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A selection from
Dr. Patrick Walsh's Guide to Surviving Prostate Cancer
by Patrick C. Walsh, M.D., and Janet Farrar Worthington
pages 213-214
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Perfecting the Radical Prostatectomy
It turns out that some men have a significant anatomical
variation. Previously, everyone believed that the neurovascular
bundle took a rather straight pathway from its origin in the sacrum
along the lateral surface of the prostate to the urethra. But I learned
that in many patients the bundle curves around the apex of the
prostate, and is tucked just beneath the sphincter and held there by a
small group of vessels. And that, if one attempts in good faith to preserve as much of the sphincter as possible, the neurovascular bundle
can be damaged, and recovery of sexual function delayed. Indeed, the
eight men who at eighteen months had not yet recovered full sexual
function all seemed to have this variant curve.
Part two of this project was to make the study "blind." I went back
over the operations again - this time without identifying the patient
or the outcome - to see if the steps I had identified checked out. Fortunately, they did.
Incontinence is a long-term significant problem for only about 2
percent of our patients at Johns Hopkins, and I was unable to find evidence that anything I did or did not do during surgery would make a
difference there. Clearly, it had nothing to do with preservation of the
sphincter. There was one man with perfect preservation of the
sphincter who was still wearing a pad one year after the surgery. For
this reason, I am now taking a different approach, by working to
refine the procedure for reconstructing the bladder neck during radical prostatectomy.
To the best of my knowledge, this is the first time that any surgeon
in any field used retrospective reviews of intraoperative videotapes to
improve any surgical technique. I believe many surgeons could benefit from regularly reviewing their operations in this way. Because
many surgeons use different techniques, it's likely that each surgeon
may be able to identify other important, arbitrary variations that may
help patients. Also, for surgeons whose patients seem prone to more
side effects than usual, the review of early successful cases may help
them identify ways to modify their technique, and improve the outcome of future patients. If I had videotaped that first successful operation in 1977 - after which the man was potent immediately - I
would have discovered the location of the nerves four years sooner.
end of selection
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