Underscoring the Importance of Experience

According to a recent study, the risk of a prostate cancer recurrence after radical prostatectomy appears to depend in large part on how many procedures the surgeon has performed. The take-home message: experience counts.

Radical prostatectomy was developed at Johns Hopkins at the beginning of the 20th century. The operation was not popular at first because of the high rate of erectile dysfunction and urinary incontinence associated with the prostate surgery procedure.

But in the early 1980s, Johns Hopkins urologist Patrick Walsh, M.D., developed a new approach to the prostate surgery operation. He devised a "road map" that allows surgeons to remove the prostate with less risk of damaging the nerves that are essential for erections and urinary control. This "nerve-sparing" prostate technique has reduced the risk of severe incontinence to 1-3% and the risk of mild incontinence to around 10%.

The risk of erectile dysfunction varies according to a man's age and the surgeon's skill. One group of researchers reported that nerve-sparing prostate surgery achieved successful recovery of erections in 68% of patients. Dr. Walsh has performed the prostate procedure on more than 2,000 men with early prostate cancer, preserving erectile function in 90% of men in their 40s, 75% of those in their 50s, and 60% of those in their 60s.

The importance of surgeon's experience as it relates to prostate cancer outcome is underscored by the results of a study reported in the Journal of the National Cancer Institute (volume 99, page 1171).

Researchers analyzed the outcomes of 7,765 radical prostatectomies performed by 72 surgeons between January 1987 and December 2003 at four major academic medical centers. "Biochemical" recurrence was defined as a postsurgery PSA level greater than 0.4 ng/mL followed by a subsequent higher PSA level. The analysis took into account patient and tumor characteristics, such as pre-operative PSA level and Gleason grade. The men's PSA levels were measured every three to four months in the first year after surgery, twice in the second year, and annually during the following years.

The researchers found that surgical outcomes improved along with the number of radical prostatectomies a surgeon had performed, leveling off only after about 250 surgeries. The five-year probability of experiencing a recurrence of prostate cancer was 18% for surgeons who had performed only 10 operations compared with 11% for surgeons who had performed at least 250 surgeries.

Bottom line on prostate cancer surgery: The results suggest that you can improve your odds of a successful outcome from radical prostatectomy by taking time to find a surgeon with extensive experience.