"Nerve-sparing" Surgery Turns 20
FLASHBACK: The bad old days, the late 1970s. Doctors who treated prostate cancer had few weapons in their arsenal. One was radical prostatectomy, developed by Johns Hopkins urologist Hugh Hampton Young in 1904; another was the retropubic approach, first described in the 1940s.
Both procedures were known to cure cancer, if it was still contained within the prostate, but at a terrible price. Every man was impotent after surgery, and 25 percent had severe problems with urinary control. Worse, the retropubic procedure itself was life-threatening, because of the horrendous bleeding that went along with it.
Another option was external-beam radiation treatment, introduced in the 1960s. Radiation did not cure prostate cancer as well as surgery, but at least it had fewer side effects—and to many men, this presented a more attractive alternative. Hormonal therapy, a stopgap measure, was also bleak—castration, which immediately shut off the production of testosterone, and temporarily slowed the growth of cancer.
Urologist-in-chief Patrick C. Walsh, M.D., began devising the procedure that would later bear his name with the simple goal of finding surgical methods to lessen the bleeding""so we could actually see what we were doing, instead of blindly feeling our way," he recalls. "Like many urologic surgeons, I was appalled by the blood loss in these men."
Walsh spent years studying the anatomy of the blood vessels (particularly, the large veins) surrounding the prostate, and developed new techniques, which did two things: First, with the bleeding under control, the operation became much safer. And with the now "bloodless field," for the first time, critical structures"which previously had been unrecognized and damaged, simply because they were swimming in blood and invisible"could be looked for and saved. More precise dissection and reconstruction reduced the likelihood of significant urinary incontinence to 2 percent, and of those 2 percent, incontinence is generally mild.Breakthrough In Understanding How Potency Works
But what about impotence? "Everybody believed that penile nerves were automatically damaged by the radical prostatectomy," says Walsh. The assumption was that the nerves that controlled erection ran through the prostate, and were destroyed when the prostate was removed. This was considered an unavoidable hazard, the price of curing cancer.
"Even the textbooks said that this was the case," Walsh says. "One highly respected anatomy textbook stated merely that the nerves that enable erection were "extremely small, difficult to follow in the adult cadaver," and that their location was known "merely through experimental studies." But it didn"t make sense to me that the nerves from one organ would run through another organ."
"If we could just figure out where these nerves were" and then find a way to save them but still cure prostate cancer"then men would no longer be faced with an either-or situation. They could be cured of cancer, and remain potent."
Around this time, "something unbelievable" happened to Walsh. "In 1977, one of my patients returned for a follow-up visit three months after surgery and reported that he was potent. To me, this news was staggering"how could this man be potent, if the nerves that control potency were inside the prostate that I had removed? Furthermore, if this could happen to one man, then why only this one? Why weren"t all men potent after radical prostatectomy? The key was finding these elusive nerves. If we could just figure out where they were"and then find a way to save them but still cure prostate cancer" then men would no longer be faced with an either-or situation. They could be cured of cancer, and remain potent."
In 1981, Walsh went to the Netherlands for a conference, and met Pieter Donker, a urology professor, recently retired, who was studying anatomy and tackling unanswered questions. "No one had successfully dissected the nerves to the bladder, because they were difficult to identify in adults" says Walsh. "However, these nerves are not nearly so obscured in infants." At the laboratory where Donker was working to trace these nerves in the cadaver of a stillborn male infant, Walsh asked the Dutch urologist if he knew what happened to the other end of this plexus of nerves""the ones that controlled penile erection. "I"ve never looked," he said. We got to work. Four hours later, we were jubilant. We could see clearly that the nerves were outside the capsule of the prostate"and that, indeed, it was possible to completely remove the prostate and preserve sexual function!"
The next step was to apply what Walsh and Donker had found in infant cadavers (where nerves are easier to see for many reasons, including the fact that infants have less fatty fibrous tissue than adults), and locate these tiny structures in the deep, complicated recesses of the pelvis in adult men. Over the next months, Walsh made another important discovery: He noticed a jumble of arteries and veins that traveled along the edge of the prostate in the exact location where these nerves were found in the infant cadaver. Perhaps, he thought, these blood vessels acted as they do elsewhere in the body"maybe they provided a scaffolding for these microscopic nerves. And maybe he could use the bundles"instead of pinpointing the microscopic nerves themselves"as landmarks. Donker agreed. Walsh tested this theory while performing an operation called a radical cystectomy, removal of the prostate and bladder, in a 67-year-old man. "I had never seen or heard of a patient who had been potent after this operation. But 10 days after surgery, this man stated that he awoke in the morning with a normal erection."
A month later, on April 26, 1982, Walsh performed the first purposeful nerve-sparing radical prostatectomy, on a 52-year-old professor of psychology. This man regained his sexual function within a year, and has remained complication-free "and cancer-free"ever since. Over the years, Walsh has made many modifications in his original operation. "Now that we"ve learned exactly where the scalpel can and cannot go, depending on the extent of a man"s cancer, it has become possible either to save these nerves deliberately, or to remove more tissue by cutting these bundles away than we previously had believed possible." It used to be that surgeons never excised these nerves, because they were adherent to the rectum; instead, surgeons just cut the nerves and unknowingly left them in place.
With these anatomical techniques, "we now have a better chance of removing all the cancer," says Walsh. "Many people call this a nerve-sparing operation, but a more accurate description is that it"s an anatomic radical prostatectomy, because there are actually two things going on. One is preserving the nerves; the other is creating wider margins, by excising them when necessary, removing as much tissue as possible around the cancer, and making this a better cancer operation."
Impotence was considered an unavoidable hazard, the price of curing cancer.
Of Walsh"s patients, 86 percent of men under age 65 who undergo radical prostatectomy are potent, only 2 percent wear a pad that they change more than once a day, and the cancer control rates are used as the "gold standard," to which all other forms of treatment are compared. For more on this operation"s significance in prostate cancer treatment, see "From the Director"