Surgeon experience

Bill_in_Portland

I was diagnosed with intermediate risk Prostate Cancer a few weeks ago.  Currently trying to decide on treatment,  radiation or surgery?  PSA 4.31, Clinical T2a, Gleason 4+3=7  The urologist Ive been talking with is young, out of residency only one year. I am getting second surgery opinion and discussing with radiation oncologist. When I asked how many surgeries the young Urologist has performed, he said the more important consideration was how comfortable he is in performing the surgery.  Is this a bad sign, how difficult is a radical prostatectomy? I like the guy and he has been very forthcoming with information.  He would be accompanied by a more senior surgeon from the practice? Fore River Urology in South Portland?  anybody with experience?

Old Salt

You don't want to be part of his learning curve...

I would choose a surgeon who has done at least 500 prostatectomies. No surgery is simple and complications do arise.

More in general, do consider all options for your situation.

Max Former Hodgkins Stage 3

Perspective

Bill,

At some point, the best current robotic surgeon in the world had not done a single Prostectomy....  

But experience is important.  Dr Peter Scardino, Chief of Surgery at Sloan-Ketterign in NYC states in his book entitled simply The Prostate Book that proficiency is usually assumed by around 200 operations.  Do find out how many this guy has done.  If you choose him, I definitely would demand that a highly regarded fellow surgeon from the department be present the whole time to supervise.

You say you are speaking with a second surgeon; I would definitely ask his numbers also, and consider him also.

max

hopeful and optimistic

possibility of extracapsular extension

I wonder what the details of the results of your biopsy are. How many cores were taken, how many were positive, and the amount of cancer in each core...any other notes mentioned in the biopsy.

A 4+3=7 is intermediate aggresive, and there can be a possibility(especially if there are several cores that are positive)  that the cancer has escaped the prostate. If that is the case therre will still be cancer in your body, and you might incur side effects of surgery which can be very considerable while still having cancer that needs to be treated with radiation and or hormone treatment (and more side effects) Side effects of each treatment type is cummulative.

Please post the details of your pathology.

Did you have have any other tests, ie image tests.

There is a 3T MRI, the most refined MRI image test in clinical use. This is done with contrast and no contrast. This test may show if there is extracapsular extension. It is important to have such a test before any active treatment so you know where you stand.

As far as surgery, as Old Salt mentioned, there is a vast difference in the excellence of surgeons....there is a very steep learning curve. One criteria is the number of surgeries preformed, and some of these surgeon have done thousands. Side effects to patients are greater among non experienced surgeons such as you are seeing when compared to experienced surgeons.

Another criteria that is important is surgical margine.  You can ask each surgeon , " What is your surgical margin?

There are a few surgeons in the country that are recognized as "artists".

But to be honest, generally you will experience less side effects with various forms of radiation, with similar outcome as surgery. One radiaiton treatment that  I highly recommend, that several at this site have done successfully is SBRT. (There are various machines that deliver SBRT; cyberknife, novalis, etc....these various machines provide similar outcomes)

GeorgeG

An RP is a fairly complicated

An RP is a fairly complicated surgery and needs a competent surgeon to get the best outcome. I believe Walsh recommended a minimum of 300 operations if I remember correctly. Mine had 4,000 (Johns Hopkins). The only guys I considered all had thousands and my guy only does opens but I had an advanced case. There are a lot of good robotic guys around. 

To your point however, you also have to feel comfortable with the guy. Some of the top guys get some crappy patient feedback because they are not very patient focused and may be difficult to get a hold of later if there are problems. My guy was available 24/7 after surgery and I had zero complications so I was very satisfied.

George

 

Max Former Hodgkins Stage 3

GeorgeG said:

An RP is a fairly complicated

An RP is a fairly complicated surgery and needs a competent surgeon to get the best outcome. I believe Walsh recommended a minimum of 300 operations if I remember correctly. Mine had 4,000 (Johns Hopkins). The only guys I considered all had thousands and my guy only does opens but I had an advanced case. There are a lot of good robotic guys around. 

To your point however, you also have to feel comfortable with the guy. Some of the top guys get some crappy patient feedback because they are not very patient focused and may be difficult to get a hold of later if there are problems. My guy was available 24/7 after surgery and I had zero complications so I was very satisfied.

George

 

Thought-provoking additional point

Some surgeons are plenty competent but nonetheless somewhat marginal in natural ability, and learn less-than-best habits, but still do thousands of surgeries.... They are Board Certified, belong to a well-regarded clinic or hospital, and a career then goes through the motions. 5,000 surgeries later, they retire to their private island, or wherever.  (see reference below)

Numbers by themselves are important and the easiest reference point, but do not always prove a  man the best.  Beyond numbers performed, things get more subjective.  It is easy to ask, "How many DaVincis?"  Less easy to ask, "Are you lacking in insight, and just go through the motions once the caviity is open?"  Is the congressman who has won the most elections in a lifetime ordinarily "best" ?

max

Quotation from Director of Surgery at Sloan KCC. I would assume his title requires him to screen and evaluate new surgical hires. Dr. Peter Scardino's Prostate Book. Avery Press, 2010 [2nd Ed], Page 298.  SKCC is of course regarded as either the best or one of the very best cancer centers in the world.

While it is generally true that busier surgeons have better outcomes, this is not universally the case.  Some surgeons continue to do the same proceedure badly, even though they do it all the time...even the best reported results are not an absolute guarantee of surgical skill.  Some surgeons limit their caseloads to only the most favorable patients, artificially inflating their record of good outcomes. 

Adequate due diligence and several credible recommendations are your best route to a good surgeon.

.

contento

Bill

Bill I think the advice above is right on. A gleason 7 (4+3) is nothing to play around with. I'm sure your doctors are doing the necessary tests to help you deceide the proper treatment for your specific case. As far as doctor experience is concerned i would say absolutely yes experience counts especially with robotic RP. I had recently saw a urologist ( this visit had nothing to do with cancer , i had a kidney stone that needed blasting ) that has 25 + years experience doing open RP's . He told me he that as you would expect his business is down since most surgery patients are choosing the robotic route. He said he had every opportunity to learn robotic RP but refused to do so primarily because of the learning curve needed to attain expertise. it wasn't fair to his early patients. So bottom line if you go RP definately choose a surgeon with  extensive experience. I think GeorgeG threw out a 300 number and OldSalt threw out a 500 number . I would agree . Just as important you need to feel comfortable with your doc so you could ask the tough questions.

 

 

 

Grinder

More

Fyi there have been websites that not only list the number of procedures performed, but also the averages of procedure side effects and the severity. Of course, every surgeon will have some incidence of side effects, but the charting helped illustrate surgeons with typical side effect records vs those like Max was suggesting... surgeons who have performed many procedures, but also have an alarming number of side effects, and many of them severe in nature.

Unfortunately, the site I depended on, Surgeons Scorecard, has not been updated since 2015. But if I were facing RP, I would still look for a medical consumer information site that lists prostate cancer surgeons and their experience and success rate. There are others out there.

Six months after my RP, I was subjected to an "interview" with my DaVinci surgeon that was recorded and in the presence of a hospital administrator. I was asked questions that would establish the success of the operation, and any side effects that were not anticipated in normal RP results. I was happy to go to bat for the surgeon, figuring this would be a feather in his hat for the record. So I am also figuring this recorded interview would protect him from frivolous lawsuits as well, besides improving his success rate in the public record.

And I have to agree with the guys... You want the best surgeon possible. Yes, everybody has to do their first, second and third surgery sometime... BUT why should it be you? There will be some guys that simply cannot operate the DaVinci system, they will discover that very quickly.

My college roommate and I were interns at the PRI in Indianapolis. One of the tasks we performed was the removal of rats brains and liquified in a centrifuge to test chemical hormone levels. My roommate wanted to be a neurosurgeon, but when he attempted the removal of the brains, he was all thumbs and the brains came out a cut up mess. I myself proved very dexterous and with a few snip snips popped them out with ease. (Probably a result of intricate modeling experience as a kid). Needless to say, my roommate switched gears immediately and is now a successful GP in New Orleans.

My point is, how will the guys who are doomed to discover they are NOT very good at Davinci RP going to get the experience that helps them discover their inadequacies? Don't let it be you. Davinci robotic surgery is a different animal from open cutting.

I have read far into these archives. There is an instance of a patient taking a chance with a "newbie" implanting an AUS (artificial urinary sphincter) who also had an "experienced" surgeon supervising the operation. The result was an unmitigated disaster that had permanent side effects for the unhappy patient. 

These are our lives and we will have to live with the results. Either way the surgeons cash the checks. Does that sound harsh?

Also... There are some guys on this forum who claim the problem is with the Davinci surgery. It can be a tricky business attempting as much nerve sparring as possible... But I will continue to contend that it is more likely the ability of the surgeon than the inadequacy of the procedure. That big **** metal monstrosity hanging from the ceiling is only as good as the guy operating it.

GeorgeG

When you meet with doctors

When you meet with doctors ask them what their statistics are. Some answer the question and some don't. My experience is that the better doctors are quick to answer in detail. I passed on the ones who were evasive. It's not fool proof but it's more information.

 

George

 

TinkerbellRM27

GeorgeG said:

An RP is a fairly complicated

An RP is a fairly complicated surgery and needs a competent surgeon to get the best outcome. I believe Walsh recommended a minimum of 300 operations if I remember correctly. Mine had 4,000 (Johns Hopkins). The only guys I considered all had thousands and my guy only does opens but I had an advanced case. There are a lot of good robotic guys around. 

To your point however, you also have to feel comfortable with the guy. Some of the top guys get some crappy patient feedback because they are not very patient focused and may be difficult to get a hold of later if there are problems. My guy was available 24/7 after surgery and I had zero complications so I was very satisfied.

George

 

George, you mentioned you had

George, you mentioned you had an advance case.  What was your diagnosis, why did you decide surgery, and are you happy with your choices? Did you also have radiation? My father is really struggling between surgery or DART Radiation + Seed Implants.

 

69 years old, PSA 144, Gleason 3 + 4 (all 7 cores positive), volume 60 - 90%, bone and Pelvic MRI clear

GeneRose1

Yeah, That's a Real Bad Sign!

Bill, My RP left me with severe incontinence (4-6 Depends undergarments per day, every day, for the last three years!), ED, and the cancer came back six months later anyway. From my Urologist Surgeon's perspective, he got my prostate out and I didn't bleed to death on the operating table so it was a job well done....and I was his 556th successful surgery. My point is that a successful outcome is broadly defined and you need to hedge your bets by going to MD Anderson, John Hopkins, Cancer Treatment Centers of America; someplace that does RPs everyday and is widely noted for their professionalism and competence. If I had to do it all over again, knowing what I know now, I would have looked much harder at the seed implants. Fortunately, relative to others, you're not that bad and a lot of new treatments are either just now coming out or are finishing development. I would take a deep breath, get back on the internet and start making inquiries and appointments with the pro's at MD Anderson or similar. This is about your health and future and not about building somebody's resume. Sorry to vent but I've gone through several Doctors and have found more useful information and advise from this forum and my own research and I wish you all the best. Gene

SPT

Don't do it

Don't let the young doc near you.  I'm sure he is a nice guy but that doesn't matter. He is still learning and will be making his mistakes on your tissues.  Radical prostatectomy is a demanding operation, with very little margin for error, and you pay the price for any slips. 

 

Good luck to you.

Bill_in_Portland

second opinion

saw another practice associated with a larger hospital (Maine Med)  she has been doing RP since 2004 and does about 2 per week. Hospital has two robotic units and only do robotics. She said that yes you lose the tactle sense in not doing open but you strengthen your other senses, which i think makes sense. with the laproscopy they pump gas into your cavity so there is less bleeding and supposedly better optics. Makes sense to go with the robot with Rad as a backup if PSA is detected post op.

 

GeorgeG

Tinkerbell

Tinkerbell

I am happy with my choices. RP went well, no complications, negative margins, 100% continencs, partial erection at 6 months. Unfortunately I had SV involvement (but clear nodes) which was not knowable going in. I also got upstaged to 4+3. I then had biochemical failure and just finished SRT/ADT. We are all different and the best treatment option is not the same for everybody. I am a young 62, strong, no competing mortality risks, heal fast. Surgery made sense to me but some here would argue that radiation makes sense with an advanced case because you may be back for radiation later.

Before surgery I was 3+4 with fairly extensive volume at MRI with some risk for extracapsular extension. Either radiation or surgery would have been a good choice for me. I went to Mayo, JH, MSK and MDA before I decided. If I would have chosen radiation I liked MSK. They would have dome seeds plus EBRT at up to 80 gy. I have my surgery at Hopkins and my SRT at Mayo - just finished this week.

George

 

YOCKOMO

Prostate Doctors opinions

A urologist, an oncologist and a family doctor walk into a bar.....That is how my prostate cancer experince went. My family doctor (for 40 years) saw a rise in my PSA level but would not tell me anything after a DRA, but sent me to a urologist base on the raised PSA level (4). The urologist looked me in the eye after a DRA and said that there is an irregular shape and (gleefully) proclaimed I have cancer! After being sent for MRI. bone scan and three months of tests I return and he almost raises a fist pump in "YESSS, I nailed it" (Gleason score 6). Sends me to an oncologist who gives me a DRA with at least two fingers raming them in to elicit an orgasmic contraction! (at least I think they were his fingers" He then suggests brachiotherapy (his specialty) or prostate surgery. As the intestine keeps flopping in the way he suggested at first hormone therapy to move the intestine away from the bladder. There was almost a fistfight as the urologist never heard of such a thing. Both got fed up and sent me to another doctor. She was doing trials for Cyberknife which nobody heard of or weren't saying. Long story short after 5 treatments, no hospital stay, no surgery, still riding the bike all throughout! I am cancer free with PSA of 1.6 and testosterone of 13.2. NO SIDE EFFECTS!! PLEASE, PLEASE PLEASE look in cyberknife. Here, in Canada it is free!!

So the urologist orders a single malt scotch. the oncologist orders a blend, the family doctor asks " Is there a Vas Deferense between the two?" The Oncologist replies "The difference is in the ions, there are those in the negative state, negative ions and those in the positive state or pro-state. We can, of course, eliminate the pro-state." The family doctor says' "I will look into this digitally on line and refer to the  anals of mankind so I won't be on the dark side of the moon on this." They all drank up, put on their gloves and left.

Max Former Hodgkins Stage 3

YOCKOMO said:

Prostate Doctors opinions

A urologist, an oncologist and a family doctor walk into a bar.....That is how my prostate cancer experince went. My family doctor (for 40 years) saw a rise in my PSA level but would not tell me anything after a DRA, but sent me to a urologist base on the raised PSA level (4). The urologist looked me in the eye after a DRA and said that there is an irregular shape and (gleefully) proclaimed I have cancer! After being sent for MRI. bone scan and three months of tests I return and he almost raises a fist pump in "YESSS, I nailed it" (Gleason score 6). Sends me to an oncologist who gives me a DRA with at least two fingers raming them in to elicit an orgasmic contraction! (at least I think they were his fingers" He then suggests brachiotherapy (his specialty) or prostate surgery. As the intestine keeps flopping in the way he suggested at first hormone therapy to move the intestine away from the bladder. There was almost a fistfight as the urologist never heard of such a thing. Both got fed up and sent me to another doctor. She was doing trials for Cyberknife which nobody heard of or weren't saying. Long story short after 5 treatments, no hospital stay, no surgery, still riding the bike all throughout! I am cancer free with PSA of 1.6 and testosterone of 13.2. NO SIDE EFFECTS!! PLEASE, PLEASE PLEASE look in cyberknife. Here, in Canada it is free!!

So the urologist orders a single malt scotch. the oncologist orders a blend, the family doctor asks " Is there a Vas Deferense between the two?" The Oncologist replies "The difference is in the ions, there are those in the negative state, negative ions and those in the positive state or pro-state. We can, of course, eliminate the pro-state." The family doctor says' "I will look into this digitally on line and refer to the  anals of mankind so I won't be on the dark side of the moon on this." They all drank up, put on their gloves and left.

Very realistic

Both the CK story and the bar exchange were great, YOCKOMO.

Love the Wide Glide, or whatever model your scooter is.  In 1970, just before the first-ever Superglide was introduced, Harley sold two (2 !!) models: Sportesters, and Electra Glides. I guess they have 30 models today.  The Superglide was not a big hit, but in a few years the Low Rider came out (one color only:  dark grey on black), and Harley sales exploded.  It was the to-die-for bike.

Happy trails,

max