The lessons I’ve learnt from carrying out 3,000 prostate cancer operations

Mr Alan Doherty

I’ve recently reached the stage of having completed more than 3,000 prostatectomies over the course of 15 years. I remember very well marking my 1,000th operation and now, arriving at another milestone, I’ve been reflecting on what it means. The most salient point, I believe, is the recognition that I am still refining what I do and continuing to gain from ongoing experience.

The surgeon’s “learning curve” is well known. In terms of the prostatectomy, which is a relatively complex procedure, a surgeon will need to undertake around 500 operations to complete what is accepted as the learning curve. At the early stages of the curve, the surgeon will work very closely with more experienced colleagues. Through the curve, cancer clearance will be carefully and effectively managed. The variation occurs in other outcomes, notably continence and erectile function after surgery, which depend heavily upon the refinement of surgical skills.

I know, from my own results, how much erectile recovery and continence recovery improved after I had completed 500 operations. This is to be expected but it is interesting to reflect on how far into surgical experience improvements continue. During my last 500 operations, moving up to the 3,000 mark, there are further changes, albeit fairly subtle ones. I know I can cope with challenging situations better: if the fascia is thickened, if large blood vessels cover the prostate and if access is difficult. I am better at recognising variation in where the nerves are located and in identifying different types of tissue.

I know these adjustments are translating into outcomes. Again, the variation is not huge but from a patient recovery perspective, it is certainly significant. For example, I used to predict continence would normally return within three months. This was the case for the large majority of patients although there were a number, particularly following a laparoscopic prostatectomy, who took much longer to become dry. Now, particularly among men defined as index patients it is not unusual for them to be fully dry from the moment the catheter is removed. Men are often dry from the stage when their catheter is removed (one week after surgery), or very soon after; many who wear pads, do so as a precautionary measure. It is very clear that having very little or no continence problems post-surgery contributes enormously to the whole physical and psychological recovery process.

In my discussions with patients, I frequently ask: if I could give you a magic pill that makes your prostate vanish, what would you do? The fact that patients always say they would choose the take the pill tells me their concerns are not about losing their prostate, but are, very understandably, about the operation and potential side-effects of that operation. Accordingly, I have always considered my goal being to make surgery as close to that magic pill as possible; to continuously refine and reflect on how I do things in order to improve outcomes for patients.

Reaching the 3,000 operation stage is significant – but not if it is merely a numbers game. It does have significance if I continue to evaluate and reflect on my patients’ outcomes and use my surgical experience to refine what I do.