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Posted 10/10/2019 3:05 PM (GMT -7)
Hi everyone,

I would like to ask if anyone here would allow a urologist surgeon with only 300 RP's surgeries under their belt to operate on them? I was assigned my new urologist/surgeon when I was diagnosed with PCa. I had a long relationship with my last urologist and really liked him. We connected well. I don't have a great feeling for my new dr.

At a G6 a year ago I was ok with having cancer. Now at a G7 its a whole different ball game. I am stressed out completely and was given amitriptyline a few months ago. I am ready for a dosage increase as my starting dose is not helping my anxiety at all.

To me surgery vs RT is kind of like pay me now or pay me later in respects to side effects. I am struggling to know what to do. My wife is all for RP. Just the thought of someone cutting that part of me and taking it out just turns my stomach.

Thank you everyone for listening and any advice.

dmo

Post Edited (oceanfisher58) : 10/10/2019 4:13:39 PM (GMT-6)

Posted 10/10/2019 3:11 PM (GMT -7)

oceanfisher58 said...
Hi everyone,

I would like to ask if anyone here would allow a urologist surgeon with only 300 RP's surgeries under their belt to operate on them? I was assigned my new urologist/surgeon when I was diagnosed with PCa. I had a long relationship with my last urologist and really liked him. We connected well. I don't have a great feeling for my new dr.

At a G6 a year ago I was ok with having cancer. Now at a G7 its a whole different ball game. I am stressed out completely and was given amitriptyline a few months ago. I am ready for a dosage increase as my starting dose is not helping my anxiety at all.

To me surgery vs RT is kind of like pay me now or pay me later in respects to side effects. I am struggling to know what to do. My wife is all for RP. Just the thought of someone cutting that part of me and taking it out just turns my stomach.

Thank you everyone for listening and any advice.

dmo

if you don't feel comfortable get another doctor. as far as your feelings about side effects you'd rather have yours right away?

i'm in my ninth year of remission and I had a lot of radiation -- both seeds and IGRT -- I have never once been incontinent and what ED I do have is corrected with Cialis. I am very happy with my quality of life.

i'm not trying to steer you toward radiation. frankly I think you should do what you believe is best for you. but I do feel its incumbent on me to say I think you've been misled.

good luck to you!
age - 64
12/09 - PSA 6.8
G7 - 3+4 - all 12 cores pos
HT, BT, IGRT
6/19 - 9th year post treatment PSA .1!
PSAs .2, .3, .2, .3, .2, .1, .2, .2, .1, .1, .1, .1, .1, .1

"..You get braver as your options dwindle.." -- Fairwind

https://instagram.com/edraderphotography/
Posted 10/10/2019 3:20 PM (GMT -7)
Thank you F8 for your quick reply. No I am not leaning toward surgery at all. I have not even met with a RO yet. I have made no decision as of yet. I see many members here have had RP's as well as RT. I am still taking it all in and trying to make sense of it all. I just met with a surgeon a few days ago. Next stop is RO.

My real question is it ok to have a surgeon with only 300 surgeries to operate on me?

Thanks
dmo
Age 61
First biopsy Diagnosed PCa 2018
Gleason 3+3=6 A.S. was my treatment plan
2 cores 10% positive
Second biopsy 2019
Gleason 3+4=7
Adenocarcinoma
four cores at 3+4=7 between 5 and 30% cores positive
Posted 10/10/2019 3:26 PM (GMT -7)
Probably at least 750 procedures are required to be good as well as performing frequent and regular surgeries. The surgeon should be operating several times every week.

As to radiation, I, like F8 had double radiation (EBRT and brachytherapy) nine years ago. I have no negative treatment side effects from the radiation.

Do more research and meet with several different doctors in their specialties. See at least two more high volume surgeons and meet with radiation oncologists that specialize in SBRT and brachytherapy, both permanent seeds and HDR. Only then should you be deciding on a treatment protocol. Your risk level indicates you have plenty of time to do your assessments. I saw five different doctors in four weeks before deciding. It was the best thing I did.

And remember, “cutting it out” doesn’t guarantee success and is no better then killing it with radiation. Out or dead is the same. Also understand that all the radiation treatments will treat a larger area than the surgeon can cut. This helps for a cure in case any of those little cells are out of the surgical field. Remember that about one third of surgeries fail and require salvage radiation.
PSA 59 on 8-26-2010 age 60. Biopsy 9-8-2010 12/12 positive, 20-80% involved, PNI in 3 cores, G 3+3,3+4,and 4+3=G7, T2b.
Eligard and Jalyn started on 10-7-2010. IMRT to prostate and lymph nodes started on 11-8-2010, HDR Brachytherapy December 6 and 13, 2010.
PSA < .1 since February 2011. Located in Cumming Georgia north of Atlanta
Posted 10/10/2019 3:38 PM (GMT -7)
If you choose surgery, I think you should seek a more experienced surgeon. A radical prostatectomy is a complex procedure. I would want to be in more experienced hands. They have to learn on someone - preferably not on me.
Part I
2015 (Age 54) PSA: 20.8
Bx: All cores G7 (4+3)
RALP & Adjuvant RT
Pathology: G8 (4+4)+5
PSA nadir: 0.1, steady increase until 2019: 64.13

Part II
2019, March: Lupron/Xtandi, PSA: 1 month: 0.126; 3 months: 0.036; 6 months: <0.02
Posted 10/10/2019 4:17 PM (GMT -7)
Answer to your question.... Studies have shown that the learning curve starts to flatten out at around 300 surgeries. But with that said unless you’re in a rural area where are you really don’t have a lot of choices I would want at least 700 or 800 as JNF said. Experience is a great teacher and you want confident professor for this surgery
I am not a doctor, just another guy without a prostate
Dx Age 64 Nov 2014, PSA 4.3
BX 3 of 12 cores positive original pathology G6
RALP with Dr Ash Tewari Jan 6, 2015
Post surgical pathology G7 (3+4), - ECE, - Margins, -LN, -SV (+ frozen section apex converted to 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 November .046, March 2018 .060. June 2018 .068, July 2018 - .082, August 2018, .078, August 2018 - .08 Start ADT. Sept 2018 Start SRT
Sept 2018 thru November 2018 – T = 4, PSA = <.05
Decipher test, low risk, .37 score
My story.... tinyurl.com/qgyu3xq
Posted 10/10/2019 4:34 PM (GMT -7)
My first advice is to re-read JNF's post. He brings to mind a number of cautions for those considering treatment. Also keep in mind that as a "new" G7, you still have a reasonable amount of time to consider your options.

I'd also like to underscore JNF's point that you need to learn about the alternative treatments that may be appropriate for you medically. Then find a doc who practices each one that interests you. Unless a doc practices a particular treatment, he/she will definitely NOT be able to tell you all the pro's and con's of a particular treatment. For example, an RO who does standard IMRT/IGRT (the 40-session variety) will not be up to date with all the details about brachytherapy (seed implants), nor will they be fully knowledgeable about SBRT radiation (the 5-visit variety). They may know some information, but unless that is their "bread and butter" they just won't know all the details that you need to know in order to decide.

You haven't supplied your complete history, age, details of the biopsy report, etc., so we can't help much with the relative pro's and con's of the various treatments yet. I'm sure that if you compile a signature for your posts, others will be able to help you discern which treatments could or might not be appropriate.

You have touched upon one of my cardinal points from my own decision process -- side effects. Given that you plan to live quite a while after treatment (you do, don't you?), my advice is to learn not only about the efficacy of the various treatment options, but also about the side effect profiles of each. In many cases (my own included) there are several treatment options with the same likelihood of cure, but having greatly different side effect profiles. I chose to concentrate on the side effects, and chose the treatment modality that had the side effect profile I felt I could best live with for the decades I plan to have ahead.
Age 68 at Dx
PSA history: 2000-2012 0.9-1.2; 06/2012 started T replacement
2013-2015 3.0-3.3 (new normal); 11/2015 4.6; 05/2016 5.7
Biopsy: 12-core biopsy 07/2016; 3 cores G3+3, 5% or less; 1 core 3+4, 15%; 1 core HGPIN; 2% of gland involved. Summary G3+4.
CyberKnife SBRT with Dr. Hirsch; start 11/15/16, finish 11/23
Posted 10/10/2019 7:09 PM (GMT -7)

Paxton said...
I chose to concentrate on the side effects, and chose the treatment modality that had the side effect profile I felt I could best live with for the decades I plan to have ahead.

Ok as a guide, but I'd still advise Oceanfisher not to put too much faith into expecting certain SE's from whatever treatment. It's unpredictable and you risk being disappointed by unexpected events. I got a navicular fossa stricture indirectly from surgery (probably instrumentation injury) and the chance of that is about 0%. I'm sure it's the same for radiation treatment. Like surgery, some fly through, others have issues.

I'd definitely not go for a urologist with only 300 procedures under his belt unless no choice. That's me. It's complex surgery and the more experience the better.
2017: PSA 4.4, family history.MRI->lesions indicated.
Biopsy:carcinoma several cores, Gleason 3+4
open prostatectomy -> hist. report: pT2c, 2 pos margins. Gleason revised down to 3+3.
Navic. fossa stricture likely from catheter-> dilations ->urethroplasty op. 2018
PSA: Post surgery-Present: 0.01,0.012,0.025,0.03,0.02,0.03
Posted 10/10/2019 9:54 PM (GMT -7)
Thank you everyone for the advice. I definitely have ready the "First time diagnosed" thread and many many other members posts. I did think 300 was a minimal amount of surgeries for my surgeon.

Paxton: I did include my signature but for some reason my opening post of this thread did not include this. The other posts I made in this thread do include my signature. I put the information I thought was relevant. Any advice on anything else I should include in my signature I would be happy to add.

I honestly go back and read everyones posts many times to learn as much as possible. I have only had a surgical consult so far. I will have my RO consult soon. I will ask for referrals for specialists on every type of RT available to me. I will also ask or seek out another two surgeons with more experience. I am a member of Urology of Virginia. I would appreciate any recommendations for drs if anyone here knows of any in my area.

Will it be a problem for me to seek second and third opinions from surgeons in the same medical group? If so then I will have to find urologists from different groups I can find.

All of the advice I have received is much appreciated. This is an extremely well educated and caring group. I want to thank everyone for their input.

dmo

So far
Age 61
First biopsy Diagnosed PCa 2018
Gleason 3+3=6 A.S. was my treatment plan
2 cores 10% positive
Second biopsy 2019
Gleason 3+4=7
Adenocarcinoma
four cores at 3+4=7 between 5 and 30% cores positive
Posted 10/11/2019 3:23 AM (GMT -7)

oceanfisher58 said...
Will it be a problem for me to seek second and third opinions from surgeons in the same medical group?

With me, it wasn’t a problem going from one urologist to another in the same group. (I live in southern Appalachia). If your group operates like mine did, it was just a matter of calling the group’s receptionists/schedulers and telling them who I wanted to see. They accommodated that. As of now, you are probably “the patient of Dr. So ‘n So. They will “take you away” from being “his” patient and you will become “the patient of the other doctor”. So, there is some paper work involved for them.

I too, do not like coming across a a pain in the rear. But, the way I saw it was, “You all are going home at 5 pm to continue on with your normal lives. *I’m* the one with cancer.”

You may end up (I did) seeing the other surgeon as more competent and letting him operate on you. During the follow up care is where my surgeon and I began to have relationship problems. So, it was then that I requested to go back to the original Uroto whom I was first assigned. They did accommodate that as well. But, I will tell you, doctors, as a rule, would rather not have to fix other another doctor’s mess ups. Their attitude can be (in rural areas anyway), “Heck, HE screwed things up, let HIM fix his own problems.”

So much of this can be driven by personalities in Small Town, America. These are issues that you more than likely will not encounter. But, here...it can be fairly common.

The bottom line is to go with who you are most comfortable with to administer your treatment. The rest is just living life.

Which, I may add...you’ve got plenty of left to live.
PSA 2010 thru 2014...4.0 +/- .7
Dx 12/14 @ 56 yo...2 cores G6 <5%, 1 core G6 20%, 1 core HGPIN.
RALP 11/25/15...3+4. 3 mm G6 surgical margin, 15% involvement
(5% G4) pT2+ Decipher: non-aggressive
PSA's....2/16-.01...4/16-.00...7/16-.00...10/16-.01...1/17-.01
...4/17-.02...7/17-.02...10/17-.02...1/18-.05...3/18-.014...4/18-.02
7/18-.047...10/18-.028...1/19-.014...5/19-.027...8/19-.031
Posted 10/11/2019 3:33 AM (GMT -7)

jasperx10 said...

Paxton said...
Ok as a guide, but I'd still advise Oceanfisher not to put too much faith into expecting certain SE's from whatever treatment. It's unpredictable and you risk being disappointed by unexpected events. I got a navicular fossa stricture indirectly from surgery (probably instrumentation injury) and the chance of that is about 0%. I'm sure it's the same for radiation treatment. Like surgery, some fly through, others have issues..

wise counsel
Posted 10/11/2019 3:59 AM (GMT -7)
OF, when I was diagnosed and treated, I lived in a rural area as well. My diagnosing Uro was the only guy in town, literally. He told me up front that he did open surgery, and that the local hospital did not, and probably never would have the robotic machine. He didn't want it anyway because he didn't want to climb the learning curve.

He also told me that if I wanted robotic surgery, or radiation other than external beam, that he would gladly refer me to one of the large facilities (relatively) near by. I chose to get treated a 2 hour drive away--and he did my follow up locally.

I get it, there are special challenges in rural smaller towns. It's not always practical to travel for treatment. We all have to balance the questions, and choose the best course for us.
Age at Diagnosis: 56
RALP on 2/17/15, BJC St. Louis, Dr. Figenshau
58.5g, G3+4, 20%, 4 quadrants involved
PSA Non-Detect since April, 2015
My Story: www.healingwell.com/community/default.aspx?f=35&m=3300024
Posted 10/11/2019 4:07 AM (GMT -7)
OF, despite your anxiety you are doing the right things to make sure your choice is sound. You want to do a thorough exploration of your options and you are fortunate to be in a geographic area with lots of excellent physicians so the options are readily available to you. I previously gave you the info on my urologist. My LDR Brachy doctor has retired so I don't have that to share with you.

Regarding number of surgeries, as Prato said, studies have shown that 300 is an absolute minimum before the curve flattens. I would suggest someone more experienced than that.

There were a couple of comments about Paxton's post but personally I thought his advice was spot on. While no individual result can be predicted by the statistical averages, there is a better chance of avoiding ED and incontinence with the radiation options than with surgery. I was about your age when I was diagnosed and once I learned that any of the mainstream options was likely to cure me then side effects became a major driver in my decision. It's not "pay me now or pay me later", it's a different long term statistical difference. I will say for your info, as most others here know, that I am very biased toward radiation and against surgery.

So, let us know how your RO consult goes and remember that one RO is unlikely to be totally expert in all of the important radiation options...they likely know IMRT but SBRT, LDR Brachy and HDR Brachy each have their own set of specialists and all of those options seem possible in your case based on what you have told us.

Finally, try reading renowned prostate oncologist Dr. Scholz' book, "Invasion of the Prostate Snatchers" along with noted surgeon Dr. Walsh's, "Guide to Surviving Prostate Cancer". They are different types of books with different perspectives but both will help you in your journey. Dr. Scholz also has a newer book, "The Key to Prostate Cancer" that I understand is excellent but I have not read it yet.

Stick with us...we will help you thru this.

Jim
Forum Moderator-Prostate Cancer. Age 62 (71 now), G 3 + 4 = 7, T1C, PSA 4.2, 2/16 cancerous, 27cc. Brachytherapy 12/9/08. 73 Iodine-125 seeds. Everything continues to function normally. PSA: 6 mo: 1.4, 1 yr: 1.0, 2 yr: .8, 3 yr: .5, 4/5 yr: .2, 6-10 yr: 1. My docs are "delighted"! My journey:
https://www.healingwell.com/community/default.aspx?f=35&m=1305643&g=1305643#m1
Posted 10/13/2019 11:33 AM (GMT -7)
I too recommend those books. Prostate Snatchers is, given the subject, actually a fun read. It's organized in alternating chapters written by the patient - Ralph Blum - and Dr. Scholz. So the perspective diversity is in itself interesting. If you get Walsh's book be sure and get the latest 4th edition.

"The Key" is in fact a compendium from I think it's 30 different MDs (and one or two others as I recall) ranging from surgeons to researchers to oncologists, etc. Well worth the read.
Age 65

10/2018: TRUS biopsy, 2 of 12 cores G6
12/2018: MRI:1.5cm mass; PI-RADS 5 Uro recos treatment
1/4/19: Guided biopsy, 1 of 6 cores G6; Dr. Epstein concurs
3/26/19: Dr. Duke Bahn recs AS
4 and 6/2019: two new uros rec AS
6 and 7/2019: 2 more uros rec AS. MRI re-read by top hosp radiologist: no PI-RADs
assigned.
8/23/19: MRI re-read, no PI-RADs

PSA
8/2/18: 1.2
3/26/19: 1.8
6/14/19: 2.2
Posted 10/14/2019 5:34 PM (GMT -7)
Thanks to finding this board - I switched my surgeon (who did my biopsy ) who had only 250 under his belt to another doc who had about 2000. So far I’m happy with that decision.
You only get one chance - so choose well. Don’t be shy to steer course - to another doc or another therapy. Keep researching and you will get to the right answer.
Posted 10/14/2019 6:13 PM (GMT -7)
“Snatchers” was recommended when I arrived. As was Walsh.

Both I used as reference manuals. Both can be read in snippets or as a novel. Great reads.
Posted 10/14/2019 10:24 PM (GMT -7)
These guys all have good points. I had surgery before I found this site. URO took all my nerves. He practices at one of the largest cancer hospitals in Los Angeles. They pride their selves in getting all the cancer out. Sex is completely gone. Doc said I may need Cialis. I have an IPP. GREAT! A garden hose inside a piece of dead meat. Worst yet, the incontinence drives me nuts. about the time I think it is not bad enough for a UTI. It starts leaking again. Wear a pad. At 25 degrees with a wet front your penis is frozen. I am a very active outdoor guy that likes running bird dogs. Life has really changed for me. Other treatments have the same survivor rate. Choose well.
77 very active. Physically fit. PSA was 6.8 MRI Targeted biopsy 6/17 Gl 3+4, 2 cores 9%, RARP, 7/28/17 ,16 lymph nodes & ALL nerves removed, pT3a, pin, negative margins, EPE focal, PSA 3/18 .05, 11/18 .08,1/19,.07, 4-19 .05 implant USC, Dr Boyd 4-17-18 Dribble constantly now
Posted 10/15/2019 7:24 AM (GMT -7)
I too was worried about the side effects of RT; however, after thoroughly comparing RT with surgery I selected RT. For my circumstances it was an easy decision. With either treatment PSA monitoring becomes a normal way of life. With RP it drops to undetectable and with RT it can be bumpy and sometimes a little concerning. My RO has reminded me a couple of times that the road ahead is a marathon and not a sprint. Keep researching and seek out the very best practitioners...the decision can change your life.
Rising PSA
11/12 1.98
11/13 1.95
9/15 3.28
10/16 5.94
1/17 3.0
TRUS 1/17
Bx: Three of twelve cores adenocarcinoma Gleason 6 (3+3)
all on left side and <5%, no pni
DOB 7/21/47 good health.
Age 69 @ Dx
Treated with SBRT by Dr. Tendulcar @
Cleveland Clinic 6/23/17
Reduced ejaculate is only side effect. Everything works
PSA’s post SBRT 1.1, 1.1, .9, 1.8, 2.7, 1.0
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