FROM THE DIRECTOR
Preserving Lives, Improving Lives, Teaching Others

In this issue of Prostate Cancer Update, we report two milestones that I believe are related:

-The 20th anniversary of the first nerve-sparing operation, and

 -The first concrete evidence that aggressive treatment of localized disease saves lives.  

Twenty years ago, the first anatomic radical prostatectomy was performed. The new procedure overcame many obstacles that had kept urologists and their patients from accepting surgery as the best form of treatment for localized prostate cancer.
Before 1982, radical prostatectomy was often associated with excessive, life-threatening bleeding; as a result, 2 percent of men who underwent the operation died from it. However, with less blood loss, the operation became safer, and the mortality rate fell tenfold to where it is today, at 0.2 percent. Before 1982, all men who underwent radical prostatectomy were warned that they would be impotent afterward, and between 10 and 25 percent would have severe incontinence. It’s easy to understand why many men felt the treatment for prostate cancer was worse than having the disease itself.

With the development of this new anatomical approach, more men accepted radical prostatectomy. In 1983, only 7 percent of men with localized prostate cancer underwent surgery.

By 1993, the number had reached 35 percent. Indeed, in that year, 104,000 men underwent radical prostatectomy.

Within a decade, prostate cancer deaths in the United States plummeted. In 1993, 43,000 American men died of the disease.
By 2002, the number was down to 30,200. Is there any cause-and-effect relationship between the rise in radical prostatectomy and a reduction in prostate cancer deaths by 13,000 a year a decade later? The Scandinavian story provides some insight.

In this landmark study from Scandinavia, men who underwent radical prostatectomy were half as likely to die of prostate cancer as men who were treated with watchful waiting. This raises the intriguing possibility that the major cause for the reduction in deaths from prostate cancer now is the rise in radical prostatectomies a decade ago, simply because an operation was made safer.

Sharing what we know
Men who invested in having a radical prostatectomy over the last 20 years have made a wise decision. Unfortunately, it is not yet an “equal-opportunity” operation: Not all men have the availability of a surgeon who is skilled in performing the surgery, and either are not offered an operation, or suffer needless side effects. Over the last 20 years, I have worked to perfect this procedure—by studying videotapes of my own operations, by following my patients carefully, and understanding their true side effects, by developing new techniques, and by identifying anatomical variations in men that might affect their long-term urinary continence and potency.

Now, I have put everything I know about this operation on a DVD, which I plan to distribute around the world free of charge, to any urologist who wants to view it. My dream is that no man with prostate cancer will miss the opportunity to be cured, and to live a long, happy life free from devastating side effects.

Patrick C. Walsh, M.D. 

Patrick Walsh, seen videotaping a "nerve-sparing"
procedure for worldwide distribution to urologists