Walsh's Quest to Understand Male Anatomy Revolutionized the Prostatectomy

Published: Tuesday, May 05, 2015
Dr. Patrick Walsh

Patrick C. Walsh, MD

Until the mid-1970s, the radical prostatectomy ranked among the most dreaded of all surgeries in men. Each procedure entailed a frenzied effort to navigate uncharted anatomy and avoid copious bleeding and, following surgery, these men faced a lifetime of virtually certain impotence and probable incontinence.

The vast majority of patients with prostate cancer thus made the understandable choice to forgo surgery in favor of radiation treatments that, at that time, rarely produced cures.

Then, in 1974, Patrick C. Walsh, MD, took charge of the Brady Urological Institute at Johns Hopkins University in Baltimore, Maryland, and spent the next few decades refining the radical prostatectomy into a safe, effective, and tolerable procedure, one that has not only extended countless lives but has also preserved quality of life.

“The survival numbers for prostate cancer have improved more in the past 20 years than those of any other major type of cancer,” Walsh said. “Deaths have fallen 40%, and I thank God every day for giving me a role to play in that story.”

Hugh Young, MD, the initial chief of Urology at Hopkins, performed the first-ever radical perineal prostatectomy in 1904. Despite all its problems, the surgery represented a huge improvement over existing standards of care, and Hopkins became a world leader in prostate cancer care.

In the 1960s, however, Malcolm Bradshaw, MD, developed techniques for treating prostate cancer with high-energy radiation. The bloodless procedure quickly became the treatment of choice.

Reverse the Trend

Walsh could not have known, when he moved to Baltimore, that his discoveries would eventually reverse the trend, but he did see a major opportunity to improve those prostate surgeries that still took place.

Anatomy texts from the period provided little information about the area around the prostate because, following death, the abdominal contents settle into the pelvis, compressing the bladder and prostate into a thick pancake of tissue that defied study.

Surgeons operated without a guide, blind in a sea of blood. Patients suffered the consequences.

Walsh decided to study the veins surrounding the prostate in hopes of finding some way to prevent the blood loss. He used the operating room as an anatomy laboratory, noting whatever he could see through the blood as he raced against the clock. Eventually, he deduced that there must be a common trunk that entered the pelvis over the urethra, so he decided to ligate it.

“All of a sudden, the bleeding nearly stopped. It was like someone turned off the tap,” Walsh said. “I could see more of what I was doing and more of the surrounding area. I could also proceed at a more deliberate pace and, as a result, the operation became a safer, more complete cancer operation.”

Walsh’s technique for reducing blood loss transformed the radical prostatectomy from a dangerous operation to a safe one, but it did not inherently reduce the risk of impotence. Indeed, everyone at the time believed that the nearly universal incidence of impotence among patients who underwent radical prostatectomy indicated that the nerves responsible for erections ran through the prostate.

Walsh learned otherwise in 1977, when one of his patients reported that he had regained sexual function shortly after his surgery. That one report proved that the nerves responsible for sexual function do not run through the prostate and that all prostatectomy patients could experience full recoveries—if only Walsh could complete the map and perfect the surgery. The answer was not in any textbook.

So that’s what he set out to do.

Passed on the Windmill Museum

Walsh was at a conference in the Netherlands when he finally traced the nerves that control sexual function, the nerves he’d need to avoid. He had just given a presentation, and his friend, Pieter Donker, MD, who was head of urology at the University of Leiden, wanted to show him around town.

Donker talked up the local windmill museum, but Walsh said he’d rather tour Donker’s laboratory, so that’s where they went. At the time, Donker was performing dissections on a stillborn male infant to map the nerves to the bladder. Walsh explained his related interest in tracing the nerves that control erections.

Donker said they should look together, and, in just three hours, they mapped the relevant anatomy and noted that it lay entirely outside the prostate. But these nerves were microscopic—how could they be identified in the male pelvis?

The next breakthrough came back in Baltimore.

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