The Big 25: The Brady Remembers the Procedure That Started It All
Bob Hastings, who beat prostate cancer 25 years ago, and the surgeon
who helped him, Patrick Walsh.
It was a celebration of life — of lives saved, of quality of life, of lives changed by hope, in a disease that not too long ago was considered hopeless. It was also a recognition of the greater changes wrought by the operation — on the treatment of prostate cancer worldwide and, closer to home, on the Brady Urological Institute itself.
For many who attended the seminar in April marking the 25th anniversary of the first “nerve-sparing” radical prostatectomy — an operation developed by Patrick C. Walsh, M.D., and known worldwide as the Walsh Procedure — it felt like a family reunion, of patients, doctors, nurses, scientists, and friends. Front and center, and by many accounts stealing the show, was Bob Hastings, who in 1982 — at age 52 — became the first-ever patient to undergo Walsh’s operation.
Hastings had already had survived one brush with cancer when he was young, of the testis, but he knew that his prospects of coming unscathed through prostate cancer were nowhere near as rosy. Back then, surgery could cure the disease — although the chances of cure were much slimmer than they are today, because so many men were diagnosed after the cancer had already spread beyond the prostate. But the operation itself was devastating, involving major bleeding, and resulting in impotence for every man, and incontinence for 25 percent of men who underwent it. “It’s no exaggeration to say that we used to operate in a sea of blood,” says Walsh, University Distinguished Service Professor of Urology. “The complications of radical prostatectomy were so harsh that most men said they’d rather have the disease.” Although radiation was much less powerful than it is today, and was not often able to cure the disease, most men — 93 percent — opted for it instead. And experienced pelvic surgeons — Walsh studied with the best, at Harvard, UCLA, and the University of California, among other places — accepted these side effects as the “price for curing prostate cancer,” and never asked why they occurred, or how they could be avoided, Walsh recalls. (Walsh made this his first mission when he came to Hopkins; see story.)
Without much hope, Hastings, a college professor from Ohio, met with Walsh, who was the Director of the Brady Urological Institute, to discuss the possibility of surgery. What Walsh had to say stunned him: “He said, with complete modesty, ‘I can cure you.’ I liked that. He said, ‘I don’t think you’ll have any trouble with impotence.’ I really liked that.” Walsh told Hastings that he would be the first patient in his new surgical series. Hastings didn’t realize until years later “that I was the first one — ever.”
“He said, with complete modesty,
Walsh kept his word and cured Hastings’ cancer. The next month, he presented a scientific paper on his techniques at the 1982 meeting of the American Urological Association, and from that day onward, the Brady Urological Institute was never the same. “The phones started ringing off the wall,” says Cynthia DiFerdinando, the clinic manager. In the clinic, a low-key suite of rooms in a hall to the parking lot, with a few rows of orange plastic chairs for waiting patients — compared to today’s bustling clinic, which takes up an entire floor of the Outpatient Center — the receptionists were caught off guard. “Nerve-sparing? What nerves?” DiFerdinando recalls saying. “Are you sure you want urology? You must want neurology.”
Patients from around the world began coming to Hopkins for the operation; in fact, in June 2007, Walsh performed his 4,000th Walsh procedure. With every patient, Walsh kept meticulous, lifetime follow-up records, so that he could learn from anything that happened to these men over time, and use that knowledge to help other patients. “He single-handedly changed the field of prostate surgery,” says Alan W. Partin, M.D., Ph.D., the David Hall McConnell Professor of Urology, who recently succeeded Walsh as Director.
“Nerve-sparing? What nerves?
“Then he began teaching other surgeons, including me, how to perform this very difficult operation.” For many years, surgeons from around the world came to Hopkins to watch Walsh perform his procedure. Several years ago, with funding from The Mr. and Mrs. Robert C. Baker Foundation, Walsh made a two-hour DVD, and sent 50,000 copies free to surgeons around the world who wanted to learn how to perform the procedure better. (To view excerpts, please click here “Anatomic Radical Retropubic Prostatectomy.”)
“This is one of the best examples of knowledge being developed at Hopkins and spreading around the world,” says Partin. “The operation has had a fundamental impact on the field of urology, as well, allowing scientists to study the disease in ways — looking at the genetics, for example, or using molecular biology techniques to find ways to stop cancer, or to find new markers that are better than PSA — that were never feasible before.” Partin is, himself, a household name in the field of urology — known worldwide for, among other things, his development, with Walsh, of the Partin Tables. Based on evidence from thousands of men who underwent the Walsh Procedure, the Tables are the next best thing to a crystal ball, allowing men with prostate cancer to predict their likelihood of being cured. (See story.)
The Walsh Procedure’s ripple effect has transformed other specialties — especially pathology. “Before Dr. Walsh’s operation, almost all men diagnosed with prostate cancer were treated with either radiation or hormone therapy, with no additional tissue removed to verify the presence of cancer,” says Jonathan Epstein, M.D., the Rose-Lee and Keith Reinhard Professor of Urologic Pathology. “Many mimickers of prostate cancer on biopsy were overcalled as cancer. Conversely, limited prostate cancer on biopsy — that today would be readily recognized as malignant — was often diagnosed as ‘atypia.’ But after Dr. Walsh’s operation, pathologists had the opportunity to study prostate cancer and all of its variants in large tissue specimens. Previously, the diagnosis of cancer was based on a gestalt ‘it looks like cancer.’ Now, because of the study of radical prostatectomy specimens fostered by Dr. Walsh’s discovery, the diagnosis of prostate cancer is based on a systematic approach — and the pervasive under- and overdiagnosis of prostate cancer that prevailed in the past no longer exists.” With the development of the PSA test, which made it possible to diagnose prostate cancer at an earlier, curable stage, plus improvements in radiation therapy and proof, recently demonstrated by a large Scandinavian study, that radical prostatectomy saves lives, there has been a dramatic drop in deaths from prostate cancer in the United States. In fact, the number of men dying from prostate cancer over the last 10 years has fallen by 33 percent — the highest for any cancer in American men or women.