The "Gold Standard" Treatment forProstate Cancer

"Nerve-sparing" radical prostatectomy-the operation devised by Patrick C. Walsh, M.D., and continuously refined by him over the last 20 years, in more than 3,000 patients- has been in many ways a double-edged sword. In the hands of Walsh, and the dozens of urologic surgeons he has trained over the years, the operation preserves the delicate, microscopic nerves, which are necessary for erection, that sit on either side of the prostate-but also removes as much tissue as possible around the cancer. At the Brady Urological Institute, the high rates for cancer control and potency, and the very low incidence of incontinence and other side effects, are used as the "gold standard," against which all other forms of treatment are compared worldwide.

This is also the only form of treatment for localized prostate cancer that has been shown to prolong life. In a landmark Scandinavian study, men with localized prostate cancer were randomly assigned either to the Walsh technique of radical prostatectomy or to watchful waiting.

The Walsh procedure is notoriously difficult to perform. "He makes it look easy, but believe me, it's not."

Within as little as eight years, twice as many men in the watchful waiting group had metastatic cancer in the bone, and twice as many had died of prostate cancer. In this study, the "Walsh procedure" reduced prostate cancer deaths by about half.

But -and here's the other edge of that sword -the Walsh procedure is notoriously difficult to perform. "He makes it look easy," notes surgeon Alan Woolfenden, of the Royal Liverpool University Hospital, who recently came to Hopkins to watch Walsh perform the operation, "but believe me, it's not." For any surgeon, this procedure-technically, the anatomical radical retropubic prostatectomy- is a bumpy, treacherous road. There can be extreme blood loss. It takes years of training before a surgeon can handle the unexpected bleeding without panicking-and also without without inadvertently damaging the fragile nerves. An experienced surgeon, too, can tell much by tactile sensation-literally, feeling the tissue for hardness, adherence, or other signs of cancer, and deciding how best to remove it. A very experienced surgeon has a "Plan B" if one man's anatomical terrain is slightly different from most.

Walsh's "magnum opus," the free, 105-minute DVD for surgeons, was five years in the making.

For example, in 4 percent of patients, the arteries that supply the penis travel immediately over the prostate. Unless the surgeon knows how to preserve the blood supply in this particular situation -and unfortunately, very few surgeons do- the man will be impotent.

With Help from a Patient

How do you handle the lightning bolt of discovery -especially when you've seen its great potential to help people? Well, you could guard it jealously, like the proverbial dog in the manger, expressing dismay that other hospitals' results aren't nearly as good as yours. Or, you could do your best to share what you know -and this is what Walsh has done, with the help of a remarkable patient, Robert Baker.

Walsh has put everything he knows about this procedure onto a free, 105-minute DVD for surgeons. On the DVD, which has been five years in the making -and which he calls his "magnum opus" -are detailed descriptions of each step of the operation, including close-up video footage of intricate dissection, suturing and reconstruction, and stunningly detailed illustrations by Hopkins medical artist Juan Garcia. "You won't see this kind of illustrations in Gray's Anatomy," says Garcia. (Many of these illustrations and some video clips from the DVD are available on the Brady website, at http://urology.jhu.edu)

With the financial help of the Mr. and Mrs. Robert C. Baker Foundation, the DVD was mailed with four major journals to 40,000 urologists around the world. An additional 15,000 copies are available for free, for any urologist who wants one. "I could have gone to a drug company and asked for financing," explains Walsh, "but then they would have control of it, and over who sees it. I wanted to have something I could give to everyone in the world, including doctors in developing countries."

It's worth noting that a century ago, on April 7, 1904, the very first radical prostatectomy was performed by Johns Hopkins urologist Hugh Hampton Young. That operation laid the groundwork for the "nerve-sparing" procedure that Walsh first performed in 1982. And Walsh continues to improve the operation - "I'm at the top of my game," he says. He is sharing what he knows because he believes it's the right thing to do: "If you've been given the privilege of sailing in uncharted waters, you have the responsibility to make those charts."


© The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health System. All rights reserved. Disclaimer
Email: webmaster@urology.jhu.edu | 600 North Wolfe Street, Baltimore, Maryland 21287

urology second opinion urology second opinion