explain, I think I'm going to be a little bit controversial. But we have two types of urologists. Those who have no very good results with their prostatectomy. So in the average, in their hands or in their institutions, their rates of urinary incontinence and erectile dysfunction are unacceptable. And that's why they advocate more for active surveillance and even focal therapy. So they're biased, but they are right because the results are there. In the other extreme, you have very skilled surgeons. with very low side effects in their hands, on their high volume institutions. And they think, why to do a focal therapy? Because in my hands this has no side effects. And they have the argument that breast cancer usually is multifocal. So if you are treating a tumor, maybe you are leaving another tumor untreated and they are right as well. So the solution to these crepenses of course, has to be not to be biased. And that is what's happened with us. We have no preferences. We are very skilled surgeons with very good results in terms not only oncological, but functional. And we are very skilled doing focal therapy. So we have no preferences. We are in the middle of those extremes. So if you think all three types. are right. And that's, in my opinion, the most important source of these discrepancies.
It's an interesting point of view and thank you for sharing with us your vision. In practical terms, how does focal treatment work in your practice? Do you follow your patient from diagnosis to treatment or do you only deal with treatment?
No, of course, of course, we accompany the patient from the very beginning from the high PSA, which is a normal way to go to the urologist. A doctor have a high PSA when they discuss to perform an MRI afterwards. MRI leads you to a biopsy or not. If you have a normal MRI, you can avoid a biopsy. when then when we have an abnormal MRI, we proceed to a fusion ultrasound MRI fusion biopsy and then with the result discuss with the patients, look this is where the tumor is, the tumor is located here, the tumor has this aggressiveness because we are taking course, we are taking samples from the very center of the tumors and discuss with the patients in a shared making decision process what's the different approaches that can help him. in getting free from his tumor.
Perfect. And if we are really talking logistic, do you need several systems, machines to cover the entire patient care pathway? I mean, to make diagnosis, to make treatment, to make robotic surgery, do you need many systems or do you have like one system for making of the patient journey?
Well, this is a very interesting question. Of course, the most important is because Everything right now relies on information coming from MRI. The most important, in my opinion, is to have a very good MRI ultrasound fusion systems because the information coming from this process, these systems, depends on all. And you can discuss with your patient if you perform a robotic surgery. I think robotic surgery has allowed us surgeons to be reliable. It's the surgeon. In the volume of surgeries he performs, who gives you the results, who leads you to be a surgeon with very few side effects, is the number and your abilities, your capabilities, your skills. But robotic surgery has allowed us to be more reliable. Today, we can almost assume in a young man under 60 with a tumor. located in the prostate, we can almost assume continence and a very high probability and around 90% of the semi-potency due to the help that the robotic surgery, the precision has given us to the surgeons. And regarding focal therapy, in my opinion, you don't need a lot of technologies because it wouldn't be affordable to maybe in a public system. You need always a very good system for making so proceeding with the MRI fusion system. And then robotic is important in one or two sources, maybe one of focal therapies.
Thank you. And Dr. Mignogna, a question comes to my mind. To perform focal therapy, which approach is the best? Transrectal, Transparenal, and why?
Yes, it depends. It depends on the... In my opinion, there's no difference with the sources of energy. If you are good at a source of energy, for example, HIFU, then proceed with HIFU. You're good at cryo or fiery. Of course, if you are going to do Haifu, you have to do it. to have a transectal approach. I'm more happy with a transparent approach because it allows you to access any part of the prostate and treat only the lesion, what we call the index lesion, is that one that is visible on MRI with a security margin and preserving to treat a large amount of prostate.
Thanks for this clarification. I have another question. You mentioned MRI. Does it essential for performing focal therapies?
Of course, this isn't all of our treatments relies on information coming from MRI. Of course, you can see more suspicious areas using other technologies like micro ultrasound, but the information coming from MRI, 3D information, putting the lesion where it is and permits to translate this information to the OR is not provided by any other diagnostic tool.
So would you say that prostate care tomorrow cannot do without MRI?
Of course, because you have to take into account, in my opinion, that AI with information coming from the images, even more precise, and radiomics is including images with genes, the information coming from the expression of different genes, there's a lot of information that AI in the future are going to get together and give you not only information about what is happening in the prostate right now, this kind of picture, but what is happening in this tissue in the future. So, of course, any development of where the prostate cancer is and how to manage it is In my opinion, it will be always relying on MRI.
Thanks a lot, Dr. Mignogna, for your answers. Let's see a little further now. What projects are you working on and what are your plans for the coming months?
Oh, this is a personal question. Well, I told you before I'm working, I'm happy and honored to direct a HAP volume center which are involved in many, many basic and clinically. research progress in the educational programs, both for students in the undergraduate and postgraduate. Yesterday, we have a workshop with people coming from all over the world to see how we work. I'm very happy with this. But today, my most important goal in the short terms is we are developing an information system. It's a recruiting information from nurses, doctors from clinical registries to get, in my opinion, if we are lucky enough, in a couple of months, we will be able to get information real time of the results of our practice. This is something I've been dreaming of all my life, and I'm very close to get to this goal.
We can't wait to see the advancements. Well, Dr. Mignogna, this is the end of our interview. Before to get back to the Congress, I like to finish my interview in music. So I would like to ask a last question. What is your favorite song of all time?
My favorite? Oh, that's a very good question. My favorite song of all time. Well, of course, it has to be with mainly three great artists. A song of David Bowie, maybe Leonard Cohen. To say maybe Neil Young, I can't select one of them. You can imagine they are great, but they have to be one of ten. Did you think maybe one space holiday because I'm used to seeing this song a lot with my children since they were very, very little today. They are adults and we still sing that song together. Maybe one of the main favorites one.
Perfect. Thank you so much. Eric, an excellent choice by the way. Thanks again for your time and I hope you like the exercise and let's go back to the Congress.
Okay. Thank you very much. Been a pleasure.
Huge thanks to our dedicated listeners. If you enjoyed the podcast, make sure to subscribe for more captivating content. Your support means the world. If you found this informative, quick favor, please drop up a five-star review. Your feedback helps us grow and deliver quality insight. Have topics you'd love us to cover? Share your ideas in the comments or connect with us on social media. Your input guides the... future of Prostatalk. Thanks for being a crucial part of our community. For more urology insights, visit Curlies.com. Stay tuned and see you next time.
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