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Is my surgeon any good?

User
Posted 27 Feb 2020 at 14:45

Hi all

I have recently been diagnosed with prostate cancer and have elected to have surgery to remove it. My consultant seems like a nice bloke and did a grand job with my biopsy. However, before letting him loose on my lower regions I am keen to try and find out if he is really good at his job.

I have seen his statistics on the BAUS website, which appear good but in all honesty are hard to interpret - in particular they don't indicate if my man is e.g. an upper quartile good surgeon or a lower quartile bad one.

I assume that wanting to know how good your surgeon is, is a common theme on this site. Does anyone therefore know of any other metrics or data that can be used to judge the competence of a surgeon?

 

Edited by moderator 27 Feb 2020 at 20:01  | Reason: Doctors Name Removed

User
Posted 27 Feb 2020 at 21:24
Ask him.

The important questions are

- how many of these ops have you done / about how many do you do each year

- what % of your RP patients have a positive margin

- what % need adjuvant treatment

- what % have a recurrence within 5 or 10 years

- what % are still using pads at 12 months post op

- what % can get an erection sufficient for penetrative sex at 12 months without mechanical or chemical assistance

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 28 Feb 2020 at 00:13

I found the BAUS site pretty useful although like yourself I asked more questions than I got answers.

I was very reluctant to question the surgeon's competence and decided that as he was head of a surgical unit at a big hospital and did regular operations with what appeared a good outcome he was as good as I was likely to find without losing more time than I wanted or creating what could be a poor atmosphere perhaps to my detriment.  I got the impression he was a person who liked operating and worked at private hospitals and that gave me confidence.  Although you read of rogues you hope and expect they're rare.

I also read the CQC report for that area of the hospital.   Being a sceptic I was also a bit wary of that but it seemed good enough.

I'm not sure if the surgeon can control some of the factors in Lyn's comment.  For example if you have a positive margin what is the surgeon meant to do.  He/she could perhaps say they won't operate but are they to know.  Mine and many other cases are upgraded when they get the prostate into the lab.

On the other hand I met someone who said he was incontinent after 2 years and had been told beforehand it was the surgeon's first operation.  He said he was happy to still be here with an undetectable psa and was willing to put up with anything else.

If you feel you have time you could look up other surgeons but I was told my lesion was near the edge and I didn't want to waste time.   Although to be honest I had confidence in the surgeon so it wasn't an issue.

 

Edited by member 28 Feb 2020 at 00:15  | Reason: Not specified

User
Posted 28 Feb 2020 at 00:28
My surgeon, the world-renowned Professor Whocannotbenamedhere, a veteran of over 3000 prostatectomies, told me he would not send any friend or relative to any prostate surgeon who does less than 100 prostatectomies a year. I guess he means ‘practice makes perfect’.

Intriguingly, when I asked who he would get to do a prostatectomy on himself if it were ever needed, he didn’t mention his partner in his private clinic in England, but rather a klinik in Heidelberg, Germany!

Best of luck.

Cheers, John.

User
Posted 28 Feb 2020 at 00:31

Originally Posted by: Online Community Member
I'm not sure if the surgeon can control some of the factors in Lyn's comment. For example if you have a positive margin what is the surgeon meant to do. He/she could perhaps say they won't operate but are they to know.

 

Just to be clear, the data I have listed are the % that urological surgeons are required to report to BAUS (with a little interpretation on my part). The small adjustments are

a) surgeons report % continent at 12 months but the NHS considers 'continent' to be 'using one pad per day or less' (which many men would not consider to be continent) and

b) they only have to report how many of their patients can get an erection, not whether the erection is sufficiently hard to use or whether that is with help or natural.

A positive margin is an error, not an unfortunate and unpredictable situation. 

Edited by member 28 Feb 2020 at 00:32  | Reason: Not specified

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 28 Feb 2020 at 06:23
Thanks all for the quick replies and Lyn - thanks for suggesting those specific questions, I shall ask my consultant when I next see him.

However the challenge remains that where the answers are percentages, it seems to me that they can only be properly judged when compared to the performance of other surgeons - and also placing them in the context of the stage of cancer being treated and the general health of their patients. And this data I will not have. Oh well, I guess there are very few things in life where you have all the information you would like to have to be confident of the outcomes.

It is a minefield but I think the advice from Bollinge about not going with anyone doing less than 100 ops per year seems very sound and I think Peter's comment about having confidence in the surgeon is important too. That reflects the advice I received from the PC UK support nurse.

Let's hope my man reacts well when I talk with him - if he does then I think that bodes well and if he doesn't, then I think I will have to find someone else.

Once again, thanks for your replies

User
Posted 28 Feb 2020 at 07:35

The more operations a surgeon performs, the better they get.
The NHS has concentrated its procedures into a small number of "vanguard" centres.
So UCLH for instance performs 800 of RARP per year, with each of their 7 surgeons doing between 100 and 150 per year.

I agree with the comments made above regarding continence being a good metric. But a lot depends on the location of your tumour. Your surgeon should be able to give you a good indication of how long it should take you to regain continence in your specific case. But you should start doing pelvic floor exercises now. Get the app.

(The NHS does not give you a choice of surgeon. )

Edited by member 28 Feb 2020 at 07:40  | Reason: Not specified

User
Posted 28 Feb 2020 at 08:31
"Oh well, I guess there are very few things in life where you have all the information you would like to have to be confident of the outcomes"

Don't be misled into thinking that if you get a great surgeon you are guaranteed a great outcome. Anyone can have a bad day. There is one surgeon who consistently appears in the 'golden' list and a significant number of members here have had their op with him and are thrilled with the outcome. However, we also have a member whose life has been ruined and found that when it went wrong, the 'best' surgeon provided dreadful aftercare.

You also need to keep in mind that some surgeons (particularly those with big marketing machines for their private practice) will cherry-pick patients, only operating on men with secure T1/T2 diagnoses so that their stats continue to look good. There are others (like my husband's urologist - one of the 'top 10' at the time) who are less risk averse and will operate on a T3 if they believe it could be successful at removing the cancer - a great surgeon may then not appear to have very good stats (for example, if they didn't feel they could do nerve sparing or operated knowing there was a good chance of needing salvage RT later).

It may not be the surgeon; I guess some hospital management teams will be more risk averse than others about things that have to be published.

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 28 Feb 2020 at 10:20

Hi

Went through a similar journey last Sept/Oct. I asked my local surgeon the same thing. I also got a second opinion as found the same surgeon Bollinge saw. Finding the prof really worked well for me. I had Retzius sparing robotic assisted radical prostatectomy + neurosafe at London Bridge. I went private route as thankfully had kept my insurance running. I’m week 13.5 post op and fully continent albeit it one or two drips in the gym under stress. No noticeable loss of length. No ED issues although now effectively had a vasectomy. Recent PSA bloods <0.01 so at this stage effectively undetectable. No regrets at all and definitely worth finding a pioneering surgeon with high volume and good track record.

User
Posted 28 Feb 2020 at 10:25

I went private so different route but I was told by a close friend who is a doctor that you can choose your surgeon via NHS Choices. 

User
Posted 28 Feb 2020 at 10:54

Just picking up for clarification on the following point Lyn makes.

'A positive margin is an error, not an unfortunate and unpredictable situation.'

That's the opposite to what I'd always believed.   My reading had always been that the prostate is in effect like a golf ball attached to the bladder with nerves and other organs around it.   

If a lesion was very close to the edge leaving no margin or protruding from the prostate the surgeon can only take out the ball with the protruding or nearly protruding lesion plus nerves and other things.   The lesion would in those cases be a positive margin and there is nothing the surgeon can do about it unless it was next to the bladder when part of the bladder could be removed. 

Even then it could be a positive margin on the prostate.  I've seen photos of lab samples and the definition of margin was whether the lesion was wholly in the prostate.

User
Posted 29 Feb 2020 at 23:19
Peter, your statement is incorrect, a positive margins is indeed an "error". This can arise because the lesion is so extensive that negative margins could not be achieved or simply because the surgeon did not take enough tissue (prostate bladder or whatever) to achieve a negative margin.

You certainly can have T3 tumours that have escaped the capsule removed and have negative margins.

User
Posted 10 Mar 2020 at 12:59
Very many thanks to all that took the time to reply to my post. My consultant also provided the following metrics regarding his performance. I have T2 cancer and to my untrained eye, his stats look pretty good. Many thanks to LynEyre for suggesting the questions.

What % of RP patients have a positive margin? 21% overall. Of these T2 0%, T3 50%

What % need adjuvant treatment? 6% needed adjuvant treatment

What % are still using pads at 12 months post op? 64% no pads, 26% 1 pad, 6% 2pads, 4%>3pads

What % can get an erection sufficient for penetrative sex at 12 months without mechanical or chemical assistance? About 50% (44% with previously good erections)

Overall our units results are generally in the upper quartile case mix adjusted (we do more complicated patients here) and all the surgeons have very similar outcomes. Our T3 margin rate is a bit high because we have more advanced cases. But for the T2 disease such as mine, the T2 +ve margin rate, length of stay and blood loss are all good

User
Posted 10 Mar 2020 at 16:35

That looks pretty good to me, especially for a T2.   Not that I'd really know but I'd be happy and think what a great surgeon, get me in there.  Try to keep those good vibrations all around.

User
Posted 11 Mar 2020 at 11:17

Recommend scoping out surgeons who use Retzius sparing approach. The continence stats are compelling. I can only speak for me but game changer. 

TG

User
Posted 11 Mar 2020 at 18:53
I'd be happy with that MK Willy - I think the detailed and frank response is refreshing and 0% positive margin for T2 is great.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

 
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