When Patrick Walsh arrived at Johns Hopkins 50 years ago as a young surgeon, prostate cancer often carried a death sentence. This was the era before prostate-specific antigen (PSA) blood testing, which today is widely used to screen for prostate cancer early on, when it is still treatable. Even patients who had potentially curable disease were rarely treated with curative intent, as radiation therapy had not yet sufficiently advanced. Surgery — the radical prostatectomy pioneered in the early 1900s by Johns Hopkins’ own Hugh Hampton Young — was widely considered worse than the disease itself.
That’s because 100% of men who underwent a radical prostatectomy became impotent, Walsh explains. Roughly 25% experienced severe urinary incontinence. Few surgeons even wanted to undertake the surgery because of the massive bleeding that occurred when operating.
In the early 1980s, Walsh forever changed the grim outlook for men the world over when he developed a surgical approach that became known as nerve-sparing radical prostatectomy. The technique allowed surgeons to excise the cancer while preserving a man’s potency and urinary continence. After completing the first purposeful such surgery on April 26, 1982, Walsh would go on to refine his technique while performing nerve-sparing surgeries on thousands of men at Johns Hopkins and beyond over the next three decades, even as he led Johns Hopkins’ Brady Urological Institute and edited the book known as the “bible” of urology, Campbell’s Urology. In 2012, it was renamed Campbell-Walsh Urology in his honor.
Now University Distinguished Service Professor of Urology Emeritus, Walsh recently spoke about his path of discovery in an inspiring CIM Seminar titled, “How Listening to a Patient Transformed the Care of Men with Prostate Cancer.” As Walsh tells it, his breakthrough discovery hinged on a series of seeming coincidences — which he, as a man of deep Christian faith, attributes to divine providence. While it’s impossible to capture the full scope of Walsh’s talk in the short space available, a few highlights stand out.
In the early 1980s, Walsh forever changed the grim outlook for men the world over when he developed a surgical approach that became known as nerve-sparing radical prostatectomy.
Key Moments in Patrick Walsh’s Path to Discovery
I listened to my patient when he told me following surgery that he was sexually potent — and I wondered why.
Intent on improving the “problem with bleeding” in prostate surgery during the late 1970s and early 1980s, Walsh zeroed in on the anatomy of the veins surrounding the prostate by using the operating room as his anatomy lab. At this point, he explains, the veins that caused the bleeding had never been charted, the location of the nerves responsible for erection was unknown and the muscles for urinary control were incorrectly identified.
Walsh was able to identify a common trunk of veins over the urethra. This led to a technique that reduced blood loss dramatically, providing a safer and more thorough prostate cancer operation. Soon after using this technique, Walsh says, a patient returning for follow-up from prostate cancer surgery announced that he was fully potent.
How could that be? “At that time, everyone believed that the nerves that controlled erectile function ran through the prostate, and it would be impossible to preserve potency,” he recalls. “But from this one patient, I knew that this was not true. But where were the nerves? The answer was not available in any textbook.”
I invited an older, lonely-looking man who was a total stranger to dinner — and I met with that “lonely stranger” four years later and 4,000 miles away in Leiden, the Netherlands.
Within weeks of that momentous patient encounter, Walsh attended an international urological conference with his wife. At dinner one night, he noticed an older man about to be seated alone. “For the first and only time in my life, I went up to a total stranger and asked if he would like to join us for dinner, and I asked why he was in town,” Walsh recalls.
The man was Pieter Donker, chair of urology at the University of Leiden in the Netherlands, and the trio had a wonderful dinner together. Four years passed — a time during which Walsh continued to investigate the nerve mystery evoked by his potent patient. Donker was retired at this point, but his successor invited Walsh to attend a surgical congress in Leiden. On the last day, Walsh’s 43rd birthday, “My host told me that Dr. Donker appreciated my kindness a few years earlier and wanted to return the favor by taking me to see the windmill museum in Leiden.”
When the two met up, Donker mentioned that in retirement, he was working in an anatomy lab. Walsh suggested they abandon the museum tour and go to the lab instead, where Donker was dissecting nerves to the bladder in a stillborn baby. Once there, “when I asked about the location of the nerves responsible for erections,” says Walsh, “he said he had never looked.” The two got to work. “Three hours later, there they were, outside the prostate.”
Returning to Johns Hopkins, Walsh in 1981 found that there were vessels located in the exact site where the nerves were present in the fetal dissections. “I speculated that these vessels might provide the scaffolding for these microscopic nerves and could be used as the macroscopic landmark to identify them in the operating room,” he explains. Using that technique, Walsh performed that first nerve-sparing radical prostatectomy on a 52-year-old man in April 1982. The patient would go on to live a normal life, cancer-free.
Over the next decade, radical prostatectomy became the most common form of treatment for localized prostate cancer in the United States.
I continued to listen to my patients.
Between 1982 and January 2011, when Walsh performed his last surgery, he completed nerve-sparing prostatectomies on 4,569 patients. “I spoke to every one of those patients every three months in the first year after their surgeries — that was more than 18,000 telephone conversations,” he says. Those conversations were crucial in guiding him to further refine his surgical technique and improve quality of life measures, Walsh says. “I made 28 changes over those 29 years.”
At the time Walsh stopped operating, 93% of his patients who underwent nerve-sparing prostatectomies reported being potent at 18-month follow-up. And 95% had total urinary control.
At the time Walsh stopped operating, 93% of his patients who underwent nerve-sparing prostatectomies reported being potent at 18-month follow-up. And 95% had total urinary control.
“These results were far, far different from when I began my journey,” he says.
For CIM Director David Hellmann, Walsh’s careerlong, patient-centered approach to discovery and patient care provides a perfect case study for the importance of humanizing medicine.
Says Hellmann: “It illuminates that listening to patients is important not only because patients value it and it rejuvenates physicians and nurses, but when coupled with clinical excellence and deep scientific curiosity, listening to patients can drive dramatic discoveries and innovation — and change the way medicine is practiced for the better. That is exactly what Dr. Walsh has done.”
