IT’S NOT THE TECHNIQUE, STUPID, IT’S THE SURGEON — *OR IS IT?*

/, Doctor-Patient Relationship, Newly Diagnosed, Surgery/IT’S NOT THE TECHNIQUE, STUPID, IT’S THE SURGEON — *OR IS IT?*

NOTE: I ADDED INFORMATION TO THIS STORY AFTER I INITIALLY PUBLISHED IT.  PLEASE CONSIDER  THIS NEW INFORMATIONIT CAREFULLY.

The Wall Street Journal Health Blog entry today (Surgery for Prostate Cancer: Comparing Different Techniques, by Jacob Goldstein) concerns the results of a study recently reported in the Journal of the American Medical Association which compared the results of traditional, open radical prostatectomy (RP) with the newer minimally-invasive techniques such as laparascopic RP (LRP) and robotically assisted RP (RALP).
http://jama.ama-assn.org/cgi/content/short/302/14/1557?home

The new study did not address the comparative rates of “oncological efficacy” (i.e. cancer control), as determined by the rates of positive post-surgical margins in the two groups. But previous studies have found that cancer control is *worse* in patients who have minimally invasive RP, *unless the surgery is performed by an exceptionally skilled laparascopic surgeon* — part of an elite clique who have at least 500 surgeries under their belt (no pun intended). Obviously, for a cancer patient, NOTHING is more important than the actual results of his surgery, regardless of the technique used.

CORRECTION: The study found that cancer control was the same in both groups.

With regard to side effects, the study found that minimally invasive surgery resulted in shorter hospital stays and fewer transfusions. But the researchers also found that patients who underwent LRP or RALP had a higher incidence of incontinence and impotence than those who had open surgery. I was aware of previous findings of more “urinary bother” in men who had had minimally invasive RP, but this study went *even further* by adding the ED results to the picture.

[ADDED]

The disparity in reported side effects of genitourinary problems, incontinence and impotence was dramatic: only 2% of traditional RP patients reported persistent side effects versus 5% of MIRP patients.

The researchers stressed that the men who had minimally invasive surgery tended to be of a higher socio-economic class, so perhaps the increased rate of reported side effects had something to do with higher expectations, or maybe it’s that people who are better off complain more.

[ADDED]

Interestingly, there were differences in outcomes based on geographical areas and ethnic groups.  In spite of the fact that black men were far less likely than whites or Asians to have minimally invasive surgery, the struggling city of Detroit was at or near the top of the list.   My guess is this is because a famous minimally invasive prostate cancer surgeon practices in the Motor City, and  the patients are mostly “medical tourists”.

The ultimate meaning of this is that, if RP is in your future, ALWAYS CHOOSE THE MOST EXPERIENCED SURGEON YOU HAVE ACCESS TO, ONE WHO HAS HIGH LEVELS OF PATIENT SATISFACTION, REGARDLESS OF TECHNIQUE. THAT’S HOW YOU WILL ACHIEVE THE BEST RESULT. As Dr. Arnon Krongrad, a well-regarded laparascopic RP surgeon who also founded the New Prostate Cancer Infolink (www.prostatecancerinfolink.net) wrote in this blog, “Find your Tiger Woods and don’t micromanage the clubs.” So if the most experienced surgeon in your area happens to use the open technique, do not despair — in the hands of a competent surgeon it’s not the barbaric picture that some partisans portray it to be. A day or two extra at the hospital, at most.

[ADDED]

BASED ON NEW INFORMATION, I RECOMMEND RECONSIDERING MINIMALLY INVASIVE RP UNTIL MORE OR BETTER INFORMATION BECOMES AVAILABLE.

I know it’s hard to absorb the concept that the newest technology is not necessarily the best one for you. But as the authors of the above study put it, the adoption of the high-tech, minimally invasive approach to RP may just “be a reflection of a society and health care system enamored with new technology that . . . had yet to uniformly realize marketed or potential benefits during early adoption.”

To read the complete story from the WSJ blog, cut and paste the following URL:

http://blogs.wsj.com/health/2009/10/13/surgery-for-prostate-cancer-comparing-different-techniques/

By | 2017-10-19T10:54:28+00:00 October 13th, 2009|Choosing a Doctor, Doctor-Patient Relationship, Newly Diagnosed, Surgery|2 Comments

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2 Comments

  1. DanConte December 18, 2009 at 4:14 pm

    It’s the experience of the surgeon and not the methodology that is the key to a good result. Six weeks ago I had the robotic procedure. TOday I’m cancer free with NO negative results. I decided that the experience was the criteria. I looked at the number of procedures the surgeons did. I selected Dr. David Samadi and I selected him because of his experience. Over 2,000 procedures on robotics alone.

    Guys, if you’re concerned about all the negative possible outcomes I would encourage you to go to http://www.roboticoncology.com and see why experience is so important.

  2. Joe Garcia December 21, 2009 at 11:25 pm

    I had the robotic surgery in October of this year, 2009. My doctor is Dr David Samadi at Mount Sanai in NYC. I was 100% sexually functional 19 days after surgery. Absolutely no function lost. As far as incontinence, I am 95% back to normal, getting better every day. Robotic surgery is the best option for younger men, and Dr Samadi is simply the best there is. He has performed this surgery over 2100 times and counting. I swear by the robotic surgery, and I stand by Dr David Samadi. He is the best.

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