What does a prostate surgeon look for if he needs prostate cancer surgery?
Here is a list of the features I'd include on my personal checklist. As you review it, please keep in mind that my list reflects my personality. I am focused and action oriented. This may not be you. But either way, you, too, want things to go well. See if this list makes sense for you.
The right kind of urologist — My surgeon will come from the world of urological oncology: urologists who think about cancers of the genitourinary system. Urologic oncologists are cancer doctors who look at how to treat urologic cancer, and they grew up dealing with the management of these cancers. We are a specialty within a specialty, just like pediatric urologists are a specialty within a specialty. He or she might well be a member of a specialist organization known as the Society for Urologic Oncology. This matters to me. I know that with prostate cancer I face the risk of progression, incontinence, erectile dysfunction, hot flashes, bone loss, and other problems. This is all about my cancer — first, second, and third. I want someone who specializes in prostate cancer surgery — who has well honed technical skills related to taking out my prostate.
I want someone who is still learning to do better prostatectomies than (s)he did last year — However long (s)he has been in practice, my surgeon will still be on his or her learning curve. That is because all really good surgeons are on their learning curve forever. My surgeon will be insightful and open enough to concede that there is no end to learning. (S)he will be humble enough to stay 120% focused and alert throughout every surgical procedure. As a surgeon myself, I know that if I ever start to think I’ve seen it all, the next patient will walk in the door to prove me wrong. Sitting on a panel a while back, one of the world’s most experienced prostate cancer surgeons (and one of the most productive thinkers of our day) was asked what he considered a sufficient number of cases before finishing the learning curve. He said he has no idea because he is still on his. That surgeon is on my list.
I want someone with complete confidence in his or her abilities — My surgeon’s confidence will protect me in the operating room. My surgeon will have no trouble telling anybody what to do, how to do it, and when to do it. (S)he will be cool under fire. We aren’t going out to dinner or a drink together! I don’t have to want to spend a vacation with this person. I want my surgeon to function as well as possible in the event of crisis. Prostate cancer surgery is not for the timid, bashful, or overly diplomatic. It is for NASCAR drivers and Kentucky Derby jockeys. There are many such surgeons … people who will have only one consideration in the operating room – my short-term and long-term welfare as their patient. These are surgeons whose egos demand that I do well and whose personalities assure that I do.
I want someone who speaks to me in plain language — I want someone who is going to tell me what (s)he is going to do and why … but who will not over-simplify. Prostate cancer is a world of uncertainty. My surgeon does not know before (s)he opens me up if my cancer extends through the prostatic capsule, or into the fat. (S)he does not know what my final Gleason score will be. (S)he does not know that anatomically sparing my nerves will allow me to have great erections again later on. And (s)he will acknowledge this. My surgeon will not issue guarantees. S(he) will focus on technique, and (s)he will walk me through an analysis of what will happen to me based upon a listing of factors far more extensive than his or her gifted hands. For example, in projecting the likelihood of erections (s)he will: (a) talk about how long it will take for my erections to return, not only the likelihood of return; (b) review my age, baseline function, obesity, smoking, diabetes, depression, libido, and other issues. … I want a simple but intelligent discussion, not a series of patronizing, over-simplified bullet points. I am smart. I want to be treated that way. I can accept uncertainty but I cannot accept deception. And if I have questions later, I want my surgeon to answer them.
I want someone who is available and accessible — My wife will have questions. So will my friends. My surgeon will give me a way to let them ask these questions (directly in the case of my wife, and through me in the case of my friends). I encourage my own patients to ask questions by email. I would want my surgeon to make that possible for me. I know that I will have questions post-op. I will ask if (s)he will still make herself/himself available post-op. I will ask for the names of a few other patients. If (s)he refuses, I am “outta there.” I will ask his or her other patients if (s)he actually is still available post-op. This is a tough one. I am a prostate cancer surgeon so I will get special treatment. It’s inevitable. But you are a patient just like me and if anything you deserve even more support because you do not have the experience to know if that blood you see is good or bad. In any event, my surgeon will speak with any of my other doctors as needed.
I want someone who is not a baseless self-promoter — Some of the world’s best doctors and hospitals advertise. We all talk about ourselves one way or another. My web site shares the story of Bob Patten, a 70-year old man who broke a swimming world record soon after I did his laparoscopic radical prostatectomy. See? I just did it. Self-promotion is not in itself a bad thing, but the question I ask myself (and you should too) is if the promotion is based on reality. I saw an ad the other day that read, “The future of surgery is here, only at ….” This ad appeared a few weeks after another hospital said the same thing. “Only at?” Really? A technology or technique that is so special that it exists only at that place? Not likely. The same hospital also said that it was doing “robotic surgery … [with] fewer complications like incontinence and impotence.” There is no basis for such assertions. How could they possibly know? They can’t, unless they are really good at defining erections (which the American Urological Association has yet to do), have completed large, randomized comparative trials over a period of several years (which no one has done), and can interpret the analytical methods applied. I need a surgeon I can trust. I start with the criteria defined above and am skeptical about advertisements. Especially if the health claims made are not cleared by the FDA or supported by clinical trials. Yes, there is a problem cutting through the hype. This is why doctors are sworn to “first do no harm,” to be the guardians for patients who are at their most vulnerable. Some are guardians. But if my surgeon feels like a used car salesman …
I don’t really care what the surgeon’s office looks like — I care that the office is clean and organized and that people are paying attention to me, the patient. I don’t care if my surgeon’s desk is perfectly tidy and if his or her clinic is a little messy. I do care that my surgeon is not so busy that I am not getting his or her full attention. I do not want to be the third of four patients being operated on that day. I need the surgeon to remember my anatomy and my operation when (s)he talks with me after surgery that night. I do not care if I am first or second case, but I want to be absolutely sure that (s)he is the one doing my operation, not his or her resident in training.
It’s not about where; it’s about who — I do not care what the hospital is called or whether it’s in New York, Los Angeles or Houston (in each of which there are some very excellent prostate cancer surgeons). I care who will do my operation. If I have found the right surgeon, (s)he will have made sure that (s)he is working at a hospital that does what needs to be done for his or her patients — and does it well!
I don’t care about the gizmos — I will not micro-manage the tools my surgeon chooses to use. I will not tell my surgeon that I want UR-6 needles on my anastomosis. I will not tell him or her to avoid a Babcock clamp on my plexus of Santorini. I will not involve myself in the choice of scope holders or remote-controlled sewing machines. My surgeon has ten fingers and the wisdom to use them. Those are the gizmos that matter.
I want to be the center of surgical interest — My surgeon will not be paid by a device manufacturer. (S)he will not be marketed by a device manufacturer. (S)he is working for me and (s)he will not have a conflict of interest.
There are many great choices for prostate cancer surgeons. See if my criteria are useful to you. Do your homework. Make contact from a distance and see what you get. If you get an automated attendant during working hours, that is what you will get after surgery. If the practice will not introduce you to any previous patients, run for the hills. If the surgeon talks down to you or speaks in cliches, dogma, or absolutes, walk out the door. You are only going to have a radical prostatectomy once in your life. You deserve to make the very best possible decision for yourself.
