How To Find an Expert Prostate Cancer Surgeon

Urologists are one of the experts that treat prostate cancer with surgery or prostatectomy. How do you choose one?

How to Find an Expert Surgeon

Radical prostatectomy is a difficult operation. Many patients seen by the best surgeons still experience significant side effects from the surgery. It takes not only skill, but the kind of expertise you get only after being involved in a lot of procedures, first from the sidelines as a doctor in training, and then learning how to do it meticulously with the guidance of an expert surgeon.

The very best prostate surgeons specialize in the prostate. That’s often all they do, and they do a lot of prostatectomies every year. Do your diligence to find the right surgeon?

Find a high-volume center that performs a lot of surgeries.

  • Research shows that experience matters – typically, the more procedures a surgeon performs the better their outcomes. This is true for radical prostatectomy and "minimally invasive" laproscopic prostatectomy.
  • Support staff matter. The more procedures performed at an individual medical center typically means the nurses and support staff have more experience taking care of patients, recognizing complications and providing overall support and resources. High volume hospitals have been reported to have lower mortality rates.(4)
  • How many is enough to be experienced? Surgeons performing prostatectomies specialize in this procedure, they should be doing several a week.
  • Multidisciplinary teams working together - Look for a place where different specialties work together. Treatment centers with multidisciplinary teams of experts from different working together on prostate cancer tend to offer patients the most accurate information about prostate cancer treatment and work together in supporting patients. Optimal management of prostate cancer may include specialists in urology, radiation oncology, medical oncology, and pathology.

Prostate cancer is complicated, and there is no “one-size-fits-all” answer for every patient. With the multidisciplinary team approach, you get the opinion of a team of experts, not just one, and the benefit is a more thorough and thoughtful approach to your treatment.​

Does Robotic Surgery Improve Outcomes?

Among men who undergo radical prostatectomy for the treatment of early-stage prostate cancer, robotic-assisted laparoscopic surgery may not result in better urinary or sexual function than traditional, open surgery.

Prostatectomy may be performed using traditional open surgery, in which the surgeon makes a single, long incision, or through a laparoscopic procedure (sometimes called minimally invasive surgery), in which several small incisions are made. During laparoscopy, the surgeon inserts a small video camera through one of the incisions in order to see inside the abdomen. In a variant of laparoscopic surgery known as robotic-assisted laparoscopic surgery, the surgeon sits at a console near the operating table and performs the surgery by controlling robotic arms that hold the surgical instruments.

Use of robotic-assisted prostatectomy has increased rapidly in the United States. To compare the two procedures produces researchers evaluated Medicare claims data and surveyed men who had undergone a prostatectomy. Completed surveys were obtained from 406 men who had undergone robotic-assisted prostatectomy and 220 men who had undergone open surgery.

  • Overall, 31% of the men reported moderate or big problems with incontinence, and 88% of the men reported moderate or big problems with sexual function.
  • The frequency of sexual problems and incontinence did not vary significantly by type of surgery.

Although not definitive, the results of this study suggest that both approaches to prostatectomy (open surgery and robotic-assisted laparoscopic surgery) produce high rates of urinary incontinence and sexual dysfunction in Medicare-age men. Simply put....

Experience Still Matters With Robotic-Assisted Prostate Surgery:

A surgeon may have to perform well over a thousand robotic-assisted prostate cancer surgeries before becoming fully proficient at the procedure. Previous studies of robotic-assisted prostate surgery have suggested that it doesn’t take long for surgeons to learn how to perform the procedure safely.

To assess the number of robotic-assisted prostate surgeries that a surgeon must perform before becoming fully proficient, researchers assessed 3,794 patients who were treated by one of three surgeons.

A key outcome that was considered in the study was the rate of positive surgical margins. A positive surgical margin means that cancer is found at the edge of the tissue that was removed during surgery; it may be a sign that not all of the cancer was removed.

  • The rate of positive surgical margins declined as surgeons gained experience. The lowest rates of positive surgical margins (<10%) came after a surgeon had performed more than 1,600 robotic-assisted prostate surgeries.(ii)

Ask the surgeon about their results

Does the doctor keep results? The best surgeons typically do and have them available to share with potential patients. Ask for treatment results and the incidence of common complications in patients under their care; incontinence, impotence and what their programs does to manage them.

How do you know if the shared results are accurate?

The short answer is you don't! Ask the surgeon for names of individuals they have treated who are willing to talk to other patients. If they don't have any – consider being treated somewhere else.

Does the surgeon/clinic have a support network for their patients?

Some cancer centers have support groups or virtual communities where patients share their experience. This can be a good place to learn about the surgical outcomes from a specific doctor and cancer treatment facility.

Is the surgeon a surgeon’s surgeon?

Ask other physicians about the surgeon’s reputation. What has their experience been with referrals? Would they personally go to that surgeon?

Should you get a second opinion?

It’s always a good idea to consider a second opinion if possible. Competent medical professionals will not be offended. After all its your prostate. The Role of Second Opinions in Cancer Care

Laparoscopic Surgery and Open Surgery Produce Similar Complication Rates in Prostate Cancer.

Laparoscopic prostatectomy and open radical prostatectomy produce similar outcomes and carry similar rates of postoperative complications, according to the results of a study published in an early online version of the Journal of Urology.

A population-based study included 5,923 men aged 66 or older who underwent radical prostatectomy between 2003 and 2005; 18% of these procedures were performed laparoscopically. The researchers found that there were no differences in the rate of complications between the two surgeries. The laparoscopic procedure was associated with a 35% shorter hospital stay and a 26% lower rate of bladder neck and urethral obstruction. Patients who underwent surgery from surgeons who performed a higher volume of laparoscopic procedures tended to have shorter hospital stays and reduced chance of genitourinary and bowel complications.(33)

What Does The Research Show?

Surgeon Experience Affects Outcomes Following Prostatectomy

Results from some clinical studies have indicated that surgeons who are experienced in specific surgical procedures may provide their patients with better outcomes than surgeons who are less experienced in the procedure. Researchers from Memorial Sloan-Kettering Cancer Center conducted a clinical trial to evaluate outcomes of prostatectomies and surgeon experience with the procedure.

This study included 7,849 men with early prostate cancer who underwent a prostatectomy between 1987 and 2003 at one of the following four cancer centers: Cleveland Clinic, Wayne State University, Baylor College of Medicine, or Memorial Sloan-Kettering Cancer Center. None of the patients had received chemotherapy, hormone therapy, or radiation therapy prior to surgery. This study included 74 surgeons.

Patients had better outcomes if their prostatectomy was performed by a surgeon experienced in the procedure:

  • At 5 years, progression-free survival was 88% for patients whose surgeons had performed 250 or more prostatectomies.
  • At 5 years, progression-free survival was 79% for patients whose surgeons had done only 10 prostatectomies.
  • The rate of patients experiencing a rise in prostate-specific antigen (PSA) levels following surgery increased significantly among patients whose surgeons had performed fewer prostatectomies.

The researchers concluded that patients who undergo a prostatectomy by a surgeon who has performed a greater number of these procedures have improved outcomes compared to patients whose surgeon has performed fewer procedures. They stated that surgeons who performed 250 or more prostatectomies produced the best outcomes.

Some Side Effects of Radical Prostatectomy Reduced if Surgeon Performs Many Procedures

The risk of some side effects caused by a radical prostatectomy appear to be reduced if a patient is treated at a high-volume hospital and by a surgeon who performs a high volume of procedures annually

Recently, investigators from the Health Outcomes Research Group, Memorial Sloan-Kettering Cancer Center and the Applied Research Branch of the National Cancer Institute evaluated data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to evaluate the incidence of postoperative complications and death in relation to the volume of patients treated at a hospital or the volume of procedures performed by a surgeon. Four separate categories were evaluated: (1) postoperative complications, including life-threatening events during the 30 days after surgery involving cardiac, respiratory, vascular, renal or bleeding events, shock or the need for reoperation; (2) late urinary complications including bladder obstructions, fistulas, strictures, pelvic abscess or early incontinence that occurred 31 to 365 days after surgery; (3) postoperative death; and (4) long-term incontinence lasting over one year following surgery.

Records from over 11,500 patients who had a radical prostatectomy between 1992 and 1996 were evaluated. Postoperative complications and early urinary complications were 27% for patients treated in high-volume hospitals compared to 32% for patients treated in low-volume hospitals. Following this trend, only 26% of patients treated by a high-volume surgeon experienced late urinary complications compared to 32% of patients treated by a low-volume surgeon. Postoperative death and long-term incontinence were not affected by hospital or surgeon volume.

This data appears to indicate that patients undergoing a radical prostatectomy may have a reduced risk for developing some side effects if treated in a high-volume hospital and by a surgeon who performs a large number of prostatectomies annually.

Is Robotic Assisted Minimally Invasive Safer?

Minimally-invasive radical prostatectomy (MIRP) proves safer than traditional open surgery—resulting in fewer post-surgical complications, fewer blood transfusions, and shorter hospital stays, according to the results of a study published in European Urology.()

Prostatectomy may be performed using traditional open surgery, in which the surgeon makes a single, long incision, or through a laparoscopic procedure (sometimes called minimally invasive surgery), in which several small incisions are made. During laparoscopy, the surgeon inserts a small video camera through one of the incisions in order to see inside the abdomen. In a variant of laparoscopic surgery known as robotic-assisted laparoscopic surgery, the surgeon sits at a console near the operating table and performs the surgery by controlling robotic arms that hold the surgical instruments.

This study evaluated data from 78,232 men over age 65 who underwent prostate removal between 2003 and 2007. What makes this study unique, however, is that it included the data from 100% of Medicare patients in the United States—resulting in a comprehensive body of data that reflects results from both large and small communities from every region of the country. The large sample size enabled researchers to detect statistically significant differences in outcomes between the two methods that smaller studies might not have captured.

During the study period, 19,594 men underwent MIRP with either laparoscopy or robotic technology and 58,638 men underwent traditional open surgery (retropubic radical prostatectomy, or RRP). The use of MIRP increased during the study period—at the beginning, it was used in fewer than 5% of cases, but by the end of the study period, it was used 44.5% of the time. In contrast, the use of RRP decreased from 89.4% in 2003 to 52.9% in 2007.

The researchers found that MIRP was associated with fewer post-surgical complications, fewer blood transfusions, and shorter hospital stays. What’s more—they discovered that post-surgical complications decreased over time in the MIRP group and increased over time in the RRP group. Complication risks in the RRP group increased from 27.4% to 32% and included a significant increase in post-surgical death from 0.5% to 0.8%. Men in the MIRP group had a 0.2% risk of post-surgical death compared to 0.6% for men in the RRP group. The risk of death was small in both groups; however, this was a statistically and potentially clinically significant difference between the two groups.

The researchers concluded that between 2003 and 2007, men who underwent MIRP had fewer blood transfusions, fewer genitourinary complications, and fewer surgical complications compared to their counterparts who underwent RRP. Furthermore, RRP was associated with more post-operative mortality and complications.

Men with prostate cancer are encouraged to speak with their physician to safely evaluate the risks and benefits of the different surgical procedures.

References:

  • Bianco, FJ, et al. Outcomes Measurement Influence of the Surgeon on Cancer Control After Radical Prostatectomy. Proceedings from the ASCO/ASTRO Prostate Cancer Symposium. 2006. Abstract 272.
  • Begg C, Riedel E, Bach P, et al. Variations in morbidity after radical prostatectomy. The New England Journal of Medicine. 2002:346;1138-1144.
  • Vickers A, Bianco F, Serio A, et al. The surgical learning curve for prostate cancer control after radical prostatectomy. Journal of the National Cancer Institute [early on-line publication]. July 24, 2007. DOI: 10.1093/jnci/djm060.
  • 4Journal of Urology, Vol 16, No 3, pp 867-869, 2000)
  • xx Barry MJ, Gallagher PM, Skinner JS, Fowler FJ. Adverse effects of robotic-assisted laparoscopic versus open retropubic radical prostatectomy among a nationwide random sample of Medicare-age men. Journal of Clinical Oncology. Early online publication January 3, 2011.
  • ii Sooriakumaran P, John M, Leung R et al. A multi-institutional study of 3,794 patients undergoing robotic-assisted laparoscopic radical prostatectomy to determine the surgical learning curve for positive margins and operating time. Presented at the fourth annual Genitourinary Cancers Symposium; February 17-19, 2011; Orlando, FL. Abstract 102.
  • 33 Lowrance WT, Elkin EB, Jacks LM, et al. Comparative effectiveness of prostate cancer surgical treatments: A population based analysis of postoperative outcomes. Journal of Urology [early online publication]. February 25, 2010.
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