Surgeons and Scorecards

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brainsurgeon
Regular Member


Date Joined Jul 2009
Total Posts : 137
   Posted 10/15/2009 7:55 AM (GMT -6)   
I may be off base here, but I seem to sense an inordinate dependency on the number of cases that surgeons do weather laproscopic, robotic, or open in nature. I believe that in some cases this can lead to false impressions.

I am reminded of my intern days when I was called upon to assist a resident doing a pelvic procedure. This guy had an inflated impression of himself and loved to show it off. On occasion, he would set the operation clock and see how fast he could do this particular procedure. We can all agree that such behaviors are stupid and have no place in surgery.

Once you have done a procedure many times, enjoy doing it, and are good at it, your work can become fun. There is a fine line between this point and becoming complacent. If this happens, it is a matter of time until the fates jump up and grab you. Hopefully, this doesn't affect patient care and does serve as a wakeup call to the doctor to eat a little "Humble Pie'. This is a fact of human nature at some point. It is important to realize that all procedures have a learning curve. This curve varies from one to another. I believe that anyone with several hundred procedures under their belt is a safe bet. At some point, complacency arrives, one gets and enjoys a reputation, and one begins to have more and more surgeons come into the OR to observe and learn. These observers are a distraction but in the interest of medical teaching, they are needed.

The number of procedures done are important unless the guy is a congenital klutz. If that is the case, he eventually self destructs. I seriously question if an additional 1000 procedures added to a 1000 existing improves performance to a measurable degree. There was once a famous Mayo Clinic surgeon who had done more of a certain type of brain tumor than anyone in the world. He merely went from one OR to another, did his thing on a patient already opened, and then left for another room while others closed. I want my man to be there from step one, to do my surgery as his first case, and to have assistants that know his actions so well that they can anticipate his moves. I have seen surgical procedurs of some complexity carried out with no conversation between the surgeon and his assistants.

So, pick your procedure after hearing the pros and cons, understand that all have unique, as well as, common complications, be the first on the list in the morning, make sure he has a team that do these procedures with him, and choose a doctor with a degree of experience (how many cases?? I don't know, but more is not always better). I submit that a given surgeon with a hundred cases done may well be as good as one with 500 cases completed. Feel free to disagree!
70 years old USA citizen
Prostatic carcinoma dxed June 2009 by PSA (7.0) and then Bx
PSAs yearly since 2001 ranged 1.52 to 7.0
Neg. CT and BS
4 of 8 biopsies positive (all right side) Gleason Score 3+4=7
Robotic assisted total prostatectomy and node excision July 2009 in Luzern, Switzerland
pT2c G3 pN0 (0/14)
Catheter out in 5 days (home in 3 days)
No incontinence
Potency: beginning tumescence??? at 3 weeks post-op. Still happens at 3 months PO


James C.
Veteran Member


Date Joined Aug 2007
Total Posts : 4462
   Posted 10/15/2009 8:31 AM (GMT -6)   
An outstanding post, and I thank you for it. I tend to search out the younger, newer educated guys for my medical care, rather than the older, near the end of their careers who may have settled into their senior status a little too comfortably.
James C. Age 62
Co-Moderator- Prostate Cancer Forum
4/07 PSA 7.6, referred to Urologist, recheck 6.7
7/07 Biopsy: 3 of 16 PCa, 5% involved, left lobe, GS 3/3=6
9/07 Nerve sparing open RRP 110gms.- Path Report: GS 3+3=6 Stg. pT2c, 110gms, margins clear
24 mts: PSA's: .04 each test since surgery, Bimix .3ml PRN or Trimix .15ml PRN


qjenxu
Regular Member


Date Joined Sep 2009
Total Posts : 187
   Posted 10/15/2009 8:46 AM (GMT -6)   
very good post. Interesting to know. and will questioning during our surgeon interview.

about the time or day of the surgery, everyone is different. maybe Monday, the surgeon still hasn't recover from weekend mood, or the first surgery in the morning may be the warm up one, the second may be the best. who know. :-)

Jennfier

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 10/15/2009 9:04 AM (GMT -6)   
Good post and information there, Dr. My uro/surgeon had performed about 400 open surgeries over the years. I also feel that it is not needed to go to the best hospital in the country and seek out the best brand name surgeon money can buy. There are hundreds, if not thousands of competent surgeons spread all through out the country.

My only mistake, that due to a mis-communication with the hospital, mine was the last of the day, starting at 4 pm. My surgeon wanted it to be first of the day, but they were so overbooked on operations at that time. I will remember that in the future.

David in SC
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Latest: 7/09 met 2 rad. oncl, 7/09 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 - out  38 days, 9/14/9 - met 3rd rad. oncl.agree to start radiation, mapping on 9/21/9, 9/24 - mtg with uro/surg, 9/29- pre-op, 10/1 - 3rd corr. surgery - suprapubic cath/hard dialation, 10/5 - began IMRT SRT - 39 sessions/72 gys.


O Buddy Boy
Regular Member


Date Joined Oct 2009
Total Posts : 106
   Posted 10/15/2009 9:26 AM (GMT -6)   
You make an excellent point.

Humility is one of the critical personality traits I look for in a surgeon. Your post points out why it is such an important part of successful outcomes.

I have known many physicians in my life professionally, socially and personally. What impressed me the most is that despite the infamous "God Complex" I have found that generally that the most successful surgeons are also the most humble. Even a heart surgeon I knew quite well, was renowned for his expertise, and a bit cocky in his personality ... even he approached every procedure with extreme focus and sublime humility.

I don't need a "god" or "goddess" handling the surgical tools. I already have my God in the operating room to handle my soul.

OBB
55 yo
Dx:9/29/09
DRE: Susp
PSA: 3.5
Gleason: 3+4/7
6/12 Cores Positive
1%, 3%, 8%, 15%, 12%
RALP: 10/0/09
PATH: Not back yet


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4223
   Posted 10/15/2009 9:44 AM (GMT -6)   
It's good to hear another point of view that is well thought out. This just adds to our common knowledge base.
Thanks Doc,
JT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 4151
   Posted 10/15/2009 11:00 AM (GMT -6)   

Doc...interesting post.  FYI, here is a cut and paste I did about a year ago from Hopkins "Health alerts".  This represents at least one study that has tried to quantify the value of experience...

Tudpock

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.


Age 62, Gleason 4 +3 = 7, T1C, PSA 4.2, 2 of 16 cores cancerous, 27cc
Brachytherapy December 9, 2008.  73 Iodine-125 seeds.  Procedure went great, catheter out before I went home, only minor discomfort.  Regular activities resumed, everything continues to function normally as of 9/1/09.  6 month PSA  1.4 and my docs are "delighted"!

Mavica
Regular Member


Date Joined Jun 2008
Total Posts : 407
   Posted 10/15/2009 5:52 PM (GMT -6)   
"I may be off base here, but I seem to sense an inordinate dependency on the number of cases that surgeons do weather laproscopic, robotic, or open in nature. I believe that in some cases this can lead to false impressions."
 
I agree with that statement (above) and I wouldn't want to be within a country mile of one of the surgeons frequently recommended here who seems to be doing da Vinci procedures around the clock (impossible).  Yes, a certain level of experience is needed to reach proficiency - but there are additional factors (age and continuing education of the surgeon/physician, included) that need to be considered.


Age:  60 (58 at diagnosis - June, 2008)

April '08 PSA 4.8 ("free PSA" 7.9), up from 3.5 year prior

June '08 had biopsy, 2 days later told results positive but in less than 1% of sample

Gleason's 3+3=6

Developed sepsis 2 days post-biopsy, seriously ill in hospital for 3 days

Dr. recommended robotic removal using da Vinci

Surgery 9/10/08

Northwestern Memorial Hospital, Chicago, IL

Dr. Robert Nadler, Urologist/Surgeon

Post-op Gleason's:  3+3, Tertiary 4

Margins:  Free

Bladder & Urethral:  Free

Seminal vesicles:  Not involved

Lymphatic/Vascular Invasion:  Not involved

Tumor:  T2c; Location:  Bilateral; Volume:  20%

Catheter:  Removed 12-days after surgery

Incontinent:  Yes (1/2 light pads per day)

Combination of Cialis and MUSE (alprostadil) three times weekly started 9-27-08

Returned to work 9-29-08 (18-19 days post-op)

PSA test result, post-op, 10/08: 0.0; 12/08: 0.0; 4/09: 0.0; 9/09: 0.0

 


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 10/15/2009 6:50 PM (GMT -6)   
Very good point you added, Mavica. It's not just a numbers game or assembly line operation techniques. More of something isn't always better.
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Latest: 7/09 met 2 rad. oncl, 7/09 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 - out  38 days, 9/14/9 - met 3rd rad. oncl.agree to start radiation, mapping on 9/21/9, 9/24 - mtg with uro/surg, 9/29- pre-op, 10/1 - 3rd corr. surgery - suprapubic cath/hard dialation, 10/5 - began IMRT SRT - 39 sessions/72 gys.


T40
Regular Member


Date Joined Oct 2009
Total Posts : 103
   Posted 10/15/2009 8:07 PM (GMT -6)   
My doc had over 750 and stopped counting. He said he didn't want people to feel like a number and his assistant said the same thing. He stressed that they treat people and don't work on a conveyor belt.
Age 40
Pre-op PSA was 5.8 from wellness test on May 19, 09
Follow up test from uro was 4.6 with a 9.3% free psa
Gleason 3+3 in one core, 3+4 in second core of 12 samples taken
Uro recommended Robotic for someone of my age. My research confirms.
Surgery performed August 19th, 09.
One side nerves spared. Nerve graft on other side.
Six weeks incontinence almost over. ED a work in progress but seeing some response.
Post op October 2nd, 2009 All margins were negative. PSA results in a few days.

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