Dr. Zhan Chitalov is the chief assistant in the urology clinic at the University Hospital "St. Georgi" in Plovdiv. He graduated from the Medical University under the hills. His career began as a surgeon in Ardino. There he took part in the famous sex change operation of Adriana, which Dr. Kaloyan Persenski performed first in our country
He has specializations in endourology and extracorporeal lithotripsy (breaking kidney stones without surgery) in Bursa, Turkey, and in the Military Medical Academy under Prof. Iliya S altirov.
On June 28 this year, Dr. Chitalov was again awarded the "Doctors we trust" prize.
Dr. Chitalov, in the month dedicated to men's he alth - November, let's talk about the most serious disease threatening men's lives - prostate cancer. Has the incidence of prostate cancer increased in recent years?
- Prostate cancer is one of the leading causes of death in men.
Why does it take this unprestigious, first place? What do you think are the reasons?
- The reason is not very clear, but it is known that technologically advanced nations, where people work more sitting down, have a higher incidence of the disease.
Does the hereditary factor also play a role?
- As with all cancers, prostate carcinoma is known to require more careful monitoring in patients with a family history of cancer. About fifteen years ago, a protein in the blood called prostate-specific antigen became known. It is elevated in people who have this disease. And after many studies, first in the US and then around the world, it was decided to use this marker as a screening test.
What does screening test mean in this case?
- Screening test means that without having any complaints, men after 50 years should have their PSA checked once a year. And in the presence of high values above the norm - the upper limit is accepted as 4 ng/ml, the patient must visit his urologist in order to carry out the relevant consultation.
What is the purpose of screening?
- The goal is to detect the disease at the earliest possible stage, when effective treatment can be carried out.
Other tumor markers are known in the human body - those that look for, for example, carcinoma of the intestine, liver, etc., but this is the only organ-specific tumor marker.
What does organ-specific tumor marker mean?
- This means that this tumor marker is elevated only in diseases of the prostate gland. And with elevated values, consultation with a urologist is recommended. On this issue there is a discussion around the world, how
the value of this tumor marker can be significant at a certain age, because in men, the prostate gland usually increases in volume with advancing years. At 60-70 years old, it is around and over 50 g, and the larger the prostate gland, it would be natural to form larger values of this prostate-specific antigen. Therefore, in some cases, depending on the age of the man, even values above 5-6 nanograms per milliliter are considered normal. But not all experts share this opinion. In my practice, I have patients who live for many years with values of 5 and 6 and we do not detect prostate cancer in them. The most important thing in this case is the dynamic tracking of this prostate-specific antigen.
What does that mean?
- If the value is above 4, we do research in 2-3 months and report whether these indicators have upward dynamics. If they start to grow, we should have a red light that there may be an active process here.
How do you prove the existence of such an active process?
- It is a generally accepted rule in the American and European Association of Urology that we must, in order to treat patients with prostate cancer, have to prove it. The proof is done with a special needle through which we take a sample from the gland, which we examine under a microscope and look for tumor cells. This is a type of biopsy in which we take material through the colon from the three lobes of the prostate gland - from 10 to 12 biopsies. In recent years, however, certain centers that work only on prostate cancer sometimes operate on patients who are at risk for prostate cancer without proven carcinoma.
Last year I was at the European Congress of Urology held in London, and there were special studies there that showed cases of operated patients without proven prostate cancer, by performing a special operation - prostatectomy.
Is this practice already in Bulgaria?
- I know that in Varna they performed such an operation only because of a high risk of developing prostate cancer, which was not proven before the surgical treatment. There are such cases and they are discussed. Maybe they will become a routine practice in the future, but for now I emphasize again thickly that they are not a daily practice, because one can ask us afterwards: why did you do this operation on me without proving that I have cancer? And we really won't be able to give him a satisfactory answer. That is, the patient must accept this thesis in advance that in the operation we may not prove that there is such a cancer at all, after which this intervention can be carried out.
You mentioned the prostate biopsy. Are there different methods of applying it?
- It can be performed transrectally under ultrasound control. In this method, there are special transrectal transducers that monitor from which area of the prostate gland a sample will be taken, because in their work algorithm it is assumed to show in a certain way the areas that are suspicious for the presence of prostate cancer. And after the test results are received and cancer cells are found in them, we talk to the patient and explain to him that we have proven the presence of prostate cancer.
After that, we do a series of tests, the most important of which are: MRI (magnetic resonance imaging) - it localizes the changes in the prostate gland, it gives us information about whether this cancer has spread outside the gland and whether it affected other organs. And the other test that we do in most cases is a bone scintigraphy, because this type of cancer first spreads precisely in them, mostly in the flat bones - of the pelvis, vertebrae and ribs, as well as in the flat bones of the skull. This study looks for such lesions and bone changes that would be relevant for prostate cancer metastases.
In addition to the bones, the cancer spreads to the lymph vessels and nodes, especially in the area of the pelvis. If we find that the patient has no metastases, neither in the bones nor in the lymphatic system, we move on to surgical treatment.
How is the operative intervention carried out?
- If the tests show that the tumor is confined to the prostate gland, the patient is indicated for surgical treatment
Here I want to open a parenthesis - as a urologist, I tend to say that surgical treatment is the best, but recently a number of x-ray and other non-surgical methods of treating prostate carcinoma have been introduced. For example, the so-called "cyber knife" can irradiate only the prostate gland. The purpose of this radiation is to destroy the cancer cells inside the gland, with all the pros and cons of such radiation - it eliminates the operative risk and the complications afterwards - the most unpleasant of which are discharges when needed - in 10 - 20% of cases we can't avoid it. But open surgery has not lost its importance even now. With it, the entire prostate gland is removed, as well as the lymph nodes, which we already commented on.
You recently implemented a new laparoscopic method in your practice. Tell us more about it
- For 10-15 years we have been applying the so-called laparoscopic methods, which initially operated through the abdomen. Now we are already working without entering the abdominal cavity. We remove the entire gland and restore the communication between the bladder and the urethra through five small openings in the anterior abdominal wall. We have been applying this method in our hospital for two months. In this way, we save the greater operative trauma that occurs with the open operative technique.
By applying this method, we are not saying that it is the only and best one. Open operations have their indications - for example, in more advanced tumors or when there is evidence of involvement of surrounding organs and tissues.
Robot-assisted prostatectomies come in third place from operative treatment methods. They are known in our country - these are the "Da Vinci" devices, of which there are already third-fourth generations. With them, the very "hands of the apparatus", figuratively speaking, operate on the patient through the operator. It also has its pros and cons. The advantages are that it is much easier to work - everything is like a computer game. And the minuses - the efforts that the operator applies to the control handle and, accordingly, the force with which the operating "hands" of the apparatus affect the patient are not proportional, which can cause injuries.
PSA is the only organ-specific tumor marker in the human body
After applying the treatment according to the new laparoscopic method, is it necessary to prescribe another therapy?
- After applying the method, we send material for histological studies. And depending on the results obtained, oncologists determine whether and what treatment needs to be applied. One of the most important criteria for postoperative success and the absence of metastases is the PSA value, which we measure one month after the surgical intervention. If it has fallen to around zero, and even more so, if it does not undergo dynamic development in the coming months - i.e.f. does not rise, the results are considered excellent. Of course, this does not depend only on the operative technique, but also on whether the patient himself previously had metastases that were not detected by imaging studies. Naturally, this is understood subsequently, when the histological studies taken during the operative intervention are available.
If the cancer is detected at a time when there are already bone metastases, is there a treatment option and what is it?
- There is, of course! Logically speaking, in this case we do not resort to surgical removal of the organ. However, there are operative techniques and treatments that help these patients.
Who are they?
- As early as the middle of the last century, two authors have proven that prostate cancer is hormonally dependent on the levels of testosterone, which is produced by a man's testicles. In such cases of advanced cancer, we can remove the cells themselves inside the testicles, which can stop the cancer from growing and sometimes even shrink it. This is not a 100% radical treatment, but still, I know from experience that such patients feel well and live comfortably for years. That is, we can apply this technique by surgically removing these cells in the man's testicles and then apply hormone treatment.
What is hormone treatment?
This is to further block all androgens in the body - testosterone is a type of androgen. The adrenal glands and other cells in the body try to compensate for the lack of testosterone and produce new amounts of androgens. These preparations in tablet and injection form also block these androgens in the body and thus stop the development of cancer
These drugs are prescribed by oncologists and taken for life by the patient.
Our urologists are good specialists
“We are urologists who constantly attend the organized seminars and conferences in our speci alty. The bad thing is that the clinical paths in our country are very low valued by the He alth Fund, and therefore we are not able to acquire the necessary funds so quickly to be technologically abreast of the best centers in the world. But, nevertheless, I can state that there are 5-6 centers in Bulgaria that apply all these modern methods and are not inferior in quality to the best urologists in the world.
Unfortunately, the treatment is not covered by the NHS to the required extent. In the high-tech technique we use, the electroknife handle alone, for example, costs about 800 euros per patient. And it's not just her - staplers are included, the tools used to work with, special threads are also used… All these consumables must be paid for - one part is covered by the clinic, another - by the patient. Since they are disposable, the He alth Insurance Fund does not cover them. It is important for us to maintain our reputation and to work according to the most modern methods. You understand that not everything is about money, it is important for our center to have these devices and to apply them when necessary", added the specialist.
About the he althcare system
"The he althcare system requires a strong hand and a strategy," said Dr. Chitalov. And he adds that he does not see this strategy. "We are struggling piecemeal to solve things. Look at what is happening in the periphery - in cities outside of Plovdiv, Sofia, Varna, a person, if something happens to him, there is no one to operate on him, because there are no specialists there, they left. And when they don't work, they are dequalified. And now, even if they want to work in 2-3 years, they won't be able to. We, narrow specialists in our field, have been building for years. And at some point, if the state, for some reason, which it considers the most appropriate, does not provide us with the opportunity to work - for example, through increased requirements (5-6 doctors) for opening a urological unit, the problems will deepen even more. If we look at our he alth care system as a whole, I am not optimistic at all. What we do in our center as specialists costs us a lot of nerves, our own personal time, because we throw our efforts around the clock in this direction - I research which is the best equipment, prepare the relevant contracts, contact the companies. You have to be a trader, a doctor, and a manager… The fact that we combine several activities, that we have reduced the non-medical staff as much as possible, allows us to be a working hospital with a good perspective. Otherwise we're stuck right away. In Bulgaria, if only a certain type and number of operative interventions are performed, as in the specialized clinics in the west, we will not survive."
The pages were prepared by Milena VASSILEVA