Professor Dr. med. Marko Brock is a leading specialist in urology and robot-assisted surgery and heads the Department of Urology and Minimally Invasive/Robotic Surgery at Prosper-Hospital Recklinghausen. With his many years of experience and expertise, he has earned an outstanding reputation in the treatment of urological diseases. Prof. Dr. Brock is particularly renowned for his use of the Da Vinci surgical system, which enables exceptionally precise and gentle procedures.
His clinical focus includes the treatment of prostate cancer, bladder and kidney tumors, as well as benign prostatic enlargement. Of special note is his expertise in robot-assisted prostatectomy and in the management of complex urological conditions in which minimally invasive techniques play a decisive role. With more than 390 robot-assisted procedures in 2023 – including over 230 radical prostatectomies – Prof. Dr. Brock impressively demonstrates his high level of proficiency and experience in this field. In addition to his surgical work, Prof. Dr. Brock is deeply involved in medical research, particularly in the imaging diagnostics of prostate cancer.
As a member of numerous urological professional societies, he actively promotes knowledge exchange and the advancement of urological medicine. Prof. Dr. Brock is valued not only for his medical excellence but also for his personal and compassionate care of his patients. Through his combination of state-of-the-art technology, scientific expertise, and a human touch, he ensures optimal care for every individual patient.
The editorial team of the Leading Medicine Guide had the opportunity to speak with Prof. Dr. Brock specifically about prostate diagnostics.
Prostate diagnostics has made significant strides in recent years, particularly through the use of modern imaging modalities such as magnetic resonance imaging (MRI) and fusion imaging. These technologies enable earlier and more precise detection of prostate cancer and provide a basis for individualized treatment strategies. Especially in surgical therapy, image-guided techniques are employed that make it possible to localize tumors exactly and perform minimally invasive procedures with the highest precision. This not only optimizes tumor removal but also helps preserve surrounding healthy tissue.
In recent years, prostate diagnostics has advanced considerably through the use of cutting-edge imaging techniques, allowing for substantial improvements in diagnosis and more precise therapy planning.
„Particularly exciting in this context is the concept of fusion imaging. Personally, I have a long-standing connection here, as I have been working with MRI imaging in prostate cancer for over ten years. Initially, before MRI was widely available and established in Germany, we relied heavily on ultrasound techniques – for example, with contrast agents, classic B-mode ultrasound, or elastography, where mechanical waves are transmitted into the tissue. At that time, efforts were made to visualize prostate cancer from different perspectives, but this ultimately led to MRI. Today, MRI has a firm place in the diagnostics of prostate cancer and of the prostate as a whole. With the current revision of the German S3 guideline, MRI has gained even more importance: the classic digital rectal exam is increasingly moving into the background in preventive care. Instead, in the event of an elevated PSA level or a rapid PSA rise, MRI is now recommended directly – which confirms the existing diagnostic concept. Ultrasound and contrast-enhanced ultrasound are limited in their diagnostic value. Even if there are newer developments in high-resolution ultrasound in which certain prostate areas do not seem inferior to MRI, ultrasound overall remains limited – both in sensitivity and specificity. In contrast, MRI is technically standardized. Multiparametric MRI combines different sequences such as diffusion-weighted imaging, T2-weighted imaging, and contrast-based techniques. This standardization makes it the preferred method for visualizing prostate cancers“, explains Prof. Dr. Brock at the beginning of our conversation, adding:
„Elastography hardly plays a role today. Since MRI has become available at this level of quality, it is rarely used in practice. The method is simply too inaccurate, too subjective, and prone to error. Many of the abnormalities seen there ultimately do not correspond to cancer. Therefore, the use of elastography for prostate diagnostics is clearly discouraged – even though it is still employed in some practices or clinics. From a professional standpoint, this is hardly justifiable, especially since the S3 guideline clearly advises against using elastography for diagnosing prostate cancer. If anything, it might be used adjunctively for size assessment – but it is unsuitable for predicting cancer“. 
One of the greatest strengths of fusion imaging is its ability to avoid misdiagnoses. In conventional biopsies, in which samples are usually taken blindly from several areas of the prostate, tumors can be missed or samples may be taken from less affected regions. With image-guided fusion biopsy, however, tissue is taken directly from suspicious areas, resulting in a higher hit rate and more accurate diagnosis.
Before surgery is even considered, detailed imaging is performed – in this case, MRI of the prostate. It is important to note: MRI itself does not make the diagnosis.
„The diagnosis of prostate cancer is always made histologically, that is, through a tissue examination. Imaging, however, provides a crucial indication as to whether there is a suspicion of cancer and whether a biopsy – a tissue sample – is necessary. This is precisely where MRI shows its major advantage. In patients who have not yet undergone a biopsy, MRI can achieve a five to ten percent higher sensitivity. That means the likelihood of actually detecting a tumor increases. At the same time, MRI allows for more precise tumor characterization. Multiple foci can be present within the prostate – but it is crucial to identify the focus with the highest metastatic potential. Only so-called clinically significant cancers actually require treatment. This is where MRI excels. If there is an elevated PSA level or other suspicion, an MRI is performed first. Subsequently – if necessary – a targeted fusion biopsy is carried out, combining MRI images with live ultrasound. If the tumor is histologically confirmed and precisely localized, a kind of ‘tumor map’ is created on which therapy planning is based. Especially in the case of planned surgery, this MRI-based planning provides critical information: for example, the exact location of the tumor in relation to the bladder neck, the sphincter, the urethra, or the rectum. This allows for significantly more precise surgical planning. These insights also help determine whether a nerve-sparing approach is feasible and to what extent“, specifies Prof. Dr. Brock.
Image-guided surgical methods and robot-assisted techniques offer numerous advantages over traditional surgical procedures in the treatment of prostate cancer.
One of the greatest strengths of these modern approaches is markedly improved precision. By combining imaging modalities such as MRI and ultrasound, surgeons can visualize the exact location of the tumor in real time, enabling targeted and minimally invasive removal of the cancer. This leads to reduced tissue loss, as healthy areas of the organ can be preserved. Compared to traditional approaches, where surgeons may have to rely on blurry or less detailed images, image-guided surgery allows for more precise planning and execution of procedures.
„Robotics plays a central role in our surgeries, especially in prostate procedures. The diagnostics performed beforehand are crucial for surgical planning. For example, in cases of intermediate-risk prostate cancer, we determine whether lymph node dissection is necessary based on the location and size of the tumor on MRI and the risk of metastasis, which we calculate using nomograms. This approach helps us avoid unnecessary lymph node dissections and thereby reduce complications such as lymphedema or thrombosis. We now perform prostate surgeries exclusively with robot assistance using the Da Vinci system, with roughly 300 procedures for prostate cancer each year alone. In addition, about 40 radical cystectomies with reconstruction in the abdomen and around 100 kidney tumor operations, including partial nephrectomies, are performed. The Da Vinci system was first introduced here in 2008 with an older generation at the time. Today, we have the latest four-arm system from Intuitive, and we operate with two devices. Patients are hardly unsettled by robotics today, as this technology has become standard and is no longer a unique selling point. We can particularly distinguish ourselves through the excellent quality-of-life data that we collect systematically. As a certified German cancer center and uro-oncological center, we are evaluated based on quality parameters. These include, among other things, margin negativity, recurrence rates, and, above all, patients’ quality of life – such as the frequency of urinary incontinence or erectile dysfunction. In these areas, we have ranked among the top centers compared with over 130 centers in Germany, Austria, and Switzerland for several years, and we even held first place in the past two years“, states Prof. Dr. Brock. 
The introduction of image-guided surgery has significantly improved healing and postoperative recovery for patients with prostate cancer. These modern technologies, particularly the combination of high-resolution imaging such as magnetic resonance imaging (MRI) and ultrasound, as well as the use of robot-assisted surgery, provide surgeons with more precise visualization and procedural planning. This leads to a range of benefits that positively influence healing and recovery after surgery.
„Tumor-specific prognosis in prostate cancer – that is, whether a tumor recurs or metastasizes – depends largely on the tumor’s aggressiveness and the timing of diagnosis. Today, surgery is generally performed from stage 2 onward, and early diagnostics and modern imaging, which capture tumor size even before surgery, allow for nearly 100 percent margin-negative resections. Tumors detected later that may already involve lymph node metastases or adjacent organs, however, carry a high risk of recurrence despite surgery. It is therefore essential to tailor both diagnostics and therapy to the patient and the individual case. The patient’s personal need for security, as well as that of their family, plays an important role. While younger patients generally want to undergo biopsy for certainty, older patients often consciously decline further testing and prefer to live with a certain level of risk. Therapy is likewise adapted to personal risk and individual needs, for example through closer follow-up or additional adjuvant treatments in the case of higher recurrence risk“, explains Prof. Dr. Brock, offering an important note:
„If a finding is only monitored, follow-up is carried out strictly according to guidelines. Patients are usually enrolled in an observational study such as the PRIAS study (Prostate Cancer Research International: Active Surveillance), which is reviewed annually on an international basis. Currently, around 70 patients are recorded in it. Follow-ups are performed in collaboration with community physicians, with PSA values measured every three months. A repeat MRI is recommended after one and three years according to defined criteria, or earlier if there is a notable change in the PSA level. Unfortunately, many men are little aware of these options and the current data situation, as there is a lot of misinformation on the internet. It is therefore advisable to consult a competent physician“.
The typical prostate cancer patient is around their mid-60s, with preventive checkups recommended starting at age 45 or 50, as risk increases significantly during this period. There is a clear need for education here, as men attend preventive screenings less often than women.
Prof. Dr. Brock recommends: „However, preventive care is particularly important, since tumors can be treated or monitored more effectively at an early stage. A major problem is the lack of coverage for prostate MRI by statutory health insurance. PSA tests are also not covered benefits but rather individual health services that patients must pay for themselves. MRI, which is recommended by the guidelines to refine diagnosis, costs patients several hundred euros. This financial burden means that many patients are not treated in accordance with guidelines, which represents a significant disadvantage compared to other cancers, such as breast cancer in women, where mammography is covered by insurance. This issue receives little political attention, even though prostate cancer is the most common tumor in men. Studies demonstrating the benefits of MRI and fusion biopsy are sometimes ignored, as assessments, for example from IQWiG (Institute for Quality and Efficiency in Health Care), reach different conclusions without involving urologists. For providers, this creates a conflict: they want to treat patients in line with guidelines but cannot always order the recommended examinations because they are not reimbursed, which limits diagnostic quality“.
Prostate cancer is considered one of the most treatable cancers when detected early!
Prof. Dr. Brock explains: „In the past, treatment often involved immediate surgery or radiation upon diagnosis, which was associated with considerable side effects such as incontinence and erectile problems. Today we know that many early-stage tumors can initially be monitored, and only about 40 percent of patients will require treatment over time if the tumor becomes more aggressive. The fear many men have of incontinence or impotence after a diagnosis is therefore often unfounded. Modern, nerve-sparing surgical techniques lead to complete continence without pads in over 90 percent of cases in patients without additional risk factors such as diabetes or obesity. Factors like pre-existing incontinence or prior radiation therapy can worsen outcomes, but the surgery itself is not always the cause of such issues. That’s why individualized, patient-centered treatment planning is crucial to preserve quality of life as much as possible and to operate only on those patients for whom the benefits clearly outweigh the risks“.
Health policy in Germany is undergoing a comprehensive transformation, primarily shaped by the current hospital reform. This reform aims to improve care by centralizing complex procedures at specialized clinics with the requisite experience.
Studies show that higher case volumes improve treatment quality in demanding surgeries. At the same time, practical implementation of the reform in many regions, for example due to a lack of information and short lead times, poses challenges. In addition, financial aspects, such as adjustments to reimbursement systems, and the long-overdue digitization of the healthcare sector are important issues that are crucial for sustainably ensuring high-quality patient care.
„I basically welcome the current hospital reform that centralizes procedures in facilities with certain experience levels. Studies show that the quality of complex cancer operations improves when they are performed more frequently. However, I find the mode of implementation, especially here in North Rhine-Westphalia, problematic – there was too little information and lead time, which makes practical implementation difficult. It would also be desirable to make quality measurable and to reward better quality with higher reimbursement, for example through a quality-oriented DRG (Diagnosis Related Group). In urology, specifically in prostate cancer, this is currently being attempted, but we are still far from achieving it. Another major issue is the revision of the medical fee schedule for private billing. We have significant concerns here because revenue from private insurance cross-subsidizes the healthcare system. If the fee schedule becomes more restrictive and we can only bill for standard services, substantial revenue losses threaten. This, in turn, jeopardizes cross-subsidies, such as prostate MRI for statutory-insured patients, which often is not covered“, says Prof. Dr. Brock, and continues:
„Hospitals are already fighting for survival and must constantly invest in new technology to remain competitive. Good economic efficiency and digitization are essential. Unfortunately, digitization still lags behind in many hospitals. For example, there is still no widespread implementation of electronic discharge letters or integration with electronic patient records. While digitization is progressing in medical practices, hospitals often remain stuck with outdated systems. Data protection requirements also make it difficult to send findings by email, and fax is still in use, which I consider long outdated. Politics must invest more and push implementation, because the financial outlay is a major hurdle for hospitals“.
In closing, a clear appeal to all men!
„More preventive care, less Dr. Google. Preventive checkups are recommended starting at age 45 or 50 and usually take place once a year. If the PSA level is low at the outset, the intervals can be extended to up to three years. The digital rectal exam is becoming less important, but it is still performed to estimate prostate size, for example. Thanks to modern technology, preventive care can now also be conveniently conducted via blood draw and video call – making participation even easier and more practical for patients“, advises Prof. Dr. Brock, and with that, we conclude our conversation.
Professor Dr. Brock, thank you very much for these important insights into prostate diagnostics!
