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More data that the skill level of the surgeon counts for a lot.

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Posted 11/28/2010 11:25 PM (GMT 0)
The latest research reaffirms that it pays to be careful in your choice of surgeon.


Eur Urol. 2010 Nov 10.

Cancer Control and Functional Outcomes After Radical Prostatectomy as Markers of Surgical Quality: Analysis of Heterogeneity Between Surgeons at a Single Cancer Center.

Vickers A, Savage C, Bianco F, Mulhall J, Sandhu J, Guillonneau B, Cronin A, Scardino P.

Department of Surgery and Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center

BACKGROUND: Previous studies have shown that complications and biochemical recurrence rates after radical prostatectomy (RP) vary between different surgeons to a greater extent than might be expected by chance. Data on urinary and erectile outcomes, however, are lacking.

OBJECTIVE: In this study, we examined whether between-surgeon variation, known as heterogeneity, exists for urinary and erectile outcomes after RP.

DESIGN, SETTING, AND PARTICIPANTS: Our study consisted of 1910 RP patients who were treated by 1 of 11 surgeons between January 1999 and July 2007.

INTERVENTION: All patients underwent RP at Memorial Sloan-Kettering Cancer Center.

MEASUREMENTS: Patients were evaluated for functional outcome 1 yr after surgery. Multivariable random effects models were used to evaluate the heterogeneity in erectile or urinary outcome between surgeons, after adjustment for case mix (age, prostate-specific antigen, pathologic stage and grade, comorbidities) and year of surgery.

RESULTS AND LIMITATIONS: We found significant heterogeneity in functional outcomes after RP (p<0.001 for both urinary and erectile function). Four surgeons had adjusted rates of full continence <75%, whereas three had rates >85%. For erectile function, two surgeons in our series had adjusted rates <20%; another two had rates >45%. We found some evidence suggesting that surgeons' erectile and urinary outcomes were correlated. Contrary to the hypothesis that surgeons "trade off" functional outcomes and cancer control, better rates of functional preservation were associated with lower biochemical recurrence rates.

CONCLUSIONS: A patient's likelihood of recovering erectile and urinary function may differ depending on which of two surgeons performs his RP. Functional preservation does not appear to come at the expense of cancer control; rather, both are related to surgical quality.
Posted 11/29/2010 12:15 AM (GMT 0)
Thank you for finding this reference. I bet you there is some tension in the MSK urology department.

Memo to those who read proscapt's post: Don't let any surgeon cut on you unless you have done everything possible to check out their abilities. If you can, find out the rates of ED and urinary problems in their prostatectomy patients. If you can't get good information to judge them, see if you can find another surgeon.
Posted 11/29/2010 12:43 AM (GMT 0)
This complements data I posted on this forum in November of 2008 as follows:

I subscribe to John Hopkins health alerts on "Prostate Disorders".  The following is quoted from today's bulletin and emphasizes what many veteran HW members have advised re surgical experience:

The importance of surgeon's experience as it relates to prostate cancer outcome is underscored by the results of a study reported in the Journal of the National Cancer Institute (volume 99, page 1171).

Researchers analyzed the outcomes of 7,765 radical prostatectomies performed by 72 surgeons between January 1987 and December 2003 at four major academic medical centers. "Biochemical" recurrence was defined as a postsurgery PSA level greater than 0.4 ng/mL followed by a subsequent higher PSA level. The analysis took into account patient and tumor characteristics, such as pre-operative PSA level and Gleason grade. The men's PSA levels were measured every three to four months in the first year after surgery, twice in the second year, and annually during the following years.

The researchers found that surgical outcomes improved along with the number of radical prostatectomies a surgeon had performed, leveling off only after about 250 surgeries. The five-year probability of experiencing a recurrence of prostate cancer was 18% for surgeons who had performed only 10 operations compared with 11% for surgeons who had performed at least 250 surgeries.

Bottom line on prostate cancer surgery: The results suggest that you can improve your odds of a successful outcome from radical prostatectomy by taking time to find a surgeon with extensive experience.

Tudpock (Jim)


Posted 11/29/2010 1:01 AM (GMT 0)
ugh we were thinking of going there. Wish we could find out who had what rate.
Posted 11/29/2010 1:43 AM (GMT 0)
I certainly feel that this may add some fuel to the discussion regarding a University setting at which the

 surgeon may allow another to perform a portion of the procedure that he or she may not label as critical.

Posted 11/29/2010 2:13 AM (GMT 0)
I suspect the majority of surgeries are performed outside the University setting, or Center of Excellence for that matter. I also suspect obtaining the stats on any given surgeon would be next to impossible..Most surgeons will tell you it would be impossible to track all their patients for years as they tend to scatter to the four winds...They will talk to you in generalities, but that's about it...If you ask for the results of their last 200 surgeries, I don't think you will get that from ANY doctor without at court order..
Posted 11/29/2010 2:27 AM (GMT 0)
My doctor at Cleveland Clinic had stats of his continence and ED rates, and a detailed questionnaire on follow up visits tracking my progress in those areas.

That being said, I can't say I have any great confidence in the stats, based on the fact that they are kept and managed by the surgeon. I would not be surprised if " 1 pad a day" is interepreted as full continence.

That being said, I still believe that the surgeon's skill was primarily responsible for my results thus far. I think that less experienced surgeons would have had positive margins.

Could be however, as Mr. Bill suggests that the nereves were handled by a first year resident.

So far, I still wouldn't trade the ED for BCR. As long as I can keep my PSA low, I'll figure out other solutions for the ED.
Posted 11/29/2010 11:25 AM (GMT 0)
I questioned the consent form the surgeon presented me. I cannot remember the exact wording, however, it eluded to the fact that someone else may perform a portion of the surgery.  His response was that he would perform the critical stages and in no way did he give me the impression he was doing the entire surgery, only the critical stages.  I should have asked for a definition of critical as it pertained to this procedure.  Even his surgical notes from medicial records stated he performed all critical stages. However, they also indicated another Dr., the resident, was assisting. 

I guess I should have inquired further, but at that stage I am lucky to have had enough sense to tie my shoes. The mindset is "just get that out!"

How trusting we can be...

 

Post Edited (mr bill) : 11/29/2010 4:28:25 AM (GMT-7)

Posted 11/29/2010 3:44 PM (GMT 0)
My experience at the Cleveland Clinic was similar to Goodlife's.

My uro gave me very specific probabilities for ED, long-term incontinence, bladder neck constriction, etc. He said those probabilities were based on his patients who were "similar" to me. This was after the biopsy, so I assumed he meant Gleason score and stage and perhaps age.

I agree with Mr. Bill that you do have to take this with a grain of salt. It would be nice if these data were kept and reported by some disinterested party, but then inexperienced surgeons would never get to be experienced ones.

I also wonder about the role of the resident. My doc was pretty up front about the fact that a resident would have an important role in the surgery. He also assured me that he would be there the entire time.

The truth is that you can only ask so many questions, and the answers will only be as good as the integrity of the surgeon. I think you just have to educate yourself, try to ask questions that will elicit revealing answers, try to get a sense of the inner doc, and finally do what your gut tells you.

The jury is still out regarding outcomes in my case. Mine was a well-experienced surgeon, so I'm hopeful. It's hard to argue against the value of experience though. That's kind of a no-brainer.
Posted 11/29/2010 5:02 PM (GMT 0)
I had complete confidence in the surgeon.  I just wish there had been mor emphasis on what role the resident would play...
Posted 11/29/2010 6:17 PM (GMT 0)
Dr Scardino at MSK also referrenced the fact that there was a major difference in the positive margin rate among surgeons at MSK. The best having an 11% rate and the worst having a 49% rate with the average being 23%. It may be part of the same study and certainly is a part of the same record keeping methods at MSK.  I don;t know why it is so difficult for some to believe that there is a major difference in the skill level of surgeons as this is true with just about every facet of life. Some people are just better than others in performing complex tasks especially when exceptional skill is necessary.

JohnT

Posted 11/29/2010 6:33 PM (GMT 0)
I agree the skill and experience of the surgeon is paramont in how things can turn out, don't think anyone would argue that point. Not convinced that all the talk about Univeristy Centers, Centers of Excellence, or some brand-name Surgeon always makes a difference. There are other factors at work beyond any of that: the specific nature of the patient himself, their previous medical history, the strand or variety of cancer at work and its actual progression, etc.

It's not just about picking some top-ten named surgeon and you are going to get the best deal. I still say, there are hundreds, if not more, good experienced quality surgeons that no one has ever heard of outside of a local area, and an equal number of high quality hospitals in small cities and towns in Americal that you would never hear about unless you lived there.

With my open surgery, my guy had 30 years of experience, all open, and his assistant, as required by law, was the #2 surgeon at his practice. This was no intern or trainee in the room. The guy that put me under, had nearly 30 years experienced. I at least got what I was expecting.
And my surgeon made no foolish promises or guarantees ahead of time.

We got some good brothers here that went out of their way to go all over the country to get hooked up with the "best of the best" and ended up with terrible results. Even that effort doesnt guarantee anything.

David
Posted 11/29/2010 6:44 PM (GMT 0)
Correct you are John, but how does the patient separate the wheat from the chaff?? Even at MSK identifying that worst surgeon with the 49% positive margins, would be very difficult..

Makes you wonder, backstage, if the poorest performing surgeons get some remedial training or are perhaps encouraged to take up another line of work....Or are they just allowed to move to another state and continue doing shoddy work??

The medical profession is pretty much self-policing, but you wonder how well that system works..
Posted 11/29/2010 7:38 PM (GMT 0)
My urologist told me he was certified in da Vinci, but was not the most experienced, so he referred me to another doctor in the practice with 700+ procedures. The surgeon, told me straight up that no one other than himself and his surgery partner (equally experienced) would be performing any part of my da Vinci surgery. One at the controls and one at the bedside. So far, their skills (and a lot of prayer) is being reflected in my recovery.
Posted 11/29/2010 8:25 PM (GMT 0)
Then there's the part about the best surgeon in the world having a bad day/week/month/year.

Ya catch your wife in bed with the pool guy and it wrecks your whole day.

Having a terminaly ill family member in the house will break concentration.

Loosing a golf match with your doctor buddies and drinking too much the day before surgery can reek havoc.

The list goes on.

Posted 11/29/2010 8:26 PM (GMT 0)
Fairwind, excellent question.
Doctors know who is good and who is poor. The poor patient has no way of knowing except if another doctor is kind enough to mention it. When my wife was having breast surgery she chose this doctor with excellent credentials. Her oncologist's partner who had worked with that doctor mentoned to us that although that doctor was an excellent surgeon he would not be the best doctor to perform breast surgery. We were thankful for the advice and for his openess. I don't think that many doctors would go out of their way to discourage a patient from using a surgeon they had already chosen.
JT
Posted 11/30/2010 2:03 PM (GMT 0)

I think there are two aspects of this, experience and excellence.  Of course one does not always follow the other so it is necessary, IMO, for the patient to do his due diligence on both.

In the case of experience, there are studies (previously posted on this forum) that show more successful surgical outcomes with 250+ procedures.  It is fairly easy, IMO, to discern whether or not your physician has the requisite number of procedures.  I think it is a rare doc who will lie about the number of operations he or she has performed and this can usualy be confirmed by the office staff.  So, number one, make sure the doc has the requisite experiece level.

Excellence is the obviously more difficult area as the statistics are usually non-existent and, even if they are, they can be misleading (e.g. one pad per day = continence).  So, one needs to work a little harder in this area.  "Brand name" certainly is an indicator.  There are known experts who have been acknowledged by their peers and choosing one of them increases your odds of success.  However, there are also ways to find other highly competent physicians.  John mentioned references from other physicians, e.g. "who would you choose for your procedure?".  Also, nurses and other health related professionals usually know about local reputation.  Personally I reached out not only to my PCP, but to neighbors, old friends and anyone else who could confirm or deny my personal feelings about my chosen physician.

I guess my point is that there is nothing one can do to "always" insure success.  But, there is a lot one can do to increase the odds and that is the service we can provide to newbies who are in search mode.

Tudpock (Jim)

Posted 11/30/2010 8:28 PM (GMT 0)
My urologist/surgeon told me had performed approximately 50 DaVinci procedures. Since we're near Chicago, my wife and I discussed having the surgery done at one of the major hospitals there. It occurred to me, however, that I should ask my daughter-in-law's mother, who is an operating technician, what the medical opinion was concerning my uro/surgeon. She has seen a whole lot of doctors in the operating theater, and she assured me that my guy is the best she's seen, an outstanding surgeon, either in traditional surgery or in robotic surgery. This she said, is the consensus of other technicians and nurses, and she encouraged me to trust in his abilities and have the surgery. I visited two area hospitals for blood work and tests, and the staff at those locations, when they found out who would be doing my surgery, unanimously said I had made an excellent choice. He's a gentleman of about my age (65) who has been doing traditional prostatectomies for a long, long time, and who began doing the DaVinci procedure four or five years ago.

Yes, doctors know who's good and who's not so good, but it's my feeling that those who assist in the operating room know who's good and who's not so good. They can tell you in a heartbeat who they would want doing the surgery if it were being performed on them. I have a niece who is an O.R. nurse in New York. She told me on Thanksgiving that she works every day with certain doctors whom she would never allow to work on her or on anyone she cared for.

This is what I did, and it has worked out well for me. I guess I'm agreeing with much of what others have already said, except that I'm not so sure about the need for the surgeon to have performed the DaVinci or other procedures into the hundreds of times.

On the day I had surgery, I was my surgeon's only patient that day. He wasn't tired from two or three previous surgeries. He wasn't in a hurry to finish because he had to get to his next surgery. He even took the time to repair a lot of intestinal adhesions, where a busier surgeon might have seen them but done nothing because it took an extra hour to do the repair.

Excellence is apparent to those in a position to see it well before that, and I can't think of a better source than those who assist during the surgeries.
Posted 11/30/2010 10:50 PM (GMT 0)
With all respect to clocknut, I think the OR staff have their own perspective.  They like are impressed by surgeons who are cool and pleasant in the OR, and handle crises well.  They have no way of knowing how the patients do after surgery, especially longterm.  Patients don't go back to the OR to give feedback.  With prostate surgery, it's the long term complications that are the main issue.

I picked my surgeons carefully.  Other doctors thought he was great, but he also had detailed statistics, verified by an outside person, on his extensive surgical outcomes.  That's what made up my mind.  When I was going into the OR, the nurses were telling me what a great doc I had picked. 

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