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A pioneer in prostate cancer surgery

The Baltimore Sun

For many years, prostate cancer surgery was feared because it almost always resulted in loss of sexual function and urinary control. That began to change 25 years ago yesterday, when Dr. Patrick Walsh of the Johns Hopkins School of Medicine tried out a new technique designed to spare the nerves that control these functions.

Since then, nerve-sparing radical prostatectomy has become a standard in urology. What made it possible was Walsh's observation that the nerves that maintain sexual function and urinary continence run alongside the prostate - not through it as doctors had thought. Armed with this knowledge, Walsh then developed a technique that removed the prostate while leaving the nerves intact.

This week, Hopkins celebrated the 25th anniversary of the first nerve-sparing operation with a symposium that included remarks by Walsh and his first patient, Robert Hastings of Fort Myers, Fla.

Hastings, now 78, spent an anxious year after the operation, worrying whether he'd ever regain function. When he did, he said in an interview, "I wasn't so surprised as I was through and through elated." His cancer has not returned.

Recently, The Sun asked Walsh, 70, to reflect on the first operation and its significance in the years that followed.

Do you have any idea how many of the nerve-sparing operations you've performed?

I know exactly how many. I've got four this week, so it will be 3,977. And I know that in June, I'm going to do my 4,000th.

Let's go back to your first. Once you figured out where the nerves were located and designed the operation accordingly, how confident were you that the operation would work as planned?

Shortly after [discovering the nerves], I removed the bladder and the prostate from a man who had bladder cancer. I had never heard of anyone being potent after that operation. I used the technique, and he woke up and 10 days post-op he had normal erections.

I knew from that experience that that anatomy made sense, but I did not know what the [overall] timetable of recovery would be - if he'd be normal immediately or whether it would take time.

When I operated on Mr. Hastings ... it took him about a year until he was back to normal. He was very open about his process of recovery and was helpful in providing milestones that I've used for other patients.

Has that one-year timetable held for other patients?

There's tremendous variability. What I learned over the years is that some people can take up to four years to get recovery. But by a year, many patients, but not all, have experienced substantial recovery.

Will some take less than a year?

Yes, about a third will be able to have intercourse within three months.

There are about 230,000 new cases of prostate cancer diagnosed each year in the United States, and about 30,000 deaths. Why would nature design an organ so prone to cancer?

Don Coffey [Dr. Donald S. Coffey, former head of urological research at Hopkins] has puzzled over this for a long time. Another organ that runs alongside it is the seminal vesicle, and it never gets cancer while the prostate does.

One of the major contributions of this operation is that for the first time a large amount of material [the diseased prostates] could be studied - so we could understand what causes the disease. And one of the things we've learned through our pathologists is that inflammation may play a major role in causing prostate cancer.

The prostate is situated in an area where inflammation can reasonably occur from bacterial infections and other causes. When the final chapter is written, it may well be that because of this location, it's more prone to infections or autoimmune responses to infections, which may be why there are so many cancers.

You've heard this many times, but Don Coffey has called you the "Michelangelo of prostate surgery." Please take this the right way, but Michelangelo painted and sculpted many things, and you perform one operation, over and over. Does it ever get boring?

There are a couple of good answers. First of all, I will say there is more variation in the anatomy of the pelvis than in every golf course in the world. If some people can get out and follow a little white ball and do it over and over and not get bored, there are more reasons why I can do this and not get bored. Because of the variability, everyone's a little different.

Secondly, I have constantly improved my surgical technique. Previously, if men were fully potent beforehand, 76 percent of them were potent [afterward]. The number went up to 90 percent. I have jokingly said, when everyone is fully continent and fully potent in three months, I'm going to stop operating.

It's long been said that one of the great barriers to reducing prostate cancer deaths is getting men to talk about and confront their urological health. Do you see that changing?

Previously, when you told a patient they had prostate cancer and they were going to have an operation where there'd be a 100 percent chance they would be impotent and a very strong chance they'd have little or no control over urination, they wouldn't be very happy ... or willing to talk to someone about the disease. By making it possible to perform surgery and avoid these side effects, many more men who found out they had prostate cancer were willing to do so.

Today, thousands of radical prostatectomies are done robotically, with surgeons operating levers and foot controls that manipulate the fine instruments that do the cutting. Have you tried this? Would you try this? And do you support it?

We do about 1,200 radical prostatectomies [annually] at Hopkins. About 25 percent of them are done robotically. We have not seen that pain and recovery from the operation are any different from the open operation.

All patients, whether they're done open or robotically, eat the night of surgery, stop narcotics the next morning and can go home that day or the next day on a regular diet and have their catheter out at the same time. I have not seen any short-term advantage.

I'm a firm believer that the open technique remains the best way to make sure all the cancer is removed because of the ability of the surgeon to be able to have a fine sense of touch, which is absent by having a robot.

So why use the robot at all?

Patients want it. It's patient-driven. I wouldn't say it was worse. I'd just say that wasn't any better.

You've had so many famous patients - John Kerry, Roone Arledge, Marion Barry, the king of Belgium. You see ordinary folks, too?

Ask my wife - I am in tremendous demand. I personally counsel everyone about their treatment course ... and I give every patient my home number. If one does that, you cannot operate on everyone. I've done five operations a week, and have surrounded myself with excellent associates who give the same kind of care.

Now that you're closing in on your 4,000th procedure, what are you plans for the future?

I'm in my 70th year. I have no arthritis. My vision is excellent, my hands steady and my fingers limber. I've been blessed with good health. I videotape my own operations and watch them. I'm still at the top of my game.

jonathan.bor@baltsun.com

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