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High Number of Procedures

txbarton's picture
txbarton
Posts: 89
Joined: Aug 2009

When i told my son that my surgeon will have more than 2000 daVinci procedures by the end of this year he remarked that he doesn't think he has done anything 2000 times which made me think about it.

If you drive to work every day, starting your car to go and to come it will take you almost 4 years to start your car 2000 times.

If you don't nap and only fall asleep once a night it will take over 5 years to fall asleep 2000 times. Same for BMs if you go once a day.

It will take 2 years to eat 2000 meals at 3/day.

Now imagine the surgeons that have 3000 or more procedures.

Just a little perspective.

VB

jhagerup
Posts: 68
Joined: Oct 2009

My surgeon had done about 225 before he did me. I was a little concerned about that low number but: 1) someone said that the learning curve levels off after 100, 2) I was dry the moment they removed the catheter and 3) My gut feel is that my surgeon is very skilled (he's done many of the "open" type before he learned to do daVinci).

Certainly higher #'s are better but I would think that with a good surgeon, numbers in the 200's are OK.

William Parkinson
Posts: 60
Joined: Oct 2009

The number sounds high to me, simply because the DiVinci did not become widely available until 2003 I think. I thought I might mention on the topic of jhagerup that your surgeon was close. The offically accepted study claims that 250 surgeries are the point when the surgeons increasing level of skill begins to level off. (_J Natl Cancer Inst._ 2007 Aug 1;99(15):1171-7. Epub 2007 Jul 24. "The surgical learning curve for prostate cancer control after radical prostatectomy." Vickers AJ, Bianco FJ, Serio AM, Eastham JA, Schrag D, Klein EA, Reuther AM, Kattan MW, Pontes JE, Scardino PT.) This is more important that people know, for even cancer control improves with the level of experience of the surgeon, as this paper demonstrates ("The learning curve for prostate cancer recurrence after radical prostatectomy was steep and did not start to plateau until a surgeon had completed approximately 250 prior operations..."; taken from the abstract). Someone said it earlier in some other post that the best idea is to go with the best surgeon that you have access to, no matter whether it is using the robotic approach or the open approach.
Cheers
Bill

txbarton's picture
txbarton
Posts: 89
Joined: Aug 2009

The intent of the post was to give some perspective to how long it takes to develop experience with anything. It was not a reference to or recommendation of my surgeon.

daVinci is the only robotic device approved for radical prostatectomy and was FDA approved in 2000. daVinci accounted for ~8% of radical prostatectomies in 2003 and >80% today. The first in the US was performed by Dr. Menon in Detroit (Sonny's surgeon). Data on him indicates he is the most exeprienced in the world with over 5000 procedures. My surgeon, Randy Fagin, is in the top 10 in the world by volume. His 2008 resume is located at http://www.prostatecenterofaustin.com/fagin-resume.php at that time he had 1700 procdures. He limits his practice to daVinci prostatectomy and performs ~200/year.

The first laparoscopic prostatectomy was conducted in 1992, the next in 1997 by the same surgeon, Kessler.

High numbers are not an assurance of quality as low numbers are not an indicator of low quality.

VB

novaguy
Posts: 76
Joined: Jul 2009

That's interesting. My own surgeon had done about 4-500 da vinci prostatectomies, and is regarded as one of the top in our region. He did a fantastic job with mine, and I have no complaints. When I interviewed him I asked if prostatectomies was all he did, and he told me no, he does a lot of kidney, bladder, and other surgeries. He said if all he did was prostatectomies he would get bored. That got me to thinking that maybe a high number of the same kind of procedures may not be good for all surgeons. I don't think I could do thousands of repetitive jobs over and over, no matter what the job was or the pay. But others can, and I suppose they become extremely skillful at it.

WHW's picture
WHW
Posts: 189
Joined: Jul 2009

Nova, you might be right about surgeons that only do PCa work.

But how about another perspective. Those that only do prostate surgeries are usually with the larger clinics and outfits that have more money to do research. Can't speak to them all of course, but my doc and yours continues to fine tune the process and see what can be done to make every surgery more successful than the last.

Kinda reminds me of the axiom we use with baseball umpires. Comparing 2 guys with 10 years of experience. One has umpired 10 years and strives to learn something new every time he goes on the field. Wants to take his game to the next level constantly. He truly has 10 years experience.

The other goes out the first year. Feels comfortable with his skills. Feels in his own mind he can't get any better and then repeats the same experience for the next nine years.

The first year out is kinda like the learning curve on the da Vinci surgeries for docs.

On the books they both have 10 years experience, but it doesn't take long to tell them apart.

Guess that is just about the same in every vocation and walk of life.

Just my opinion for what it's worth,

Sonny

lion1
Posts: 241
Joined: May 2007

Just a comment to all- As you read the many posts of our PC Friends, you can't help but notice how everyone says--my surgeon is the best or one of the best in the country.

Of course, this is all based on outcome---- No ED, NO Incontinence, No Cancer!! Well I had 2 out of 3 go well. So my doctor is in the top 66.6% of prostate cancer surgeons in the country and there's a lot of Prostate Cancer Surgeons in the Country. However, I still believe in any field that 66.6% is a failing grade????

The fact of the matter is if all goes well-you had the best Surgeon. If it doesn't then you're surgeon is the best most of the time-----darn, if you're not in the most of the time group!!!

It great to have total success and God Bless you all who have and oh by the way I am working on getting my grade of 66.6% up to at least 90% withing the next 6 months.

Stay positive mates----Lion1

Food for thought only---God Bless you all!!!!

txbarton's picture
txbarton
Posts: 89
Joined: Aug 2009

I don't recall anyone ever saying their surgeon was the best in the country. Most only reference their surgeons experience based on number of procedures.

Note my post said Fagin is in the top ten in the world "by volume." Menon in Detroit is the most experienced with over 5000 procedures. Nothing was said about success rates, I don't think they would or could publish success rates. My feeling is that if your PSA goes to zero or near zero your surgery was a success, incontinence and impotence was a potential consequence we all knew going in.

High numbers only mean you've done it a lot and does not directly relate to high quality as low numbers don't relate directly to low quality.

Again, my intent was not to tout the quality or qualification of my surgeon or any other, number of procedures is discussed a lot here, I was merely trying to apply some perspective. It was misconstrued and challenged so much I really wish I had not made the original post.

VB

WHW's picture
WHW
Posts: 189
Joined: Jul 2009

VB,

You should not regret starting this thread. A lot of good information is contained in this conversation. Let us all not forget that we all came here looking for answers in the beginning.

There are many more that will come here for the same reasons, unfortunately. Every decision we make is ours and ours alone. WE all have our reasons for making them and once made we all have to have that comfort and confidence to carry us through the fight.

None of us have the alphabets after our names that make us experts and all of us can/should be talking from the standpoint of our own experiences. In that we are somewhat expert. We each can only walk in our own shoes.

Good healthy conversation and debate is useful. We always need to remember that there are many others that are reading our conversations without participating. Our words are there for all to see and learn from.

Disagreement is good at times and thought provoking, as long as it is done with respect and ultimately caring for our fellow PCa brothers and their families.

Just the humble opinion of one of the brothers,

Sonny

novaguy
Posts: 76
Joined: Jul 2009

Well, I only said that my surgeon "is regarded as one of the top in our region." Let me tell you why I said this, and it may help others who are looking for a good surgeon.

First, I researched the literature and found studies that said the learning curve for da vinci surgery begins to flatten out at 260 cases. So my first criteria: my surgeon must have a bare minimum of 260 da vinci prostatectomies, and preferably more than that. Again from the literature, I found that a 10% positive margin rate was pretty much the best. Some claim 5% but I think it's BS.

Second, I then began searching for top rated urologists in my region by asking my own doctor, and by looking through publications like Top Doctors and, in our region, the Washingtonian magazine and the Checkbook service. The last two use peer reviews, listing the doctors most recommended by other doctors.

Third, I interviewed five urologists from my short list, and asked them their number of da vincis and their positive margin rate. I also asked who they would recommend to do the surgery if they could not do it, and who they would not recommend. I couldn't get any of them to give me a negative recommendation, but I did get positive recommendations for a couple of urologists. The good recommendations were for others already on the list, so that may me feel comfortable. The number of da vincis weeded out one guy who I thought otherwise was very good, but he had only done 100. That left two others, and they claimed a 10% positive margin rate but to be honest I could not tell if they were accurate or not, I just went with my intuition if they were telling me the truth.

Fourth, I got references from the urologist I had chosen, and called a couple of his patients, who had nothing but positives to say about that doctor. They were also honest with me about some of the side effects and negative things about the surgery (catherer, etc), but they only had good things to say about the doctor.

That's it, I then closed my eyes and went with it, refusing to entertain second guess type thoughts, which are normal with something this critical.

In the end, I am very happy with my selection. I got negative margins, continent right away, but still have significant ED. I like to think that even if it had not turned out so good I would still be comnfortable that I had done all of my homework.

hopeful and opt...
Posts: 2226
Joined: Apr 2009

I wonder what criteria does one use to select a surgeon. Is there an independent agency, that measures successes and failures?

Which profession criteria is most import about the surgeon: number of procedures, outcomes with most success and least failure, hospital facilities and staff, medical school attended , age, etc......or how important is word of mouth or doctor image.

I wonder if there has been a mathematical analysis done to measure what attributes in a doctor and facilities that are most important to a successful operation.

How does one really know who the "world class" surgeons are?

Ira

lion1
Posts: 241
Joined: May 2007

I believe you all who commented took this way too personal. If you reread my post I was simply pointing out once again that each is an individual. And I was speaking of Outcome, Outcome, what we continue to deal with after the cancer is gone, in my case. I didn't say my Doctor wasn't one of the best. I pointed out if we should measure the success baseed on Outcome???? WHO KNOWS---IT'S A ROLL OF THE DICE. Let one of you previously said, at least we're discussing this----100's who read this won't even chime in------Thanks.

And yes my Surgeon really is one of the Foremost on LRP and noone could touch him----see what I mean. Lokk at the foundation and effort he has put into Prostate Cancer --it's remarkable and yes he can't guarantee continence!

LION1

NM
Posts: 214
Joined: Jul 2009

Hi and I agree to a point with all of you. If your procedure goes great yours is the best surgeon in the country. Its all a matter of perspective. I agree that after 200 plus surgeries its also a matter of this,did you doctor take his time do his best and how did your recovery go. As said there are no guarantees so each of us has to know going in,as I did, the risks and rewards factor.

Thanks to all who posted and continue to post as even when we dont all agree we give others a perspective that there are always pros and cons and lets air everything out so a decision in the future for those yet to come have all the info they can

Nick

lion1
Posts: 241
Joined: May 2007

Nick,

Good follow-up...............we're on the same page.

Lion1

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