As I wrote in my last blog, once your family doctor has referred you to a local urologist and you have been diagnosed with prostate cancer, your first and most important decision is choosing a doctor with the necessary skill and experience to help you weigh all your options and determine your best course of action. This doctor may not be your community urologist.
Provided the cancer is still contained within the prostate gland, and provided there is no medical reason surgery is contraindicated, your urologist (who is a surgeon) will almost certainly recommend it. And in your emotionally vulnerable state, and with a natural desire to just get rid of the cancer, it is quite likely you will uncritically take his advice, without question or research.
After talking with your urologist you may come away with the impression that prostate cancer surgery is fairly straightforward. It is not. Anatomically, the prostate is in absolutely the wrong place for a simple surgical procedure. Located as it is within millimeters of the bladder and the rectum, there is zero tolerance for a slip of the scalpel. To make matters worse, there is prolific venous blood supply surrounding the gland, and on a bad day even the best surgeons can end up operating in a pool of blood, and with restricted ability to see clearly in order to spare the miniscule nerves (thinner than a human hair) that control erections. With such an intricate and complex procedure the high rates of impotence are hardly surprising.
So much skill is required to successfully perform a radical prostatectomy that being operated on by less than the very finest surgeons dramatically increases the chances for a poor outcome. Levels of ability vary widely from surgeon to surgeon even in prestigious university centers. In 2004, Dr. Peter Scardino, Chief of Urology at Memorial Sloan-Kettering, published a study documenting the differenced in “talent” in this unregulated field. The study evaluated the surgical skill of twenty-six urologists on staff at Sloan-Kettering and Baylor. The indicator used to measure skill was the frequency of leaving cancer behind after the operation (the technical term is “positive surgical margin”). The study reported that the best doctor in the group left cancer behind in 10% of his cases. The positive margin rates of the other twenty-five urologists ranged from 11% to a shocking 48%.
Despite these disturbing statistics surgery is still the primary treatment of choice for those diagnosed with prostate cancer. Yet while a select few surgeons perform dozens, perhaps a hundred or more procedures, generally speaking, the average urologist performs fewer than half a dozen prostate operations a year. In the U.S. there are somewhere around 70,000 radical prostatectomies done annually, and there are 10,000 urologists. If you do the math it’s clear that your community urologist is probably not doing enough prostate surgeries to stay proficient.
So buyer beware. Before you consent to surgery be sure to ask your urologist how many nerve-sparing prostatectomies he has performed--it should be at least 50. Preferably upwards of 200. Did often he get positive surgical margins? What percentage of the men he operated on are sexually potent a year after the procedure? What percentage suffers from incontinence a year later? And if you are over 70 years old and your urologist is recommending surgery, find another urologist, or better still, a prostate oncologist.
I hope this short essay has helped convey the importance of not rushing into treatment. It bears repeating: Go slowly. Do your homework. I have avoided surgery for almost 25 years. Consider the options, including—since surgery is only right for some of you—“Do nothing,” which for many men translates as “Die with prostate cancer, not from it."