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Posted 3/31/2015 2:05 PM (GMT 0)
Found out yesterday that my uro at USC has performed between 150-200 robotic prostate removals.  Seems on the low side but he said he takes his time and the surgery takes about 3 hours for him.  Should I continue searching for a more experienced surgeon?  Also interested in brachytherapy and would like to see if anyone had any recommendations on a physician for this in Los Angeles.

Age 54 as of 2015

PSA 2009=2.9, 2010=2.8, 2011=3.2, 2012=3.1, Feb 2013=2.76, Mar 2014=3.12, Jul 2014 3.5, Jan 2015=3.46, several different Labs and Assays but labs from 2013 were all USC

Bx and Dx Feb 2015 = 1 of 12 cores all G6 (USC)

2nd opinion of slides at UCLA - 4 of 12 cores all G6 (5%, 10%, 15%, 25%)

Posted 3/31/2015 2:23 PM (GMT 0)
Hi Journey:

I think that number is on the low side. I posted an article here some years ago that indicated 250 was the minimum for open surgery. www.medicalnewstoday.com/releases/78223.php This is a little old now but I suspect it still holds true and that the learning curve may be even steeper for robotic.

You stats indicated that LDR brachy would be a good choice for cure but I can't help you with a local referral. You might also look into SBRT and HDR brachy as both of those could be good options as well. Finally, you might consider not giving up on AS as you still meet most accepted criteria.

Jim
Posted 3/31/2015 2:32 PM (GMT 0)
Journey - I'm not an expert by any means, the guys/gals with more background on this will respond soon. With that said I would continue to look for other surgeons.

My Uro had done 1600+ surgeries and his complication rate is less than national averages. Some of the surgeons in the 'big' hospitals, Mayo, NYC etc have done 3 or 4 thousand.

In addition to the number of surgeries, I would also ask about his/her specific rates of recurrence after surgery and complications.

And do follow up with an RO. Making the decision to have surgery became easier for me once I had talked with the doctors that do HDR / LDR Brachy and 2 Surgeons.


Jon
Posted 3/31/2015 2:39 PM (GMT 0)
The number is very low.I need to see 1000+ to feel confident.
Posted 3/31/2015 2:49 PM (GMT 0)
Interesting thing about # of surgeries needed. A low number, to me, is scary, but experience itself can be scary also. Some with 30 years, may be have learned nothing,having 30 years of the same experience. You know get in a rut of doing things the same way over and over and others can get complacent due to experience. I've heard it said that the Capt of the Titanic had 30 years of experience working against him. Personally I like Gold Horses number.
Posted 3/31/2015 3:41 PM (GMT 0)
This isn't a surgery one wants messed up and it's not simple. (We're talking more than ED and continence problems here)

> 250 is a minimum.

FWIW...The surgeons I've spoken with have admitted to them themselves not being as good as they would have liked to have been below that number.

Good luck with whatever course you take.
Posted 3/31/2015 4:14 PM (GMT 0)
I was originally set up with a robotic surgeon with the date scheduled for removal. When he told me had done 150 or so I backed out an opted for open with a surgeon who had done thousands. You want the guy who has done the most and has the best track record...
Posted 3/31/2015 4:30 PM (GMT 0)
To all,

Thanks for your feedback.  I still had my surgery scheduled at USC on 4/15 because I was concerned that I needed to take it out right away.  I've had my concerns about the number of surgeries my uro has performed and will cancel my surgery.  Will be looking for a surgeon with at least 500+ prostatectomy surgeries to consult with.   

Age 54 as of 2015

PSA 2009=2.9, 2010=2.8, 2011=3.2, 2012=3.1, Feb 2013=2.76, Mar 2014=3.12, Jul 2014 3.5, Jan 2015=3.46, several different Labs and Assays but labs from 2013 were all USC

Bx and Dx Feb 2015 = 1 of 12 cores all G6 (USC)

2nd opinion of slides at UCLA - 4 of 12 cores all G6 (5%, 10%, 15%, 25%)

Posted 3/31/2015 4:53 PM (GMT 0)
The below looks like a pretty good article to read: "How to Pick a Prostate Cancer Surgeon", written by a prostate cancer surgeon.

He takes the approach "If I had to have PC surgery myself, what would I look for/expect from the surgeon?"

prostatecancerinfolink.net/tips-tools/pick-surgeon/
Posted 3/31/2015 4:54 PM (GMT 0)
With your G6 diagnosis, you have a lot of time to decide.

As to your question about brachytherapists in Los Angeles, you should talk to Dr Demanes at UCLA. He and his team perform HDR brachy--in fact he was the pioneer of the technique--and several folks here have used him including myself. As a G9 I had HDR brachy as a combo therapy in conjunction with IMRT and HT. As a G6, it would be as a mono therapy for you.

One other thought--as a low risk G6 have you considered Active Surveillance? Not everyone's cut out for that, but I'm also 54 and anything I could do to delay the SEs of treatment I would serious consider. Prostate Oncology Specialists in Marina del Rey has an AS program and it would be worth checking out, IMHO.
Posted 3/31/2015 7:03 PM (GMT 0)
Michael_T,

Keeping all of my options open right now including AS.  My 2nd opinion was with Dr. Leonard Marks at UCLA who is an AS advocate.  I am having a confirmatory mpMRI in June with Dr. Marks.  I will ask him for a referral to Dr. Demanes when I see him again.

 

Age 54 as of 2015

PSA 2009=2.9, 2010=2.8, 2011=3.2, 2012=3.1, Feb 2013=2.76, Mar 2014=3.12, Jul 2014 3.5, Jan 2015=3.46, several different Labs and Assays but labs from 2013 were all USC

Bx and Dx Feb 2015 = 1 of 12 cores all G6 (USC)

2nd opinion of slides at UCLA - 4 of 12 cores all G6 (5%, 10%, 15%, 25%)

Posted 3/31/2015 7:22 PM (GMT 0)
1. Yeah, that's low.

2. The big name surgeon in the LA area is Mark Kawachi at City of Hope. He's had more experience than anyone.

3. Get a second opinion from Epstein or Bostwick - not UCLA. It may make a difference.

4. Based on your numbers, you are a good candidate for active surveillance. UCLA has an excellent active surveillance program (suggest you talk to Leonard Marks). This also means you have plenty of time to decide - take it. Instead of scheduling treatment, schedule meetings with doctors.

5. Suggested meetings: Dr King at UCLA for SBRT; Dr Demanes at UCLA for HDR brachytherapy; Al Taira in Mountain View for LDR brachytherapy (I can't recommend a good seed guy in LA).
Posted 3/31/2015 7:56 PM (GMT 0)
Dr Marks was the urologist on the team when I had my surgical implant to prep for my brachy so I presume he works regularly with Dr Demanes.
Posted 3/31/2015 8:02 PM (GMT 0)
He is one of several uros that implant fiducials at UCLA. ROs generally don't do that themselves because it's considered to be a surgical procedure. Marks' big projects are now are mpMRI/US fusion-guided biopsies for active surveillance, and focal laser ablation.

- Allen
Posted 3/31/2015 10:48 PM (GMT 0)
In Canada, because the difference in the way our healthcare system operates, it is very difficult to find a surgeon who has 500 robotic prostate operations under his belt. US medicine tends to be more specialized where urologists here treat a wide variety of conditions (kidney ailments, bladder issues, etc.) My surgeon only had a little under 200 robotic surgeries but he also had significant previous experience with open surgeries and he is head of the urology dept. Early in the game yet but it is appearing that I'm having a very good result from my surgery.
Posted 4/1/2015 1:58 AM (GMT 0)
My local uro does only open surgery. He told me that when the robot came out, he looked into it, and when he heard that to get good at it, he'd need to do at least 250 procedures, he "didn't want to lose his reputation during the learning process." I also doubt he could have convinced the local small town hospital to buy the robot system and build a full team around it.

This whole idea, however, creates a struggle in my mind...if several hundred surgeries is the bare minimum to consider a particular surgeon....if no one goes to the new surgeon, how is he/she going to get the required minimum experience? I know my surgeon introduced at least 2 different residents and 1 surgical fellow. At some point, however, they actually have to sit in the booth and take the controls in their hands.
Posted 4/1/2015 12:01 PM (GMT 0)
Absolutely correct Hal! Only thing to add is, what about the 2000 plus guy who haves a bad day?

Cheers, Doug
Posted 4/1/2015 12:30 PM (GMT 0)
With your diagnosis I certainly wouldn't be racing to surgery.   As TallAllen said, get a better read on your slide and then consider AS.   If you simply feel compelled to treat the cancer, then please look at HDR Brachytherapy.   You are an excellent candidate for mono-therapy.

HDR Brachytherapy provides cancer control with very minimal side effects.   Dr. Demanes wrote the book on it and I have been handing out his website for more than four years because it is the best source for HDR by the pioneer.   www.cetmc.com.   I had HDR more than four years ago and am free of any side effects.   Glad I went that route and I strongly encourage you to research and consider it as well. 

Posted 4/1/2015 12:35 PM (GMT 0)
As to the number of surgeries to become excellent, JohnT has used a number of more than 750, as I recollect, based on a statistical analysis. Of course you don't want a busy hack so the quality, quantity, and frequency all are very important. You might find a surgeon with 1,000, but hasn't operated for a few months, I would stay away.

Too many people minimize the significant difficulty of prostate surgery. My uro says the brain surgeons are very glad they don't have to remove prostates!
Posted 4/1/2015 1:56 PM (GMT 0)
JNF,

Thanks for the HDR Brachytherapy link. Lots of information to consider. Do you know how the BCR rates for HDR brachy compare to surgery? Also, if I do have HDR brachy does that mean that surgical removal of prostate is out?

____________________________________________________
Age 54 as of 2015

PSA 2009=2.9, 2010=2.8, 2011=3.2, 2012=3.1, Feb 2013=2.76, Mar 2014=3.12, Jul 2014 3.5, Jan 2015=3.46, several different Labs and Assays but labs from 2013 were all USC

Bx and Dx Feb 2015 = 1 of 12 cores all G6 (USC)

2nd opinion of slides at UCLA - 4 of 12 cores all G6 (5%, 10%, 15%, 25%)
Posted 4/1/2015 2:28 PM (GMT 0)
I'll let other quote specific rates or studies, but the success rates between surgery and brachy are similar. I'm sure the guys at UCLA can quote you stats as well.

Regarding your second question, there would be little reason to remove a prostate after brachy. First off, there's a high success rate so it's quite unlikely that any cancer remains in the prostate. Second, brachy actually treats a somewhat larger area than just the prostate so any cancer cells nearby are also treated. BTW, in the very unlikely event that some cancer remains in the prostate, there are still other treatments. In the case of your G6, all of this is rather hypothetical since the chances of you being cured with your initial treatment--either surgery or brachy--is so high.

And glad to hear you're still considering AS!
Posted 4/1/2015 3:33 PM (GMT 0)
Good info Michael. The "you can easily have radiation after surgery fails, but it is very difficult to operate after radiation" is a very misleading red herring. I would not go to a uro that gave me that line as a reason to have surgery.

Actually, if radiation does not control the local cancer, HDR can be used successfully as salvage treatment. Almost always, if there is a recurrence after radiation it is because the cancer was already systemic before the treatment.

There is a compilation of thousands of peer reviewed reports, studies, and the like that was put together a couple of years ago as the Prostate Cancer Results Study Group (PCRSG) (google the title and you will get the report) that compares treatment efficacy and side effects for different risk levels. A very useful read.
Posted 4/1/2015 5:35 PM (GMT 0)
I did not have the luxury (read money) to go outside of my provider (Kaiser). My Urologist only performs open surgeries, so he talked to me about the six surgeons in the Kaiser system that perform RALPs in this area. Of those, he recommended two of them. I did research on both of them. One had a bit more experience, started out as a regular Urologist and transitioned to RALP, the other, who was relatively young (at least younger than me), had only been performing RALPs. It was clear that performing RALPs was his main focus, above all else.

I met with the younger surgeon and was a little worried when I asked him about numbers. He said he wasn't sure, but that it was in the hundreds. He currently performs a few every week.

These were not encouraging numbers, certainly. Not in comparison to someone who's racked up thousands, but based on his personality and focus on this procedure, I felt good about him performing my surgery. I was not disappointed. I am eight weeks post-op today. Completely dry, and have nearly regained my erectile function.

In talking with a very knowledgeable friend, he mentioned that younger surgeons, who have specialized, are often better than older surgeons who have simply racked up a lot of surgeries, because they are more up-to-date on the latest advancements in their given field.

So, all of this is to say that numbers alone are not the best indicator of success. My brother's surgeon had performed thousands of RALPs and managed to bungle just about every aspect of his operation.
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