How Serendipity Helped
Like most overnight successes, this one took years of hard work. Patrick Walsh took the helm of the Brady in 1974, and spent the next three years figuring out how to reduce the drastic bleeding that had plagued radical prostatectomy ever since it was invented (at Hopkins) in 1904, by surgeon Hugh Hampton Young. Walsh developed surgical techniques that kept bleeding to a minimum and then, with a near-bloodless field, was able to reduce men’s likelihood of incontinence, because he could see urinary sphincter muscles and other structures that, previously, had been routinely destroyed. By 1977, Walsh had excellent rates of continence, but still hated the fact that all men were impotent after surgery.
Then, a 58-year-old patient from Philadelphia reported that he was fully potent within a year after surgery — and instantly, Walsh realized that everything surgeons had thought about the nerves that are responsible for erection — that they ran through the prostate, and were inevitably severed when the prostate was removed — was wrong. “Nobody knew where the nerves actually went,” Walsh recalls, “and this is because the only way we learned anatomy was by studying adult cadavers.”
Unfortunately, he adds, when cadavers are preserved, the fixative solution dissolves the fatty tissue that separates tissue planes, and in the postmortem state, the abdominal contents compress the pelvic organs into a thick pancake of tissue, making anatomic dissections impossible. Walsh began studying living anatomy — examining the nerves, blood vessels, and tissue surrounding the prostate — in the operating room, as he performed surgery.
A 58-year-old man reported that
he was fully potent within a year
after surgery — and instantly,
Walsh realized that everything
surgeons had thought about the
nerves that are responsible for
erection — that they ran through
the prostate, and were inevitably
severed when the prostate was
removed — was wrong
“That same year, I attended my first meeting of the American Association of Genitourinary Surgeons,” Walsh recalls. The night before the meeting, he and his wife, Peg, went to a restaurant and saw an older man standing by himself and, Walsh suspected, feeling rather lonely. On the spur of the moment, Walsh asked the man if he were also attending the meeting, and if he would care to join them for dinner. “That night was the first time I met Pieter Donker, the Professor and Chairman of Urology at the University of Leiden.” They became friends. Walsh continued to try to decipher the anatomy of the pelvic nerves, and in 1981, at a meeting in Leiden, the Netherlands, he met up with Donker again. “Had it not been for that dinner four years earlier, we would never have met, and this opportunity would have been missed.”
Donker had retired as Chairman, and was spending his days dissecting out the nerves to the bladder, which had never been done successfully before. “He was using infant cadavers,” says Walsh, “and when I asked why, he said that this was the best model,” because the nerves were much more visible than in adult cadavers. Walsh studied his drawings, and asked Donker about the location of the nerve branches to the penis. “He said that he had never looked. Three hours later, both of us could see that the nerves were located outside the prostate.” Walsh and Donker continued their anatomical studies, looking for landmarks to identify these nerves in adult men. Back in Baltimore, “in the operating room, I noticed that there was a cluster of vessels, the capsular arteries and veins of the prostate, that traveled in this exact location, the neurovascular bundle, which I concluded could be used during surgery to preserve the nerves.”
By April 26, 1982, Walsh was ready to test his newfound knowledge on a patient. Today, that patient, Bob Hastings, remains cancer-free, with an excellent quality of life.
This happy occasion was featured on National Public Radio’s “All Things Considered.” To hear the story, go to http://www.npr.org.