Why your DaVinci Uro should be experienced!

There is also a story in this morning's Boston Globe about complications in some robotic surgery and hospitals' needing to promote the use of their expensive robotic equipment.

http://www.bostonglobe.com/lifestyle/health-wellness/2013/03/25/state-cautions-hospitals-about-patient-complications-during-robot-assisted-surgery/xOAsxR80qH5mVENDdktjKL/story.html?p1=Well_BG_Links

Sad story.

I read a news report yesterday showing 1600 robotic surgeries as optimal and it went into this company a bit too:

www.bloomberg.com/news/2011-02-16/doctors-need-1-600-robot-aided-prostate-surgeries-for-skills-study-finds.html

Doctors Need 1,600 Robot-Aided Prostate Surgeries for Skills, Study Finds said...


Doctors who perform robotic-assisted prostate cancer surgery aren’t proficient and able to remove all the malignant cells surrounding the tumor until they have done the procedure more than 1,600 times, researchers said.

Results from a study suggest the operations using Intuitive Surgical Inc.’s da Vinci robot are being performed too often at community hospitals by surgeons without enough experience, said Prasanna Sooriakumaran, lead author and urologist at the Weill Cornell Medical College in New York. Doctors have embraced the approach because studies show it can be learned quickly, uses smaller incisions, causes less blood loss and speeds recovery.

More than 90,000 men in the U.S. have their prostate gland removed each year because of cancer, according to the American Society of Clinical Oncology. The surgery is done mainly with robotic technology introduced in 2000 by Sunnyvale, California- based Intuitive Surgical, typically by doctors who perform 100 or fewer procedures annually, Sooriakumaran said.

We've had this discussion several times in the past few years.

I'm inclined to agree with the Intuitive spokesperson who finds the 1,600 number "absurd."

I say "absurd" for this reason.  IF it's true, I would argue that the DaVinci robot should be outlawed.  If surgeons don't develop full competency until they've operated on 1,599 patients, then really only a few men each year are getting their full money's worth.  The rest of us are not being properly served.

What if some study concluded that airline pilots aren't really proficient until they have logged 1,600 flights?  Would you fly on an airline whose pilot had only flown 100 times?  I'm afraid we wouldn't have many planes in the air.  We would probably conclude that airplanes are simply too complicated for human beings to fly, and we would ban them.

So, I say the 1,600 number is absurd.  If the DaVinci robot is that difficult to master; if all those tens of thousands of men are receiving less tham optimum surgeries; if we're risking recurrence because it takes that long to learn to remove all the cancer cells (or at least 90 percent of them), then what that says to me is that the machine is overly difficult, dangerous, and should be outlawed.

I realize that we frequently tell newcomers to the site to find a surgeon who has done "at least" 1,000 or more DaVinci surgeries (which always leaves me wondering how badly the first 999 were butchered).  Undoubtedly there's a learning curve, but if it's really as steep as 1,600, this is an untenable situation.  Maybe the question is, "How high do we set the bar in defining success in a prostatectomy?"

 

 

My sister, who is a physician, asked around before my husband's surgery. What she was told was that there was a steep learning curve for DaVinci prostate surgery and that 600 operations was the point at which a surgeon becomes proficient.

Hi Guys:

Several years ago I posted the following on a thread called, "Experience Counts".  It's a bit dated and applies to open surgery and not DaVinci but it does provide some scientific data re the value of experience.  So, while 1600 may be over the top, I would think that "several hundred" is probably reasonable. 

Jim

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.

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Not sure what the answers are, but I would also suspect that the learning curve is much higher for older surgeons who are not real comfortable with technology. The new surgeons coming out of med school have and still are playing video games by the hour, with great proficiency as well as living on their cell phones, tablets, and laptops.

I believe that the DaVinci is much like the ultimate video game. Eye/hand coordination, comfort levels with technology, and really understanding how it all works is probably where the 1600 number came.

Goodlife

I have always heard the number "1000" from forums - some say 300 (and I guess that comes from Walsh's book). No idea what the real number is but I have to go with the studies over anecdotal evidence.

From what I have read the training is not good enough:

It’s not the robot, it’s (almost certainly) the humans that are the problem
prostatecancerinfolink.net/2013/03/21/its-not-the-robot-its-almost-certainly-the-humans-that-are-the-problem

I think the studies are compelling. Is it the final word? No, but it does point out a serious problem.

While it may be true that complications, anastomotic leakage and nerve sparing reach a plateau after the experience of performing only several hundred operations, it seems to require much greater experience to "get it all"-- to achieve a low positive surgical margin rate. There is a world of difference between the surgical factories like Johns Hopkins and urosurgeons in community practice on this dimension. It's especially critical among patients who present with higher stage disease.

Every time I hear that someone had positive surgical margins, I wonder if they'd asked their surgeons how many such surgeries they'd performed, and what was their positive surgical margin rate in the last year. The Johns Hopkins experience shows that it can get as low as about 10% (there will always be some, unless they are selecting only low risk patients).

I don't care how they got enough practice to be proficient. That's their business, not mine. I'm not altruistic enough to volunteer to be their guinea pig for their learning curve.

Here's an abstract of the Sooriakumaran study for anyone who hasn't seen it:

Sooriakumaran et al. said...

Minerva Urol Nefrol. 2011 Sep;63(3):191-8.
Learning curve for robotic assisted laparoscopic prostatectomy: a multi-institutional study of 3794 patients.
Sooriakumaran P, John M, Wiklund P, Lee D, Nilsson A, Tewari AK.
Source
Department of Urology, Weill Cornell Medical College, New York, NY, USA.
Abstract

AIM:
The aim of this study was to define the learning curve for positive surgical margin (PSM) rate and operative time (OT) for robotic assisted laparoscopic radical prostatectomy (RALP); while the learning curve appears shorter for surgical safety for RALP compared to other surgical modalities, this has not been well established for the above parameters.

METHODS:
We performed a retrospective cohort study of 3794 patients who underwent RALP between Jan 2003 and Sep 2009 by three surgeons (DL, PW, AKT) from three centers (UPenn, Karolinska, Cornell). Mean overall PSM rates and mean overall OT were calculated for all three surgeons at intervals of 50 RALPs per surgeon, and learning curves for these means were fit using a loess method. R version 2.71 was used for all statistical analysis.

RESULTS:
The learning curve for PSM rates for all patients demonstrated improvements continued with increasing surgeon experience, with over 1600 cases required to get a PSM rate <10%. When pT3 patients were evaluated, the learning curve started to plateau after 1000-1500 cases. Mean OT plateaued after 750 cases though with further surgical experience the OTs started to climb again.

CONCLUSION:
The learning curve for RALP is not as short as previously thought, and a large number of cases are needed to get PSM rates and OTs to a minimum. This suggests that RALP should be performed by high volume surgeons in order to optimize patient outcomes.

I agree with David. We cannot randomly assign a number to a specific task and say that once you reach that number you are an expert. There are way to many variables. Where was the surgeon trained? What is his/her educational back round? My wife has always said “one may educated, but that does not make them smart.” Where is the surgery to be performed? It seems that most of the larger teaching institutions have the best of everything. The surgeon I had attended Sloan Kettering then moved on to the clinic, I doubt he had 1,600 surgeries under his belt, but he was good. He took time with me, and I understood he would be doing all of the critical procedures. He was a specialist in robotic PCa surgery. I would not feel comfortable with a general surgeon who may have done 500 robotic prostate removals and then moved on to gall bladder surgery. Once again I don’t think quantity should be equated with quality. However, I would not want to be number 1.

Clocknut,

Well said.  For example, I have been an amateur photographer for many years.

My images are not going to come anywhere near a professional's even though I have taken close to 25,000.  He/she may have achieved fame and fortune with only 10,000.

I think the point of the "experience" issue is not to necessarily select an exact number that will insure success.  Rather it's to manage the variables as best as possible to increase the odds of success.  There are many variables and experience is one of them.  This does not mean that the community doctor who does 10 RP's per year can't do it as well as the big city guy who does 1000 per year.  However, the odds are that over a number of cases the ones with more experience (up to a point) will yield better results in terms of cure and side effects. 

That is why is remains prudent to advise newcomers to look for some significant experience level (hundreds?).  This is one of the variables that we can manage to improve our odds.

Jim

As patients, we can only make decisions based on probabilities. It is up to us to find the doctor who will most probably do the best job, based on both quantitative and qualitative considerations. Yes, there probably are prodigies out there who can perform the surgery expertly with little training, just as their are musical prodigies who can play Chopin at the age of 4. But we would be foolish to bet that a given surgeon is one of those surgical prodigies. If we have data telling us the positive surgical margin rate is substantially reduced after 1600 surgeries, why wouldn't we seek out a surgeon with such experience rather than hope that some guy we may personally like can do as a good a job? Why wouldn't we ask for their positive surgical margin rate in the last year? Don't we look at performance statistics and track records when we make major purchases like a car? Don't we look at relevant experience when we hire an employee, and interview several before deciding on the best? Isn't our body at least as important? We are not at the mercy of referring doctors. There are ways we can find the best ones for ourselves.