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Posted 12/24/2009 5:20 PM (GMT 0)
The Billings Clinic (known to those of us who have been around a while as Deaconess Hospital) has been given (or at least partly given) the machine to do da vinci robotic surgery. Buzz Aldrin, yes the astronaut, donated $600K towards purchase of the machine and it'll be here with the new year.

My urologist sounded thrilled in the newspaper.
Posted 12/24/2009 5:47 PM (GMT 0)
The machine is great, but having surgeons who have experience is the next hurdle. Common consent is that is takes several hundred surgeries before a surgeon is considered "expert" at it.

Along with the comparisons of side effects between open and DaVinci, which may be accounted for by inexperienced DaVinci surgeons, sometimes I think the small centers amy be better off with the open.

Anyway, hope it all goes well.

Goodlife
Posted 12/24/2009 6:20 PM (GMT 0)
According to Scardino and others only 20% of doctors currently doing Divince are qualified or skilled enough to have good outcomes. 500 procedures are necesssary to develop skill level and it contiunes to increase to about 1,000 procedures. So just because a hospital has a million dollar robot, if it's run by a dime operator it's just a piece of metal.
JT
Posted 12/24/2009 7:52 PM (GMT 0)
That's great news for, say, 2013 and beyond. Unless they bring in an experienced operator laterally. That's what M. D. Anderson did.

Zen9
Posted 12/25/2009 12:02 AM (GMT 0)
Great news on the machine part for the hospital, but I agree with JohnT, wouldnt want any part of that until they have some serious learning curve behind them.

David in SC
Posted 12/25/2009 12:49 PM (GMT 0)
You know, I think a lot of what is said here on this topic is true, BUT it is not possible to do more than give a gross estimate of what number of any procedure gifts one with competence. Having spent two thirds of my life in operating rooms with doctors of varying talents, I say that there are those who attain competence with 50 cases of any procedure. Others may need twenty times that number. I have never done a laproscopic procedure, but I do know that when we embarked on a new technique with lasers, stereotaxsis, microsurgery, or otherwise, we always had someone at our side to keep us out of trouble until all felt and were confident. With RALRP, one has an option to convert to open prostatectomy at any point when conditions warrant. While one doc may have a hard time, another may find it no problem. A lot of surgical training is based on the "see one, do one, teach one" principle. If one takes a number of any given power and puts it into the "one" space, you have a good teaching principle in my opinion. So, for doctor A, 100 procedures may give confident competence, whereas doctor B may need a multiple of 100. Clue: Ask a recovery room nurse. They see the good, bad, and in between results.
Posted 12/26/2009 5:11 AM (GMT 0)
"According to Scardino and others only 20% of doctors currently doing Divince are qualified or skilled enough to have good outcomes. 500 procedures are necesssary to develop skill level and it contiunes to increase to about 1,000 procedures. So just because a hospital has a million dollar robot, if it's run by a dime operator it's just a piece of metal.
JT"

One can read all sorts of wild statements and inaccuracies on this website, and I think the first sentence of the above quote is one of those things should just pass by without giving much credence to it.
Posted 12/26/2009 6:10 PM (GMT 0)
I think Scardino, who is one of the most recognized prostate surgeons in the US, would not have made that statement without good reason. If you don't believe him who are you going to believe, your local urologist?
JT
Posted 12/26/2009 8:11 PM (GMT 0)
John T,

You have my full support on this issue.

Zen9
Posted 12/26/2009 8:36 PM (GMT 0)

John T said...
I think Scardino, who is one of the most recognized prostate surgeons in the US, would not have made that statement without good reason. If you don't believe him who are you going to believe, your local urologist?
JT

Brainsurgeon makes several excellent points and I agree with him.  On the other hand I find the posturing and bragging by people like

Dr Scardino to be adolescent at best and destructive at worst.  While most of us agree that we want an experienced surgeon, comments that only 20% of the DaVinci surgeons are competent is out of line and Not provable.  I don't see why he needs to demean others in his profession, it certainly doesn't make him look more competent.

And John, yes I am going to believe someone who has given me reason to respect and trust him.  In this case it is not Scardino.

Posted 12/26/2009 10:01 PM (GMT 0)

Mavica...not sure why you would want to ridicule either JT or Dr. Peter Scardino and lifeguyd, congratulations on having a local doctor with better qualifications than Scardino.  C'mon guys...Dr. Scardino is Head of Surgery at Memorial Sloan-Kettering and a world recognized expert prostate surgeon.  That, of course, does not mean everything he says is true.  But...rather than sticking your heads in the sand...you might want to respectfully listen to what he has to say and at least consider that he might have a point.  He does have a bit of experience...

Tudpcok

Posted 12/26/2009 10:10 PM (GMT 0)
Scardino went on to talk about the fact that urologists need to become more acceptant of the reality that radical prostatectomy (by any technique) is a very difficult operation to learn to do well and may not be appropriate for all patients. He points out carefully that:

For patients with truly low-risk cancer, with pathologically proven Gleason grade 6 disease (or lower based on older pathological staging), the risk of prostate cancer-specific mortality is now minimal, at around 2 percent of all such patients.
Even highly experienced surgeons exhibit considerable variation in their outcomes over time.
It takes about 250 operations to learn to do a radical prostatectomy well.
Even then, good surgeons are improving their skill and technique until they have done at least 1,000 procedures.
Within the MSKCC database, there is clear evidence that laparoscopic surgery has been associated with lower levels of continence and a greater risk for readmissions for additional surgery than open surgery.
Scardino concludes by presenting the following personal viewpoint:

When well performed, surgery provides excellent control of localized prostate cancer (cT1-cT3a disease).
Surgery is an appropriate first-line treatment for men with selected, high-risk cancers (cT3, Gleason 8-10, PSA > 20).
Surgery should be reserved for men with forms of prostate cancer that present a “meaningful threat” for long-term metastasis and prostate cancer-specific death
Surgery should not be used as a first-line treatment for men with low-risk cancers or elderly men.
Radical prostatectomy is a “technically challenging” procedure that is commonly associated with “troublesome” complications and side effects.
Achieving cancer control and achieving full recovery of continence and erectile function (the “trifecta”) is difficult (even for experienced surgeons).
Surgical outcomes are extremely sensitive to individual surgical technique.
Also during the course of this presentation, Scardino more than once makes the point that surgery is so successful at preventing prostate cancer-specific deaths for patients with low-risk disease that “one has to ask oneself” whether many of those patients couldn’t just be monitored and treated later if necessary.

There would be little argument in the urologic oncology community that Dr. Scardino is one of the very best prostate cancer surgeons of his generation — if not the best. For him to be making a presentation of this type with this degree of clarity would again suggest to The “New” Prostate Cancer InfoLink that there is a major mindset shift taking place in the urology community about who really should get immediate surgical treatment for very early stage prostate cancer. It is clear that Dr. Scardino and his colleagues at MSKCC have already come to some specific conclusions — although they may still find themselves under pressure from newly diagnosed, low-risk patients to “just get it outta there
He also makes the point that the vast amount of robotic surgeries are done by doctors that do less than 10 per year and this is just not sufficient to maintain skill levels.
Posted 12/26/2009 10:34 PM (GMT 0)
With all due respect to Dr. Scardino, our surgeon did not have 500 to 1000 surgeries under his belt - he had several hundred robotic surgeries plus hundreds more of the traditional open ones. What I do know is that he trained at Intuit (the developer and manufacturer of the Da Vinci robot) and at Johns Hopkins and Hackensack Medical Center (a first class cancer hospital in New Jersey), and he proctors other surgeons who are training on the robot. He is also the head of the prostate cancer division at our local hospital. Experience is important with any surgery, but experience does not necessarily translate to thousands of operations.

Our doctor may not have the numbers but he achieved good results for my husband, and he's a nice guy to boot. Scardino is no doubt a top notch surgeon in his field but he's not the ONLY good surgeon out there. Do I respect Dr. Scardino and do I think his opinion is valid - yes to both. But, I caution the use of these quotes especially for those who are newly diagnosed and whose anxiety is already high. Makes it sound like if you don't use one of the experts, you don't have a chance. Granted, in some situations, an "expert" is needed - in fact, it may be necessary. When someone who is highly touted in their field comes out with a statement like this, it sounds too much like a p***ing contest. That kind of schoolyard behavior has no place in medicine.
Posted 12/27/2009 12:20 AM (GMT 0)
Sephie,

If you take the time to listen to Dr. Scardino's presentation and view his slides (I linked from a previous JT thread), I think you will find that he is neither engaging is a p***ing contest nor saying things that would insult the decision that you and your husband made.  You need to get the context.

There is a slide that clearly shows a sharp inflection/improvement in cure rate after a surgeon performs 250 or so procedures.  Then the results continue to get even better as JT has indicated in his posts.  These figures are not conjecture but are based on solid data.  Similar studies have shown the same thing...i.e. experience counts!  Based on your decision to go with a guy who had performed hundreds of procedures, I would think that you and your husband would be highly supportive of Dr. Scardino's conclusions.  He is not saying that he is the "...ONLY good surgeon out there."  Again, I urge you to watch and listen to the presentation before criticizing...I think you will find that JT summarized it properly and that Dr. Scardino was not being disrespectul or arrogant...rather was presenting some facts and some well founded conclusions.

And, I think these quotes and posts are EXACTLY what the anxiety filled new members of this forum should hear.  New patients need to know the facts and understand that, however nice and friendly their local doc may be, if he or she does not have the requisite experience then their odds of cure and quality of life can seriously deteriorate.

If, after viewing the presentation you disagree with my comments, I would be more than happy to hear where you think I am mistaken.

Tudpock

Posted 12/27/2009 2:02 AM (GMT 0)
Tudpock, I was responding to a quote attributed to Scardino and was unaware that there it came from a presentation - thanks for pointing me in the right direction. I will take a look at it and see what I think.
Posted 12/27/2009 3:40 AM (GMT 0)

I think the following will shock most of you.

A new analysis of data from two independent databases suggests that (in the US) only 20 percent of urologic surgeons carried out 10 or more radical prostatectomies in 2005.

The “New” Prostate Cancer InfoLink has consistently emphasized the fact that  surgeons who carry out a relatively high number of radical prostatectomies each year have lower complication rates than those who do relatively few such procedures. It has also been shown that (on average) a surgeon needs to carry out at least 250 radical prostatectomies before he or she has learned how maximize cancer control. These first 250 or so procedures represent what is known as the surgical “learning curve” for radical prostatectomy.

Savage and Vickers analyzed data from the Nationwide Inpatient Sample (a nationally representative sample) and from New York State’s  Statewide Planning and Research Cooperative System (a complete record of all hospital discharges from the state) to gain a perspective on the actual numbers of radical prostatectomies carried out by individual surgeons in 2005.

According to their analysis:

  • > 25 percent of surgeons conducting radical prostatectomies in the US in 2005 performed just one procedure.
  • Approximately 80 percent of surgeons performed < 10 procedures per year.

The authors state that this suggests that 80 percent of urologists who carried out a radical prostatectomy in 2005 were unlikely to reach the plateau of the learning curve during their surgical career. They go on to conclude that, “The current pattern of surgical treatment for prostate cancer leads to many patients being treated by surgeons with low annual caseloads, with likely poorer outcomes as a result.”

As far as The “New” Postate Cancer InfoLink is aware, this is the first time that data of this type have actually been documented in a publicly available journal. While we have to say that we are not actually shocked by these data, we suspect that many people may be, and we intend to redouble our emphasis on the critical importance of surgical treatment for prostate cancer by appropriately skilled and experienced surgeons.

Fil

Posted 12/27/2009 3:55 AM (GMT 0)
I think this whole discussion is getting blown way out of sensibilty. I think we would all agree that any kind of radical prostate surgery is very complex, even with the best of doctors and the best of conditions. I think we would all agree, that if one is going to undergo surgery, they need to have the most experienced surgeon that they access and resources for, those two things go hand in hand.

When you get into the experience factor with a surgeon, its not so cut and dry. It's not something you can look up in a book and simply make a choice. The experience level depends on lots of factors, not just how many robotic or how many open surgeries the dr. has done. A better question, does he do them well? How does he treat his patients? Is he really in tune to them? What kind of follow up does the doctor do with his patients? Etc, etc. The raw number part is very subjective at best.

On behalf of some of the newer men in here, or their "other halves" representing them, sometimes it hangs in the air, that unless you have some "name brand" surgeon operating out of a "name brand" hospital or clinic, you are going to get something less than first class treatment or results. I don't like that kind of thinking. Picking medical services shouldn't be like some botique shopping experience.

For the average Joe in here, like me, and probably for most that frequent here, we don't have unlimited time, money, logistics, or perhaps not even the greatest of health insurance to secure the alledged premium doctors and hospitals.  Not everyone can fly to Europe for a test, or have a non-FDA treatment done outside the US, or go to a John Hopkins class hospital.  But that doesn't mean our doctors, hospitals, or radiation clinics are any less first class.

I for one, am still content having a local surgeon, with nearly 30 years experience, that had done around 400-500 open surgeries, and had it done at the hospital that most of your would never have heard of , nor would I expecty anyone outside of SC to, that wins year after years the best patient care in the state.

I do not blame my surgeon for my recurrance issue, or my blockage issues. My problems are related to my own case and my own body.

Some times, in my opinion, these technical disccusions here get way beyond the needs of the average guy/patient dealing with PC. Disputes on how many surgeries a doctor has or hasn't done, won't help someone make an intelligent choice.

We also have men here, that chose and could afford to go to some of the best names in the country, at a top 10 hospital, etc, and have not had any better "luck" in erradicating their cancer then the rest of us.  Some of these men have had almost instant recurrance, or terrible ED results despite having expert surgeons doing the nerve sparing ops.

On the issue of overtreatment, I think there is merit for that, but I am not sure by what standards we could all agree to. Giving bone scans, cat scans, and MRI as a prelude to an entry level, low grade, low core/% gleason 6 case to me, seems like an incredible waste of resources. That money could be well spent in other areas.

The problem would be, would it be fair to tell a man with a Gleason 6 in the perfect criteria for AS/WW that he can't have surgery, or cant undergo RT, until his cancer shows that is on the more, or has become more agressive? Who would get to decide that? With what I know now, after the fact, and considering just what I have and am still going thorugh, if I had met the criteria with a non-agressive low grade dose of PC, I for one, would absolutely be doing AS/WW without a doubt.

I have already played out my surgery card and my salvage radiation cards, in just a little over 13 months. I don't anything left curative on the table. No, not feeling sorry for myself, just the cards I was dealt, and I am trying to make the best out of it, and hoping I don't lose out on the next round of percentages.

As long as there are radiation clinics making big bucks, and surgeons making big bucks and hospitals competing for the same patients along with health insurance providers making deals in the dark for the money, not sure how it could ever be resolved.

Something needs to change. From a PC patient vantage, I think, and it has been discussed here a million times, that perhaps when a perfect test method that can tell the difference between non agressive and agressive prostate cancer can be developed, this circle will probably keep going round and round.

Meanwhile, all of us, experienced or new to the cancer world, will just have to keep making choices with what we have in front of us, and hope for the best for our own lives.

David in SC
Posted 12/27/2009 4:03 AM (GMT 0)
JohnT

Been following closely your input on this thread with great interest. However, on your last one above, and let me put down what caught my eye?

According to their analysis:

> 25 percent of surgeons conducting radical prostatectomies in the US in 2005 performed just one procedure.
Approximately 80 percent of surgeons performed < 10 procedures per year

I simply don't believe that can accurate. Not saying that you didn't post correctly what you read, just don't believe those low numbers. What was the exact source, and what was their angle or approach or motivation for the study? Who sponsered it?

It that were true, then it would really imply something terribly wrong. My gut tells me the numbers are loaded bad (not by you of course, you are the messenger) for a reason. Can you clarify?

David in SC
Posted 12/27/2009 5:43 AM (GMT 0)
David,
The post is accurrate; It was a cut and paste from the New Prostate Cancer Info Link and the link to the study is in the post (Savage and Vickers) It was originally published in the Journel of Urology.
Unfortunately the numbers are real and a disgrace to the medical profession. You forget that the vast majority of patients don't follow this forum or do any research outside of what their 1st doctor recommended. There are 225,000 new cases of PC DXed each year; there are probably less than 1,000 that visit this site or other sites and get information that most of us take for granted.
I can only guess at the motivations of the doctors that perform these procedures.
Posted 12/27/2009 5:57 AM (GMT 0)
Been following the discussion re the number of radical  prostatectomies performed by various urologists in the United States.

John T's link to Savage and Vickers does indeed provide the info that

  • > 25 percent of surgeons conducting radical prostatectomies in the US in 2005 performed just one procedure.
  • Approximately 80 percent of surgeons performed < 10 procedures per year.

    • Since this info is posted at a .gov website associated with the National Institute of Health,  I would have to accept this data as true.

    I find this info very surprising!!redface 

    However, since almost every story I have read on HW to date indicates that those who have had an RRP sought out the best surgeon they could find with the greatest number of surgeries (myself included!), perhaps I should not be so suprised by this data.

    All the more reason then to advise those considering a RRP to seek a surgeon with a large number of surgeries and an excellent reputation.

    Skeener

    Posted 12/27/2009 6:05 AM (GMT 0)
    John,

    Thanks for the reply. I do realize that although we are a pretty tight-knit family here in HW Prostate, that at best, we only represent a speck out of all the men that are newly dx each year with pc, or already have survived pc in the past, and that doesn't account for the 25-30k that perish each year of our cancer.

    I don't know how informed other on-line PC groups are to be honest. I have never been to another similar site online. I fell into HW on a single search, and been here ever since.

    I just assumed what we know here, and what we share, and even our differences in treatments and their effects, would be common knowledge in general.

    My own surgeon made it clear to me from the moment of my dx, that the surgery is extremely complex and probamatic with its side effects, in particular the incontinence and ED issues. He was very upfront with that with my wife and I. We spent a lot of time prior to surgery going over the risks in detail, and I felt as prepared as I could, and even factored in worses case scenerios.

    Again, I assumed that most surgeons would do the same. Perhaps I take the good fortune of some of my treatment process and the medical team I have access to even here in a small, lesser populated state for granite. Never really thought about this before.

    My uro/surgeon is anxious to have be back in his custody so to speak after I meet for the last time with my Radiation Oncologist on the 28th of this month. He has been deeply concerned about the difficulties I went through with SRT, and worried about what lingering damage it may or may not have done in my already messed up bladder neck connection. What's odd, is that I take some comfort in his concern, because I trust him and his judgement with my situation.

    I couldnt imagine going through such a radical and complex surgery with a surgeon that only did the low numbers you stated above. It's frightening at best.

    David in SC
    Posted 12/27/2009 8:20 AM (GMT 0)

    Ok, here's the main point all of you make:

    FIND AN EXPERIENCED SURGEON.

    David, you talk about the fact that we can find very good surgeons everywhere. But a prerequisite would certainly be an experienced surgeon. You indicated your surgeon has done hundreds of such procedures. That is crucial.

    It is also important to have a surgeon with a good bedside manner, given the emotional nature of this disease. But the bottom line is I want someone who is extremely competent, and experience is a key. We are dealing with odds here all over the place. Our biopsy and post op. pathology all comtain numbers and then we extrapolate some odds. Well, ditto for the quality of surgical care, and those odds are inherent in the experience factor.

    Mel

    Posted 12/27/2009 9:56 AM (GMT 0)
    Aside from religious politics, possibly, there is no dirtier a business than medical politics. Every specialty has its prima donnas. I observed several and worked with a few. Ego is easily fostered and very hard to resist. When you are the lead dog in any specialty, there is added pressure. I was told some years ago that there were twelve hospitals in the USA that did an intracranial aneurysm repair more than 10 times a year. I knew that was BS because I was doing an average one a month in a local hospital with a hundred thousand population drawing area less than a hundred miles in diameter. The fact that the man who made this statement was a world recognized expert in aneurysm surgery colored my opinion greatly. I knew which aneurysms I could treat, and I referred the ones that needed more complex treatment to those who could do it.

    REMEMBER, all docs put their pants on one leg at a time. Being an "expert" places a greater burden on one's shoulder but also can lead to complacency. This has no place in an OR.
    Posted 1/4/2010 3:46 AM (GMT 0)
    Hello guys..I am trying to find the best doctor to do Da Vinci on my father. Which Dr in the US has the most experience and number of successful procedures under his belt, hence the best choice for this surgery?

    My Dad has to have this surgery within a couple of months and I need to know who is the BEST of the best.

    Thanks for your suggestions..
    Posted 1/4/2010 4:37 AM (GMT 0)
    After careful research, I chose:

    http://www.drmanimenon.com/vui.php

    Mel

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