Walsh's Quest to Understand Male Anatomy Revolutionized the Prostatectomy

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.

Walsh was operating on an adult patient when he noticed a group of blood vessels that took exactly the same path past the prostate as did the nerves he and Donker had found. He hypothesized that the nerves were part of the cluster and that he could avoid the nerves by avoiding the blood vessels. He tested the theory during a radical cystectomy on a 67-year-old man. There were no reports of anyone regaining potency after such an operation, but 10 days after losing both his bladder and prostate, that man was able to have a normal erection.

A month later, on April 26, 1982, Walsh performed the first intentional nerve-sparing radical prostatectomy on a 52-year-old professor of management. It took several months for the patient to make a full recovery, but he has remained fully functional and cancer-free ever since.

“Once the first patient [in 1977] regained sexual function and proved that such a procedure was possible, it was only a matter of time until Pat figured out how to do it [intentionally]. His focus is incredible.

He will work relentlessly to accomplish anything he decides must be done,” said Mani Menon, MD, a protégé who runs the Vattikuti Urological Institute in Detroit, Michigan.

Self-Sufficient Childhood

Walsh was born in 1938 and raised in Akron, Ohio, where his father owned a tobacco shop. He was a standout student from his first days in school, the sort of boy who spent his spare time observing animals to learn biology and taking apart household electronics to see how they work.

Walsh did not have nearly as much spare time as other boys, however, because his father believed children should learn to be self-sufficient as soon as possible.

He began delivering newspapers in elementary school and later supplemented that job with stints as a construction worker and a parking-lot attendant.

Walsh received full scholarships for both his undergraduate work and his medical degree at Case Western Reserve University and then began an internship at Peter Bent Brigham Hospital in Boston.

He went to Boston with the intention of becoming a neurosurgeon but switched to urology a year later after deciding that urology would allow him to perform both diagnosis and surgery and then let him follow patients for years afterward.

Walsh’s talents stood out, even at a hospital affiliated with Harvard Medical School. Francis Moore, MD, who was Brigham’s surgeon-in-chief and the Moseley Professor of Surgery at Harvard, approached Walsh toward the end of his internship and said that he wanted Walsh to spend a few years doing additional training and research at UCLA before coming back to take over Brigham’s urology department.

Walsh dutifully went to UCLA to study under Willard E. Goodwin, MD, and then spent two years fulfilling military obligations in San Diego.

In late 1972, Hopkins asked Ben Gittes, MD, who was Walsh’s mentor in San Diego, to succeed William Wallace Scott, MD, as the director of the Brady Institute.

Gittes declined the job and recommended his 35-year-old mentee. Hopkins interviewed Walsh and made the offer. Harvard countered by interviewing him for the same post at Brigham. Ultimately, Walsh’s wife, Peg, convinced him to take the Hopkins job— even though she preferred Boston over Baltimore— because she thought it was a better match for his interests and skills.

“If you want to succeed in academic medicine, you need a spouse who inspires and supports your dreams despite all the sacrifices, and my wife, quite simply, is a saint,” Walsh said. “The Brady Institute hasn’t been my life for the past 40 years. It has been our life.”

Walsh’s first nerve-sparing radical prostatectomy was a medical milestone, one that might seem like the end of the story, but it was really just the beginning.

Subsequent operations sometimes resulted in the sort of complete recovery experienced by the first patient. But other patients never recovered sexual function or full bladder control.

Honing His Surgical Technique

Walsh realized that minute and almost imperceptible differences in his technique were producing huge variations in results, so he dedicated himself to noting the smallest details of each procedure and evaluating how variations affected outcomes.

He built a database that stored his initial observations and detailed notes on his surgical technique for each patient, along with frequently updated reports on the patient’s health and quality of life.

He also enlisted help from the noted medical illustrator Leon Schlossberg, who watched procedures and made ever-more-detailed notes about the anatomy around the prostate, its variation among patients, and the possible implications of the surgery.

“His biggest concern was that his effort to maintain [sexual] potency might be compromising cancer control, that skeptics might be right in calling it a ‘cancer-sparing’ surgery,” said Herbert Lepor, MD, another Walsh protégé, who runs the Urology Department at New York University’s Langone Medical Center.

“He asked pathologists to meticulously examine the data after 100 surgeries and he kept reexamining after that, ready to pull the plug on the procedure if there were any concerns at all. He knew the surgery was going to be his legacy one way or the other, but he searched more aggressively than anyone else for problems because he felt responsible,” Lepor said.

Eventually, the quest to hone his surgical technique inspired Walsh to give himself another view of the procedure by videotaping each one. Professional athletes and their coaches have long found videos among the most powerful tools for enhancing performance. Walsh believes they’re just as valuable for surgeons.

“When you’re actually performing a surgery, the only thing you really see is the area around your own fingertips. When you’re watching a video, you see everything,” Walsh said. “You learn an unbelievable amount about the impact of what you are doing on surrounding structures.”

28 Significant Changes

During the following quarter century, the process of testing potential improvements one at a time led Walsh to make 28 significant changes in the original nerve-sparing radical prostatectomy.

After 100 surgeries, for example, he realized that was it possible to widely excise the neurovascular bundle on one side of the prostate to produce a wider margin of excision than was previously possible using the perineal technique.

He learned that mucosal eversion at the bladder neck would reduce bladder neck contractures, that direct division of the posterior striated sphincter would improve surgical margins, and that using the McDougal clamp often was associated with inadvertent entry into the anterior prostatic tissue or excessive excision of the striated sphincter.

In 2011, after 4569 nerve-sparing prostatectomies, Walsh stopped performing surgery. He had, by that time, refined the procedure to the point that 94% of his patients regained sexual function and only 2% of them needed to wear any sort of sanitary pad.

Walsh’s legacy extends far beyond the patients he treated himself. The advances he made to the prostatectomy procedure transformed what was a fringe therapy into a mainstay of treatment, extending countless lives.

Prostatectomy is, for many patients, a more effective treatment than radiation. It is also a treatment that helps doctors evaluate the need for follow-up therapy in a way that radiation cannot, by providing tissue samples for analysis.

Nevertheless, it took Walsh’s procedure many years to win the sort of widespread respect and usage it enjoys today. Some urologists read the initial reports of prostatectomy patients regaining their sexual function and concluded that Walsh’s technique must leave cancer behind. Others resisted the procedure simply because it’s far more difficult than radiation.

Walsh initially believed that any urologist who performs surgery could learn the technique. Indeed, he spent 5 years producing a 105-minute DVD and gave 50,000 of them away free of charge. In recent years, however, he has come to believe that only specialists who perform the operation regularly should perform it at all.

Walsh has spent his entire professional career working as hard as a resident. In addition to his research and his clinical practice, he spent three decades running the Brady Institute, teaching students, editing major urology textbooks, reviewing 150 to 200 new papers each week, and writing four books. Asked what he did during his spare time, Walsh responded by asking what spare time was.

Now that he has retired from both administrative duties and surgery, he continues to teach students, perform research, and follow his 4569 patients.

He is also writing a book about the history of the Brady Institute and providing ministry to prisoners who are awaiting trial or sentencing.

“The challenge isn’t finding worthwhile things to do with my time,” he said, “it’s finding time to do all the worthwhile things that need to be done.”

Saluting an Oncology Superstar

James Mohler, MD

Associate Director and Senior Vice PresidentTranslational ResearchRoswell Park Cancer InstituteBuffalo, NY

“Dr Patrick Walsh and LeBron James have two things in common—they attended the same high school and both are superstars in their respective fields. Dr Walsh changed urology by defining the anatomy of the male pelvis so that radical prostatectomy and radical cystectomy could be performed more precisely and with less blood loss. The result is that millions of men have been cured of prostate cancer and men have less chance of impotence and urinary incontinence after prostate or bladder removal."

“Dr Walsh has made important contributions to the oncology field as well. In particular, he performed much of the early work on and maintained an interest in 5-alpha-reductase, an enzyme involved in steroid metabolism. He proposed that prostate cancer clustered in families, and he and his colleagues identified the first prostate cancer hereditary gene.

“But Dr Walsh’s greatest contribution probably is his training of many of the leaders in urology today, including numerous urology department chairs via the incredibly strong academic environment he maintained at Johns Hopkins for his entire career. Dr Walsh has also served as a great role model for academic urologists—he combines incredible intellect, knowledge, work ethic, integrity, and clinical skill, whereas Mr James need only play basketball.”

Mario A. Eisenberger, MD

R. Dale Hughes Professor of Oncology and UrologyJohns Hopkins Sidney Kimmel Comprehnsive Cancer CenterBaltimore, MD

“Dr Patrick Walsh is a pioneer and a visionary in many aspects. First, he established the safety and efficacy of anatomic radical prostatectomy in prostate cancer. To accomplish this, he meticulously studied human anatomy, identifying previously unidentified neurovascular bundles that, if preserved, would dramatically reduce the incidence of erectile dysfunction. Also, by sparing the anatomic sphincter, the incidence of urinary incontinence was reduced dramatically.

“Dr Walsh is one of the most insightful clinicians I have ever worked with. His views on hormonal therapy and the data collected on the natural history of patients with biochemical relapses are among some of the significant aspects on management of relapsed prostate cancer that have made a major impact on considerations by clinicians.

“He developed one of the most successful departments of urology in the world, maybe of all time. This department is responsible for training some of the most prominent urologists and oncologists in the world.

On a personal note, I consider Dr Walsh a mentor and a friend who profoundly affected my way of thinking. I definitely owe him a great deal amount of my gratitude for my accomplishments.”

Dr. Walsh's Selected Papers

• Teerlink CC, Thibodeau SN, McDonnell SK, et al. Association analysis of 9,560 prostate cancer cases from the International Consortium Of Prostate Cancer Genetics confirms the role of reported prostate cancer associated SNPs for familial disease [published online October 26, 2013]. Hum Genet. 2014;133(3):347-356.
• Mohler JL, Kantoff PW, Armstrong AJ, et al. Prostate cancer, version 1.2014. J Natl Compr Canc Netw. 2013;11(12):1471-1479.
• Pierorazio PM, Gorin MA, Ross AE, et al. Pathological and oncologic outcomes for men with positive lymph nodes at radical prostatectomy: the Johns Hopkins Hospital 30-year experience [published online September 9, 2013]. Prostate. 2013;73(15):1673-1680.
• Bivalacqua TJ, Pierorazio PM, Gorin MA, et al. Anatomic extent of pelvic lymph node dissection: impact on long-term cancer-specific outcomes in men with positive lymph nodes at time of radical prostatectomy. Urology. 2013;82(3):653-658.
• Tosoian JJ, JohnBull E, Trock BJ, et al. Pathological outcomes in men with low risk and very low risk prostate cancer: implications on the practice of active surveillance [published online April 30, 2013]. J Urol. 2013;190(4):1218-1222.
• Walsh PC. How surgical innovation reduced death and suffering from prostate cancer. J Craniofac Surg. 2013;24(1):49-50.
• Walsh PC. 2008 Whitmore Lecture: radical prostatectomy—where we were and where we are going. Urol Oncol. 2009;27(3):246-250.
• Walsh PC. Perfecting nerve-sparing radical prostatectomy: sailing in uncharted waters. Can J Urol. 2008;15(5):4230-4232.
• Freedland SJ, Mangold LA, Walsh PC, Partin AW. The prostatic specific antigen era is alive and well: prostatic specific antigen and biochemical progression following radical prostatectomy. J Urol. 2005;174(4, pt 1):1276-1281.
• Walsh PC, Mostwin JL. Radical prostatectomy and cystoprostatectomy with preservation of potency. Results using a new nerve-sparing technique. Br J Urol. 1984;56(6):694-697.
• Walsh PC, Lepor H, Eggleston JC. Radical prostatectomy with preservation of sexual function: anatomical and pathological considerations. Prostate. 1983;4(5):473-485.
• Isaacs JT, Brendler CB, Walsh PC. Changes in the metabolism of dihydrotestosterone in the hyperplastic human prostate. J Clin Endocrinol Metab. 1983;56(1):139-146.