Is it possible for a layman to vet surgical skill

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steph_beer_me
New Member


Date Joined Apr 2009
Total Posts : 14
   Posted 4/26/2009 1:49 PM (GMT -6)   
Ever since my PCa diagnosis about a month ago I've been on a fact finding mission to try and select *the* surgeon who will give me the best possible outcome on a daVinci RP.  First from a cancer cure standpoint and secondarily for side effects.
 
To date I've consulted with one urological surgeon, a radiation oncologist, and another friend-of-a-friend oncologist.  I've also attended several support groups and spoken with 20-25 men who've had surgery and gotten recommendations from them as well.  I've also watched the surgery on YouTube and it seems very technical from my non-medical professional point to view.
 
A few things I've learned in my investigations is that physicians are very reluctant to compare and contrast each other and that patients almost always recommend that surgeon that they had, even if they're not that happy with their outcome.  These two facts are making it difficult for me to reach that "it's a no brainer, go to Dr. X" decision. 
 
At this point, I've gotten my choice narrowed down to about 4-5 surgeons.  Even if I were to consult with all 5 surgeons, I still think that I would have a hard time narrowing my choice to one.  That brings me to my questions:
 
1) Is it even possible for a layman to determine and compare/contrast surgical skill within a small pool of experienced surgeons?  All I'm able to go on right now is number of surgeries performed.  Post-op side effect statistics seem to be hard to come by and if available are kept by the surgeons themselves with the inherent question of subjectivity.  Also, just because someone has the most surgeries/experience, doesn't necessarily make them the best within a given pool.
 
2) Hypothetically speaking, if 2 experienced DaVinci surgeons (say with hundreds of surgeries under their belt each) were to operate on the same patient, would an independent expert be able to tell the difference between the two post-op?  Or perhaps surgical technique just doesn't vary that much or have that much of an impact on outcome.
 
3) What types of questions can I ask a surgeon during a consult to help me determine skill level?
 
Perhaps I'm overthinking this, but ultimately, I get one shot and I'm looking for the most meticulous and best "technician" possible.  For me, bed side manner is secondary.  How do I go about finding *the* doc who's going to give me best possible outcome?
Thanks in advance!
Age 40
Diagnosed at age 40 (March 2009) as a result of routine physical
Family history - Father diagnosed and treated at 64, one of his brothers at 70, maternal uncle at 60
PSA 19.14 - my first PSA 
DRE - abnormal - 1cm nodule
14 biopsy cores - 1/4 positive on left, < 5% malignant, 3/7 positive on right, 10% malignant, 3 cores of nodule showed no malignancy
Gleason 3 + 3 = 6
Cat Scan - negative, believed to be prostate confined
Bone Scan - negative, no distant metastasis
great wife and 3 young children (ages 4, 6, 8)


TeddyG
Regular Member


Date Joined Apr 2009
Total Posts : 133
   Posted 4/26/2009 2:35 PM (GMT -6)   

Steph,

We all went through the process of decided who and where. Ultimately it is up to you but here are a few factors that guided me:

Of course experience level is critical. Though some authorities suggested a surgeon with at least 300 procedures behind them, I opted for one with over 1000 so that his/her breadth of experience was wider; I also opted for a doc associated with a major medical academic/research institution; docs experienced with various techniques i.e., open, robotic and laproscopic so that they are comfortable with their chosen technique (mine does both robotic and laproscopic), and candor. Another important factor to me was, if all things are equal, could I find a facility and surgeon close to home where my support systems, friends and family are, and follow-up would be accessable. I did not want to be in recovery in a hotel in a strange city for a week. I have a friend who went to another city and came home after 3 days and then developed an infection. he had to see totally different docs at a different facility to take care of him including hospitalization.

The actual "success statistics" that you see on some web sites for various docs are deceiving because each patient is different. You doc can say basically he/she finds that 80% this or that, but you are unique. If you find 3,4 or 5 that seem to all be fine, consider the other factors that may make the process easire for you and the family.

TeddyG 


Background:
Age 55, two teens, very fit cyclist (avg 2000+ miles per year) and weight, diet, etc. consistent with good habits. Stressful job as attorney; very supporting wife who ishelping me through every stage of this war.
Stats:
2006 PSA - 1.5
2007 PSA - 2.3
2008 PSA - 5.3 (18 mos.)
2009 Jan. 20 - Biopsy 12 samples
        Feb 3 Dx 2/12 samples positive, low volume  (5% and 7-10%)
Gleason 3+4, later downgraded by second opinion at Johns-Hopkins to 3+3, but "it's still PCa" as my Doc said.
Laproscopic surgery April 9, 3 days in hospital, catheter removal April 21.
Pathology: clear margins, no cancer in prostate: told that this is very rare but review of literature says ~1.3 %; family says "miracle."
Now working w/ post-surgery issues....
 


DJBearGuy
Veteran Member


Date Joined Dec 2008
Total Posts : 714
   Posted 4/26/2009 3:22 PM (GMT -6)   
Steph,

It's quite possible, that out of your top 5, there are maybe 3 whose skill level is pretty much the same, and excellent. Then you can look at secondary factors--Does the surgeon appear overworked? Overly eager for your business? Or does he/she put you first, and not mind if you choose to go elsewhere?

Then what about the hospital and its staff? My wife once stayed at a hospital where the staff tried to give her a pill that was 10x less than her prescribed dosage. Fortunately she was coherent enough to notice it didn't look right.

DJ
Diagnosis at age 53. PSA 2007 about 2; PSA 2008 4.3
Biopsy September 2008: 6 of 12 cores positive; Gleason 4+3 = 7
CT and Bone scan negative
Da Vinci surgery at City of Hope December 8, 2008
Radical prostatectomy and lymph node dissection
Catheter out on 7th day, replaced on 8th day, out again 14th day following negative cystogram
Pathology: pT2c; lymph nodes negative; margins involved; 41 grams, 8% involved by tumor; same Gleason 4+3=7
PSA 1/22/08 non-detectable! 8-)
4/23/09 still undetectable!


geezer99
Veteran Member


Date Joined Apr 2009
Total Posts : 990
   Posted 4/27/2009 2:00 PM (GMT -6)   
I asked my internist on the grounds that he got to see lots of patients before and after. He recommend three surgeons. I was most impressed when Doctor #2 recommend Doctor #3 as having done many more operations (1,000 versus 500) he also said that when he was just beginning robotic surgery he had Doctor #3 sit in on his operations to give advice. I went with Doctor #2 because I figured that he had few ego problems about being best, but was committed to being better.
Age at diagnosis 67, PSA 5.5
Biopsy 12/08 12 cores, 8 positive
Gleason 3 + 4 = 7
CAT scan 1/09 negative, Bone scan 1/09 negative

Robotic surgery 03/03/09 Catheter Removed 03/08/09
Post surgical pathology report. Lymph nodes negative, Seminal vesicles negative
Surgical margins positive, Capsular penetration extensive Gleason 4 + 3 = 7

Post Edited (geezer99) : 4/27/2009 2:05:04 PM (GMT-6)


LV-TX
Veteran Member


Date Joined Jul 2008
Total Posts : 966
   Posted 4/27/2009 2:49 PM (GMT -6)   
Well here is one more question to throw into the mix...

Besides how many surgeries each one has done...how many do they do in a day? So if the surgeon does three a day...are you going to be the first or the last....

It was a deciding point for me. I didn't want to be #3 with a tired surgeon...or #1 in which a surgeon was rushed to get to #2. See my point? So I opted for a surgeon that does one on the day of surgery...mine.
You are beating back cancer, so hold your head up with dignity
 
Les
 
Age 58 at Diagnosis
Oct 2006 - PSA 2.6 - DRE Normal
May 2008 - PSA 4.6 - DRE Normal / TRUS normal
July 2008 - Biopsy 4 of 12 Positive 5 - 30% Involved Bilateral w/PNI - Gleason (3+3)6 Stage T1C
Robotic Surgery Sept 18, 2008
Pathology October 1, 2008 - Gleason 7 (3+4) Staged pT2c NO MX - Gland 50 cc
Seminal Vesicles and Lymph Nodes clear
Positive Margins Right Posterior Lobe
PSA 5 week Oct 2008 <.05
                   3 month Jan 2009 .06
                   6 month April 2009 .06


Godfather
Regular Member


Date Joined Jan 2009
Total Posts : 64
   Posted 4/28/2009 8:47 AM (GMT -6)   
Steph:

Great question. First off, where are you? You'll get plenty of recommendations from those in your area when you post your location.

As you can see from my signature, I was going to travel to New York to have an open procedure done by the Chief of Urologic Surgery at Sloan Kettering. That canceled so I continued to interview surgeons in my area while waiting to be re-scheduled and found an absolute star in Sarasota, Dr Carey. I interviewed a total of 4 surgeons (2 open/2 robotic) and can tell you that it's a gut feeling - once you find the right one, you'll know it. My guy had his own statistics and does 200 a year. He does the complete procedure, including opening and closing, and does not go room to room on an assembly line basis. He does only two a day. He took over an hour to talk to me and my wife. I knew he was the guy before we left the office.

Again, if you do your homework and visit here often, the decision will be much easier. My email address on the left is active - feel free to write if you have any specific questions. I'm just sitting here with a cath in, counting the days until it's removed. Good luck to you.

Tony
Age at diagnosis 61 5'10" 260 lbs. Resides in SW Florida
12/07 PSA 2.6 12/08 PSA 4.0 Biopsy 1/09 - 6 of 8 nodes positive
Left - 2 of 4 positive, 2% involved, 4+3=7 Gleason Right - 4 of 4 positive, 40% involved, 4+3=7 Gleason
Perineural invasion is present - MRI suspicious for extracapsular extension
Scheduled for open RRP @ MSK 3/10/09 - canceled due to cardiac clearance issues
Da Vinci RLP w/ Dr Carey @ Sarasota Memorial 4/23/09
Post op pathology - staging and Gleason unchanged at T2c, 4+3=7
All lymph nodes, seminal vesicles and margins negative


lifeguyd
Veteran Member


Date Joined Jul 2006
Total Posts : 672
   Posted 4/28/2009 8:50 AM (GMT -6)   
LV-TX said...
Well here is one more question to throw into the mix...

Besides how many surgeries each one has done...how many do they do in a day? So if the surgeon does three a day...are you going to be the first or the last....

It was a deciding point for me. I didn't want to be #3 with a tired surgeon...or #1 in which a surgeon was rushed to get to #2. See my point? So I opted for a surgeon that does one on the day of surgery...mine.

    This was the big decider for me.  I chose not to use two kinds of surgeons, the "self promoters" and the "surgery factory" guys.  Although I am sure that some of them are highly skilled, I have always had more confidence in the surgeon who knows his limits and is not overselling his skill.
 
My surgeon had only 200 surgerys when he did mine, and he only does about four or five surgerys a week.  Two and a half years later, he has only done two or three hundred more DaVinci procedures, but is considered the finest most successful in our area.
 
It worked for me. April 2009 PSA still undetectable.
 
As an aside, at my recent appointment, I asked him his reaction to recent  psa testing controversy.  He just smiled and said "your diagnosis was lethal, I'm sure you were happy to find that out".
PSA up to 4.7 July 2006 , nodule noted during DRE
Biopsy 10/16/06 ,stageT2A
Aggressive Gleason 4+4=8  right side
DaVinci Surgery  January 2007
Post op confirms gleason 4+4=8
No extension or invasion identified
Few continence problems
PSA 90 day (-.01)  , (6 month -.01) , (9 month +.02) , (1 year +.02) ( 18 months +.02) (two years+.03)
One side nerve spared
still using bi-mix 
born in 1941


Swimom
Veteran Member


Date Joined Apr 2006
Total Posts : 1732
   Posted 4/28/2009 10:38 AM (GMT -6)   
Steph,

Sure there's a way to narrow the choices...Go to the surgeon, surgeons go to with a diagnosis of PCa. It is likely you will be looking for the guy with a line outside his door. If it's surgery you've chosen, seek the surgeon, not the type. Be it open or assisted, pick a surgeon with solid experience.

Paul (husband) was in in 40's. He chose David Wood at U of M because the man was honest, didn't beat around any bush. Probably is unsolicited comment.." Paul, you're too young. Incontinence won't be you're problem" is what convinced me in part. I like a man who is confident enough with his skill to hike up his Dockers and boast of his ability a little.

I think you are also asking if one surgeon can tell another's work? The answer to that is yes, in many cases. A surgeon is like any artist....he/she has a tradtmark something that marks his territoty. Since a type of surgery is often a specialists chosen favorite, he / she may have a particular stitch or clamp or perhaps a grafting style that is unique, a tradmark so to speak. W eall do that really. Eveyone has a tradmark somehting about them. I can say I've been wittness to this with surgeons several times.

Lastly, ask a question and be familiar with the term before you do. Ask if he's been published. Makes even the layperson appear to know more....Kinda like me crawling under a car at the dealership. I may have little informed knowledge but, I make em think I either know more or am working on it :>) Giving something a once over and knowing enough to sound informed really does help. Women do it all the time to keep from getting scammed :>) Entrez PubMed has hundreds of thousands of abstracts and articles available for anyone to read. Browsing a few makes a body sound more informed and a Doc is less like to be evasive. Good Luck and hang in there.

Swim
 


steph_beer_me
New Member


Date Joined Apr 2009
Total Posts : 14
   Posted 4/28/2009 12:47 PM (GMT -6)   
Thanks for the replies everyone. Of the 3 surgeons I'm considering where I live in Rochester, NY, one has done 2000 surgeries and gives seminars at the annual AUA conference including a live daVinci RP, is published, people come from all over to be operated on by him, etc. He does 12 surgeries per week. He would seem like the no-brainer I'm looking for. The only issue I have is that the 3 doctors (urologist, 2 oncologists) that I've spoken with know him, yet recommend other surgeons ahead of him (they won't say why). The other 2 surgeons on my list are less experienced (400-500 RPs each). I haven't spoken with any of them yet, but have appointments with 2 out of the 3.

Godfather, can you tell me what statistics your surgeon, Dr Carey gave you? Finding out whether my surgeon candidates keep similar stats might help me make my selection.

FYI, I'm located in Rochester, NY - any other surgeon recommendations are welcome.
Age 40
Diagnosed at age 40 (March 2009) as a result of routine physical
Family history - Father diagnosed and treated at 64, one of his brothers at 70, maternal uncle at 60
PSA 19.14 - my first PSA 
DRE - abnormal - 1cm nodule
14 biopsy cores - 1/4 positive on left, < 5% malignant, 3/7 positive on right, 10% malignant, 3 cores of nodule showed no malignancy
Gleason 3 + 3 = 6
Cat Scan - negative, believed to be prostate confined
Bone Scan - negative, no distant metastasis
great wife and 3 young children (ages 4, 6, 8)


geezer99
Veteran Member


Date Joined Apr 2009
Total Posts : 990
   Posted 4/28/2009 2:08 PM (GMT -6)   
Remember that a positive outlook is a great asset in dealing with cancer. I'd guess that any of the three is is going to be good. I"d say go with your gut, that is what will give you the advantage.

P.S. stats are never certain. For example, it is well known that for many different conditions University affiliated teaching hospitals have higher mortality rates. Why? Because that is where the real tough cases are sent.
Age at diagnosis 67, PSA 5.5
Biopsy 12/08 12 cores, 8 positive
Gleason 3 + 4 = 7
CAT scan 1/09 negative, Bone scan 1/09 negative

Robotic surgery 03/03/09 Catheter Removed 03/08/09
Post surgical pathology report. Lymph nodes negative, Seminal vesicles negative
Surgical margins positive, Capsular penetration extensive Gleason 4 + 3 = 7


Swimom
Veteran Member


Date Joined Apr 2006
Total Posts : 1732
   Posted 4/28/2009 5:47 PM (GMT -6)   
Well, what day of the week are the 3 available? I'd be a little concern about a guy who does 2-3-4 surgeries 5 days a week. Either he's available by Tuesday or I go th the surgeon who is more rested. If fatigue is of any concern to you perhaps the one who has an opening early in the day / early in the week. Just my opinion.

swim
 


Godfather
Regular Member


Date Joined Jan 2009
Total Posts : 64
   Posted 4/28/2009 6:26 PM (GMT -6)   
Steph:

He had his patients broken down by pre-op age, Gleason and stage. He "aged" the stats, first 200 patients, next 200, last 200, etc. He reported blood loss, hospital stay, post-op margin status, etc. For instance, his earlier patients had 85% negative margins and his last 200 improved to 93% so he was obviously improving on his skills. While he does 200 robotic RPs a year, he didn't dwell on that, other than to answer our questions on the subject. His focus was on me and my clinical presentation.

I may be able to shine some light on your issue about the guy doing thousands of these but not being recommended by other docs. We interviewed a surgeon who is one of the best known in the country, having done more than anyone else. He talked about being #1 and having multiple robots, going from one procedure to the next. We were able to finally get another surgeon to open up about him - he is viewed by his peers as a zealot for the DaVinci method and his focus is doing more procedures than anyone else (as a matter of fact, he told us that he signed up 60 new patients that week). We went with a guy with half that amount. My sense is that once you exceed 500 or so, you have the necessary experience.

You're going to do just fine - your intelligence literally jumps off the page and you are appropriately focused on this process. Sit down in front of these guys with your wife, look them in the eye and ask your questions. The decision will be surprisingly simple.

Good luck to you, my friend.

Tony
Age at diagnosis 61 5'10" 260 lbs. Resides in SW Florida
12/07 PSA 2.6 12/08 PSA 4.0 Biopsy 1/09 - 6 of 8 nodes positive
Left - 2 of 4 positive, 2% involved, 4+3=7 Gleason Right - 4 of 4 positive, 40% involved, 4+3=7 Gleason
Perineural invasion is present - MRI suspicious for extracapsular extension
Scheduled for open RRP @ MSK 3/10/09 - canceled due to cardiac clearance issues
Da Vinci RLP w/ Dr Carey @ Sarasota Memorial 4/23/09
Post op pathology - staging and Gleason unchanged at T2c, 4+3=7
All lymph nodes, seminal vesicles and margins negative


TeddyG
Regular Member


Date Joined Apr 2009
Total Posts : 133
   Posted 4/28/2009 6:46 PM (GMT -6)   

Steph,

The stage that you are at is, from my experience, the most stressful. Sure, the surgery and recovery are critical stages but the thing that stressed me out more than the surgery and recovery was the process of figuring out who and where to go for treatment. You are on the right track in your research. Soon you will know and then you will feel some relief. Once you decide, just do it.

Best wishes,

TeddyG


Background:
Age 55, two teens, very fit cyclist (avg 2000+ miles per year) and weight, diet, etc. consistent with good habits. Stressful job as attorney; very supporting wife who ishelping me through every stage of this war.
Stats:
2006 PSA - 1.5
2007 PSA - 2.3
2008 PSA - 5.3 (18 mos.)
2009 Jan. 20 - Biopsy 12 samples
        Feb 3 Dx 2/12 samples positive, low volume  (5% and 7-10%)
Gleason 3+4, later downgraded by second opinion at Johns-Hopkins to 3+3, but "it's still PCa" as my Doc said.
Laproscopic surgery April 9, 3 days in hospital, catheter removal April 21.
Pathology: clear margins, no cancer in prostate: told that this is very rare but review of literature says ~1.3 %; family says "miracle."
Now working w/ post-surgery issues....
 


KeyWestPirate
Regular Member


Date Joined May 2009
Total Posts : 60
   Posted 5/7/2009 10:52 AM (GMT -6)   

I had the great fortune of having a wife who is an OR nurse.  She would often discuss in generalities the differences in skill levels that she and the other nurses noticed in the surgeons they assisted.  Names were not named, but it became clear to me that surgeons are NOT created equal.  And, it's not just skill and talent.  Attitude plays a big role too.  The worst surgeons are usually the arogant and rude ones.   The assisting nurse is at ground zero and she is very sensitive to what is going on during the procedure.

I have a brother-in-law doctor (Neurologist but works ER) and two nurse sisters who left the profession.  Their advice boiled down to "Get lots of second opinions"  Neither was close enough to my home to recommend a specific surgeon.

When I realized that my first urologist was not putting my best interests first (to describe the situation politely), she (wife) started asking for references.  Her primary care physician was the source for my eventual choice.  He was described as "poor bedside manner, but crackerjack surgeon"  A doctor talking to her nurse patient can be more honest, knowing her confidence will be honored.

 I liked his committment to his ED recovery program (ED meds started immediately after surgery, use of the VED starting at 3 weeks). I was already taking 25mg Viagra daily for my BPH.   We were pretty sure that both my nerve bundles could be spared based on my pre-treatment numbers, but he said the nerves would be bruised, and the increased blood flow from the Cialis or Viagra plus the VED would accelerate their recovery.   He preferred Cialis, but I had a lot of off-shore Viagra in stock that I had been using for my BPH.   Erectile function was very important to me.  My wife is 10 years younger than I am.

  I liked his unabashed enthusiasm for the Da Vinci robot.   I'm an IT guy, and I KNOW that new is USUALLY better (except for Microsoft's operating systems).  People won't spend the money for new equipment unless there is an advantage to be realized.  I know how robots have revolutionized manufacturing processes, increasing both speed and precision.

 He talked about the importance of bladder neck re-attachment before I had ever heard the term.  He used a different word for it.  During our consultation he didn't once say "The most important thing is, we get the cancer out"  That IS important, but it's really a given.  The rest is equally important.

I agree with Godfather that just doing a huge number of surgeries should not be the only qualifier.  This is a long and tedious surgery if it's done right.  There is no way to rush the most important aspects. Someone is cutting corners, and those corners are probably your nerve bundles and bladder neck.

  I like Godfather's choice of the surgeon who kept and shared his stats.  This speaks to pride and motivation.  Wanting to do the best job possible.  Trying to improve.

  I also agree that many recommend their choice of surgeon, even though their outcomes don't speak that highly of the choice they made.  There is a natural desire to trust our physicians.  The price for this trust is often very high.

__________________________________________________________

Diagnosed June 2008 at 63, PSA 6.5 Gleason 6, On-going BPH w/ high PSA for five years, free PSA number drove the biopsy

  Robotic RP 11/2008 DR Todd Waldmann, at St Alphonsus, Boise  No pain, some (well, really LOTS of) anxiety.  I was up and walking almost immediately after the surgery. Wore some paths in the carpeted corridors outside the rooms.  What else is there to do?   "Walk and pass gas and you get to go home"   I didn't need pain meds after discharge.  Abdomen was a little tender, but that was all.

Prostate at pathology more involved than at biopsy, but still Gleason 6.  Clear margins, no extension, no other involvement, prostate size 89 grams  "We got it all"

Catheter pulled 7 days later, completely dry the following day.  "No lift, no sex for six weeks" reduced to 3 weeks. Some erectile function at 3 weeks, sufficient for penetration, but . ..  Got worse for a while, then started getting better.  Two months' testosterone replacement (5mg Androderm patch daily  -had to fight for it, urologists don't like testosterone on principle) for two months starting Jan2009 coupled with two week vacation in Arizona seemed to ice the cake.  Wife didn't have to go to work every day  wink  

 Erectile function improves steadily, but I still do not have the pre-op erection quality and drop-dead dependability at 6 months.  Continue to take daily Cialis or Viagra.  Viagra works best but makes my nose stuffy.  Continue to use the VED 3 x weekly.  I really feel that I'm doing my part    --but my penis is slacking.

The only visible evidence of the procedure is a 2" vertical scar where the camera went in and the prostate came out, the other incisions have vanished.

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