Surgeon expertise

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Subdenis
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Date Joined Aug 2017
Total Posts : 221
   Posted 11/11/2017 10:34 AM (GMT -7)   
Looking for feedback. Mu uro at Yale is a great communactor, available and I really like him. He has done 100 surgeries and participated in 750 during his post doc fellowship. His sole focus is prostate cancer treatment.

I have heard the number of 300 tossed around for competence.

Thoughts?

tennisplayer
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Date Joined Nov 2016
Total Posts : 308
   Posted 11/11/2017 10:43 AM (GMT -7)   
I've read that the learning curve is at least 300 RRP's. I was talking to the NP on my surgeon's team recently and I expressed my opinion that my immediate return to continence after my surgery has to be partially due to the surgeon's expertise. He felt that it is a factor, but there are other variables, and luck counts as well.
However, he said an inexperienced surgeon increases the chance of less than ideal return to continence. Of course that's just one professional's opinion.

When in doubt, go for the most experience. You only get one shot at a prostatectomy.
Age at diagnosis-66 Diagnosed 6/16
RALP 10/16 at U of Chicago, Dr. Shalhav. Experienced internal bleeding post op requiring transfusion of 2 units.
Pathology Gleason 3+4=7, tumor volume 15% Margins negative except for one focal margin, .1mm
pT2c,N0,MX,R1
PSA @ 6 wks <0.02;16 wks <0.02; 5/17 <0.02; 10/17 <0.02
My storywww.healingwell.com/community/default.aspx?f=35&m=3777359

Subdenis
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Date Joined Aug 2017
Total Posts : 221
   Posted 11/11/2017 10:55 AM (GMT -7)   
Thanks Tennisplayer. I will meet with a guy here in Central Florida who has done >11000

tarhoosier
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Date Joined Mar 2010
Total Posts : 470
   Posted 11/11/2017 10:58 AM (GMT -7)   
The head of Uro at my local hospital, the 2d largest system in the US, says that he did 150 robotic prostate removals before he truly felt he knew what he was doing and 250 before he was ready to tell someone else how to do it. Resident training, in other words.

Subdenis
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Date Joined Aug 2017
Total Posts : 221
   Posted 11/11/2017 11:05 AM (GMT -7)   
Thanks tarhooser. I also am reading the frequency of procedures is critical to maintain competence.
65YO healthy man, PSA 5/17 4.6, MPMRI, 5/17 lesion. 13 core biopsy 3 positive 3+3 and one positive in a lesion, All cores less than 30% 8/17 - the second opinion Yale pathology shows a small amount of (3+4) in one core, < 5%, decipher test shows intermediate risks, looking at treatment options. MRI in 11/17 to see if there are changes.
Colchester, CT summer, Clermont FL winter. Thanks Denis

Progressing
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Date Joined Aug 2017
Total Posts : 37
   Posted 11/11/2017 12:17 PM (GMT -7)   
Agree with tennisplayer and tarhoosier.
Dr. Karim Touijer at Memorial Sloan Kettering did mine on 10/31. He does 200 per year, over 2500 lifetime, and I think it due to his skill that my margins are negative and I am continent two days from removal of catheter.
Age 75, excellent health except PCa
7/20/17, Biopsy, 5/12 cores PCa all right side, none on left, Gleason 4+3, PNI, suspicion of EPE
PSA 20.44
MRI and CT no evidence of metastasis, no lymph nodes, no seminal vesicles, focal bulge
Laparoscopic surgery 10/31/17, left nerves spared
11/9/17 catheter out, little leakage, pathology report T3aN0, G4+3, focal EPE, no cancer at any surgical margins

Pratoman
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Date Joined Nov 2012
Total Posts : 4929
   Posted 11/11/2017 1:04 PM (GMT -7)   
Denis, as I've stated elsewhere, my opinion, the more the better. More surgeries means exposure to more situations and we are all different in some way.

I've seen data showing that 300 is where the learning curve flattens out, but I would rather see at least 1000. There are enough good Surgeons to choose from in most areas, with that many, I would think.
Dx Age 64 Nov 2014, 4.3
BX 3 of 12 cores positive original pathologyG6, G6, G8 (3+5)
downgraded to 3+3=6 by tDr Epstein, JH
RALP with Dr Ash Tewari Jan 6, 2015
Post surgical pathology – G7 (3+4), ECE, Margivns, LN, SV all negative
PSA @ 6 weeks 2/15, .<02, remained <0.02 until January 2017, .02, repeat Feb 2017, still .02. May 2017-.033, August 2017- .033
Decipher test, low risk, .37 score

Saipan Paradise
Regular Member


Date Joined Sep 2017
Total Posts : 62
   Posted 11/11/2017 1:33 PM (GMT -7)   
Denis, sounds like you’re meeting with Dr Patel at Florida Hospital Celebration. I’ve posted about my good experience with his team if you want to search for it, & would be happy to answer specific questions. I’m continent at 12 weeks post RP, no pads, after being an open spigot the first week post catheter.
Also check out Dr Leveillee at Bethesda West in Boynton Beach. He came recommended to me by a uro at Cleveland Clinic and I had a positive experience when I spoke with him.
Age 60 at dx
Dx July 2017 after biopsy G8 (4+4), 5/13 cores, bone scan clear
RARP Aug 11, 2017 (Dr Patel)
Post surgery pathology: pT3a, tumor 30% of gland, ETE, seminal vesicles and 3 lymph nodes clear
PSA 1/2016, 2.9
4/2017, 7.2
9/25/2017 (first post-RARP), 0.13
10/10/2017, <0.05

Subdenis
Regular Member


Date Joined Aug 2017
Total Posts : 221
   Posted 11/11/2017 4:13 PM (GMT -7)   
Thanks SP I think Patel is who I will use. Denis

Worried Guy
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Date Joined Jul 2009
Total Posts : 3726
   Posted 11/11/2017 6:13 PM (GMT -7)   
People say the more surgeries the surgeon has done the better. I am not so sure.
At some point 2000, 3000, 5000, (you pick it) the patient becomes a number and the surgeon is merely "phoning it in". I don't care how interesting or important the task at some point it becomes routine and dull. The importance and sense of urgency is diminished. Surgeons are human.

If someone said they had completed 12,000 surgeries I'd be looking for another. Remember, supposedly you are the surgeons patient "for life". With all those victims patients what must the office be like? Are patients stuffed in there like sardines? How much time do you have with the doc for the followup?

How do you know the 12000 number is real? Why aren't the surgical results posted some place? How many patients have ED? How many are incontinent? Can you get a recording of the surgery? The daVinci has the capability. Why isn't that a part of the record? Is the surgeon willing to give you a copy? Why not?

It's strange that we use word of mouth from a few folks for something as important as this yet we'll spend days looking at reviews and ratings for tires, flash lights, and power tools.

Some day there will be an Angie's List, Yelp, Google Reviews, or Apple iCut'em for this purpose.
Good luck!
Jeff
Age: 65, Mar. 42 yrs, 56 dx, PSA: 4/09 17.8, 6/09 23.2
Biop.: 6/09 Pos 7/12, 20-70%, G4+3; Bone, CT Neg
DaVin RP: 7/09, U of Roch Med Ctr
Path Rpt: G3+4, pT3aNOMx; 56g, Tumor 2.5x1.8 cm both lobes and apex
EPE, PNI extensive; Sem Ves, Vas def clear, Lymph 0/13
AdVan Sling 1/11
ED total
PSA: 10/09 .04, 7/10 <0.01, 7/11 <0.01, 1/12 <0.02, 4/13 <0.02, 3/14 <0.02, 4/15 <0.02, 5/16 <0.02, 6/17 <0.02!

Nick2017
Regular Member


Date Joined Jun 2017
Total Posts : 90
   Posted 11/11/2017 6:20 PM (GMT -7)   
100 surgeries? That's a rookie. My guy has done 4000+

This is so important that you need the MOST experienced surgeon, who has seen it all. The downside is that if he is at a teaching hospital, you have to make sure he doesn't allow his students to do it. Lots of things that can mess up leaving you impotent forever or wearing a diaper. Go for the most experienced one you can find at the largest hospital there is.

Best,

Nick
Age 64, married 34 years, Diagnosed 5/11/17, T1c, PSA 3.5, Originally Gleason 8, reduced by Dr. Epstein to Gleason 4+3, TRUS biopsy: 2 cores at 20%. MRI found PIRADS 4 & 5.

RP Surgery 7/19/17 by Dr. Zagaja at University of Chicago, both nerves spared, Negative Margins, biopsy showed Gleason (4+4), less than 5% of prostate cancerous. Now must test PSA every 6 months. Happy with my decision!

Break60
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Date Joined Jun 2013
Total Posts : 1763
   Posted 11/11/2017 6:43 PM (GMT -7)   
So should we feel sorry for the first few hundred or 1000 guinea pigs? I find it hard to believe that beginners don’t have an experienced veteran overseeing their surgeries and the vets doing thousands are not really doing them ; they’re supervising.
But clearly having either surgery or radiation at a high volume facility should produce better results.
Bob
DOB January 1944 (now age 73)
PSA: 8/12 2.7; 5/13, 6.6 (actually double due to finasteride)
7/13 (age 69) Bx GS 4+5=9 (Epstein); 2 of 6 cores, 10%, 40%; stage Pt1c
9/13 ORRP, GS 4+5=9, BLSVIs+, margin+ (4mm,G7), EPE, 10 Nodes resected (clear); stage upgraded to pt3bN0M0
PSA: 11/13 0.1; 2/14 0.2; 5/14 0.3
6/14 SRT by IMRT/IGRT, 68.2 grays/38 Fx to prostate bed, ADT (6 months Lupron)
PSA: 9/14 to 8/15: <.1, <.1, .1, .3, .7, 1.2
9/15 MRI, CT-PET finds two iliac lymph nodes suspicious for PCa; organs and soft tissue clear ; Start ADT3 plus plus Metformin, Cabergoline, Estradiol patch, Prolia , Vitamin D3, calcium. IMRT 75 grays/50 Fx to pelvic lymph nodes. Stopped ADT 11/16.
11/15-5/17: PSA rises from .03 to 2.3.
5/17: F-18 Fluciclovine (axumin) PET/CT scan finds abnormal uptake in intertrochanteric region of the proximal right femur compatible with skeletal metastasis measuring approx. 9 mm. No other adverse findings. Restart ADT3; start monthly Xgeva
6/17 SBRT, 30 grays/ 3 Fx to femur met.
7/17 PSA 0.3, T 3.0

halbert
Veteran Member


Date Joined Dec 2014
Total Posts : 3112
   Posted 11/11/2017 7:31 PM (GMT -7)   
Break has a point as well. If the new surgeon never gets any takers, what happens when the major experienced guys retire? It's a complex question. Now, when it comes to a guy with that many thousands, we know how HE works. His team lines up the 5 or 6 for the day, (or more?), does the preps and opens, sets up the robot, etc. He comes in on a strict schedule, does his thing for maybe 30 minutes, leaves, goes to the next room and does it again. Is assembly line medicine REALLY the best way to go?
Age at Diagnosis: 56
RALP on 2/17/15, BJC St. Louis, Dr. Figenshau
58.5g, G3+4, 20%, 4 quadrants involved
PSA 3/10/15: 0.10
5/18/15: <.04
8/24/15: <.04
11/30/15: <.04
2/29/16: <0.04
8/30/16: <0.04
2/15/17: <0.006
8/22/17: <0.006
My Story: www.healingwell.com/community/default.aspx?f=35&m=3300024

Saipan Paradise
Regular Member


Date Joined Sep 2017
Total Posts : 62
   Posted 11/11/2017 8:31 PM (GMT -7)   
According to Atul Gawande, assembly line medicine is definitely the way to go when it comes to the surgery itself:
https://utmedhumanities.wordpress.com/2014/10/14/the-computer-and-the-hernia-factory/
Patel’s office is always packed with patients, but I got compassionate, careful attention from his team at all stages pre and post surgery. My wife felt equally taken care of. I never felt treated like some widget in a car factory. Can’t speak for other high volume surgeons, seems right to worry that some might be dialing it in.
Age 60 at dx
Dx July 2017 after biopsy G8 (4+4), 5/13 cores, bone scan clear
RARP Aug 11, 2017 (Dr Patel)
Post surgery pathology: pT3a, tumor 30% of gland, ETE, seminal vesicles and 3 lymph nodes clear
PSA 1/2016, 2.9
4/2017, 7.2
9/25/2017 (first post-RARP), 0.13
10/10/2017, <0.05

Subdenis
Regular Member


Date Joined Aug 2017
Total Posts : 221
   Posted 11/12/2017 12:46 AM (GMT -7)   
Like most things with PC there is no clear answer. However, the common opinion is experience trumps bedside manner. SP I have heard from others about their great experience with Dr. Patel.

Thanks, everyone Denis

clocknut
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Date Joined Sep 2010
Total Posts : 2640
   Posted 11/12/2017 7:24 AM (GMT -7)   
Maybe a very important factor is that the guy must be, first and foremost, and excellent surgeon.

My uro had been doing prostate surgeries the traditional way for many years prior to the introduction of the DaVinci machine His reputation as a skilled surgeon is well known.

When he did my robotic surgery, he told me he had done about 50 robotics. So, in light of the discussion in this thread, I was a guinea pig, so to speak.

All I can say is that my return to continence was very quick, and my PSA remains undetectable 7 and a half years later.

So, if a doc has no history of traditional prostate or other urologic surgery, having only used the DaVinci machine, then maybe hundreds of surgeries are necessary. But, if he knows his way around from years of actual surgical experience, that learning curve may be much shorter. He MUST be a good surgeon and possess certain skills.

Hundreds of procedures won't turn a bad surgeon into a good one, but they will make a good surgeon better.
Age 72
Dx June 2010.
PSA rose for 3 years to 6.2
Bx shows cancer in 6 of 12 cores, all left side
Gleason 7 (3 + 4)
DaVinci 8/20/10
Negative margins; negative seminal vesicles
5 brothers, ages 59-74 ; Two of us have had PCa
Continence after 7 weeks.PSA 1/3/10: <0.01; 6/12/11: <0.01, 1/26/12: <0..01; 10/12: <0.01
8/13:<.01; 4/15:<0.01, 7/16: <.01;8/17:<0.01

InTheShop
Veteran Member


Date Joined Jan 2012
Total Posts : 7930
   Posted 11/12/2017 10:27 AM (GMT -7)   
just want to point out that the surgeon is not the only person in the room and not the only person who's going to touch/cut/sew you back up. Your surgeon leads the team and is responsible for everything that happens.

High volume surgeons rarely do every step of the procedure, often popping in to do the critical parts and leaving steps to other people. Even at non-teaching hospitals. Surgeons have to learn somewhere and their counts of how many they have done is a bit fuzzy. He's done 300? Okay, how many as the only surgeon in the room? How did he learn?
I'll be in the shop.
Age 57, 52 at DX
PSA:
4.2 10/11, 1.9 6/12, 1.2 12/12, 1.0 5/13, .6 11/13,
.7 5/14, .5 10/14, .5 4/15, .3 10/15, .3 4/16, .4 10/16, .4 5/17, .3 10/17
G 3+4
Stage T1C
2 out of 14 cores positive
Treatment IGRT - 2/2012
My latest blog post

Subdenis
Regular Member


Date Joined Aug 2017
Total Posts : 221
   Posted 11/12/2017 10:38 AM (GMT -7)   
Thanks I am not interested in being someone's learning curve.
65YO healthy man, PSA 5/17 4.6, MPMRI, 5/17 lesion. 13 core biopsy 3 positive 3+3 and one positive in a lesion, All cores less than 30% 8/17 - the second opinion Yale pathology shows a small amount of (3+4) in one core, < 5%, decipher test shows intermediate risks, looking at treatment options. MRI in 11/17 to see if there are changes.
Colchester, CT summer, Clermont FL winter. Thanks Denis

Philmire
Regular Member


Date Joined Oct 2017
Total Posts : 54
   Posted 11/12/2017 11:30 AM (GMT -7)   
Hi Denis, I'm a neighbor in Spring Hill and I am looking for the same thing but the term "HIGH VOLUME" turns me off. Here in Fl. we get used to assembly line medicine but for something like this I'd rather not. Let me know how you do and I'll really appreciate it. Thanks, Philmire

Subdenis
Regular Member


Date Joined Aug 2017
Total Posts : 221
   Posted 11/12/2017 11:38 AM (GMT -7)   
A friend of mine just had it done by Patel and said the whole process was amazing and personal
65YO healthy man, PSA 5/17 4.6, MPMRI, 5/17 lesion. 13 core biopsy 3 positive 3+3 and one positive in a lesion, All cores less than 30% 8/17 - the second opinion Yale pathology shows a small amount of (3+4) in one core, < 5%, decipher test shows intermediate risks, looking at treatment options. MRI in 11/17 to see if there are changes.
Colchester, CT summer, Clermont FL winter. Thanks Denis

Pratoman
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Date Joined Nov 2012
Total Posts : 4929
   Posted 11/12/2017 11:44 AM (GMT -7)   
Subdenis said...
A friend of mine just had it done by Patel and said the whole process was amazing and personal


Denis, I think with that kind of referral/testimonial, I think you can be very comfortable going in, with Patel.

Philmire
Regular Member


Date Joined Oct 2017
Total Posts : 54
   Posted 11/12/2017 11:51 AM (GMT -7)   
I'm one of those freaks that's allergic to high dose radiation. I've been doing intermittent ADT and I feel fine but in time I'll have to have the RP so if you will, let me know how you do. My email is in my profile, Thanks, Phil

Subdenis
Regular Member


Date Joined Aug 2017
Total Posts : 221
   Posted 11/12/2017 12:51 PM (GMT -7)   
Philmire I will.
65YO healthy man, PSA 5/17 4.6, MPMRI, 5/17 lesion. 13 core biopsy 3 positive 3+3 and one positive in a lesion, All cores less than 30% 8/17 - the second opinion Yale pathology shows a small amount of (3+4) in one core, < 5%, decipher test shows intermediate risks, looking at treatment options. MRI in 11/17 to see if there are changes.
Colchester, CT summer, Clermont FL winter. Thanks Denis
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