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The Prostate 32:149–151 (1997)
Historical Vignette
Origins of Radical Perineal and Nerve-Sparing
Retropubic Prostatectomy
William W. Scott*
James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, Maryland
In conversation with Gerald Murphy, co-editor of
this publication, your Consulting Editor has suggested
that it would be a good idea to publish a historical
account occasionally of the development of certain
disorders of the gland and treatments developed
thereof. He agreed to give it a try and asked me to
write on the origin and development of total surgical
removal designed to eradicate prostatic cancer. There
was no thought that such articles should be concerned
with the comparison of such surgical techniques with
other forms of therapy, such as local radiation, cryosurgery, etc. As a part of this conversation, consideration was given to asking others to write on the development of these other forms. The historical development of endocrine treatment will be the subject of a
later Vignette. As we proceed, it will become evident
that my association with the ‘‘prime movers’’ in the
treatment of both early and late prostatic cancer was a
close one.
It seems clear that my predecessor, Hugh Hampton
Young, Professor and Chairman of Urology at Johns
Hopkins, 1897–1941, performed the first radical perineal prostatectomy for cancer of the prostate on April
7, 1904, an operation in which the entire prostate with
its capsule and adjacent seminal vesicles were removed. He was assisted by his chief, Dr. William S.
Halsted, the first head of surgery at Johns Hopkins. In
1903, having developed the operation of removal of
the prostate via the perineum for the relief of urinary
obstruction due to benign prostatic enlargement,
Young had encountered 2 patients in whom the area
of cancer was small. He wrote, ‘‘I was struck by the
fact that had the entire prostate gland been removed
with its capsule, it would have been possible to cure
these patients.’’ He continued, ‘‘As a study of the literature revealed that no such radical operation had
ever been attempted, I made careful sketches of what
I though would be necessary and showed them to my
chief, Dr. William S. Halsted, whose reputation was
world-wide because of a very radical operation for
© 1997 Wiley-Liss, Inc.
cancer of the breast with which he had cured a large
percentage of the patients brought to him. After examining the (first) patient, Doctor Halsted carefully
reviewed my sketches. He appeared greatly impressed, strongly advised me to carry out the operation, and said he would like to assist.’’
The radical perineal prostatectomy procedure was
established, and unquestionably the originator was
Hugh H. Young. Subsequently, many radical perineal
prostatectomies for early prostatic cancer were performed by Young, and later, by J.A.C. Colston and
Hugh Jewett. The Brady Institute became one of the
main referral centers for early prostatic cancer and has
remained so for many years, including those under
my successor, Patrick C. Walsh. Hugh Jewett, in one of
several reviews from Johns Hopkins [1], established
that when a nodule of cancer was confined to one lobe
of the gland, radical perineal prostatectomy resulted
in a 15-year survivorship of close to 50% these survivors showing no clinical evidence of recurrence of
their cancers. This survival rate is very close to the rate
for age-matched controls who do not have prostatic
cancer.
One of the chief complications resulting from total
perineal prostatectomy according to Young’s method
was impotence. This caused some candidates to shy
away from the procedure. Recognizing this, my successor, Patrick C. Walsh, decided he should try to
solve this dilemma.
It is well-known that Terence Millin introduced the
retropubic approach for enucleation of benign hyperplastic prostates. Millin reported this in the December
1945 issue of the Lancet, and I well remember reading
from his article while Charlie Huggins, with myself as
his assistant, performed the first retropubic prostatec-
*Correspondence to: William W. Scott, Ph.D., M.D., David Hall McConnell Professor Urology Emeritus, James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, MD 21205.
Received 17 January 1997; Accepted 27 January 1997
150
Scott
tomy for benign hyperplasia at the University of Chicago [2]. The journal was laid open to Millin’s description, using the Bovie cautery unit as a desk. Whereas
it did not take long for Millin’s operation to become
immensely popular for benign prostate hyperplasia
(BPH) more time was required for its use in cancer.
It remained for Patrick Walsh to develop and introduce ‘‘nerve-sparing’’ radical retropubic removal of
the prostate for cancer.
One day late in 1995, I was talking with Alan Partin,
the Chief Resident at Brady, and Associate Professor
as of January 1, 1996, and asked him for references to
Walsh’s discovery. He in turn talked to Dr. Walsh,
who kindly wrote me a 5-page letter reminiscing
about his work and furnishing me with reprints (personal communication). The account which follows is
based on his letter to me, dated January 18, 1996, and
from published accounts of Walsh’s work.
In 1980 Walsh predicted the discovery. I quote:
The cause of impotence in men undergoing radical
prostatectomy is poorly understood. Presumably,
the parasympathetic innervation to the corpora cavernosa is damaged during the dissection. It is
known that the pelvic nerve travels between the
rectum and the prostate and provides the greater
and lesser cavernous nerves that are necessary for
parasympathetic innervation. Although the exact
anatomic location of these nerves is not well understood, if the nerves travel outside the capsule of the
prostate, then it might be possible to modify the
operation so that potency could be maintained. Further study along these lines is highly indicated (personal communication).
Walsh’s first consideration was not the prevention
of impotence (or preservation of potency) but to determine why blood loss incident to radical retropubic
prostatectomy was so great and then to try to do
something to control it. Blood loss was rarely a problem during radical perineal prostatectomy. During his
stint at the San Diego Naval Hospital under his Berry
Plan commitment (1971–1973), Walsh had undertaken
radical retropubic prostatectomy. He had observed
then that the results were good in terms of continence,
but he was struck by the major blood loss that occurred in some cases.
In Walsh’s letter to me he continues with a description of his search for means to control blood loss. His
‘‘first project was to determine the anatomy of Santorini’s plexus with the hope that these studies would
provide insight into how blood loss could be reduced.
. . . Armed with information from standard text books
of anatomy, I traced out the anatomy of Santorini’s
plexus and worked out a technique to reduce blood
loss’’ [3].
Shortly after developing this technique, Walsh conducted radical retropubic prostatectomy for cancer on
a 56-year-old, recently remarried man. Postoperatively he was fully potent. Walsh asked himself why,
which encouraged him to proceed with anatomical
studies to identify the nerves. Anatomical textbooks
were of little help [4].
Pieter Donker’s role in this work is of considerable
importance. It began in 1977 at a chance meeting of Dr.
Donker and Dr. Walsh at the annual meeting of the
American Association of Genitourinary Surgeons in
Miami. In 1981, Walsh revisited Donker in Leiden, The
Netherlands, and spent an afternoon with him in the
anatomy laboratories. Donker showed Walsh his
drawings of the nerves to the bladder in an infant
cadaver. These had not been precisely described before. Walsh then asked Donker where the branches
were that innervated the corpora cavernosa. The two
spent the rest of the afternoon dissecting them out. It
became quite clear that the nerves were outside the
prostate and Denonvillier’s fascia, and that it would
be possible to remove the prostate without injuring
the cavernous nerves [5].
According to Walsh, the next—and very important
step in the development of the nerve-sparing operation—resulted from the efforts of Herbert Lepor, then
in residency and now Professor and Chairman of
Urology at New York University. Quoting from
Walsh’s letter to me:
Up to this point I was unable to entice any of the
residents to work on this project. However, Herb
[Lepor] was fascinated by the findings and went to
the anatomy laboratory and repeated the dissections of Donker. Next he went to the autopsy room
and removed the prostate from an adult patient and
had it step sectioned. Here for the first time I was
able to see the relationship of the neurovascular
bundle to the fascia of the prostate [6–8].
However, Walsh still did not fully understand the
whole-mount sections of the prostate provided by
Lepor and continued to ponder the problem. In his
letter to me, Walsh related that during Christmas vacation in 1982 while reading Young and Davis’ Textbook of Urology, he saw for the first time a wholemount section of the prostate showing the periprostatic tissue [9]:
On this illustration one could see the neurovascular
bundle and the fascia of the prostate. Hugh Young
had obviously identified these anatomical relations
and stated that one needed to go beneath the fascia
Origins of Prostatectomy
to avoid bleeding and possible injury to the nerves
which he felt may be responsible for urinary control. Thus it was clear that in perineal prostatectomy one performed a subfascial dissection reflecting Santorini’s plexus off the prostate whereas in
radical retropubic prostatectomy these structures
needed to be divided.
This observation led to the publication by Walsh,
Lepor, and Eggleston in which Walsh proposed the
technique for performing his ‘‘nerve-sparing’’ operation [10].
Walsh’s operation is now history. By September
1996, he had performed 2,000 of these and had accomplished what he had set out to do: reduce blood loss
during the retropubic approach and preserve potency.
Regarding potency, Walsh told me recently that for
ages 40, 50, 60, and 70, postoperatively potency rates
were 90%, 75%, 59%, and 25%, respectively.
This was a rather remarkable achievement and suggests, as Walsh stated in his letter to me, ‘‘If someone
wants to put my name on something it should probably be ‘the neurovascular bundle of Walsh’ ’’ [11,12].
151
2. Millin T: Retropubic prostatectomy: A new extravesical technique; report on 20 cases. Lancet 2:693–696, 1945.
3. Reiner WG, Walsh PC: An anatomical approach to the surgical
management of the dorsal vein and Santorini’s plexus during
radical retropubic surgery. J Urol 121:198–200, 1979.
4. Walsh PC: Radical prostatectomy for the treatment of localized
prostatic carcinoma. Urol Clin North Am 7:583–591, 1980.
5. Walsh PC, Donker PJ: Impotence following radical prostatectomy: Insight into etiology and prevention. J Urol 128:492–497,
1982.
6. Lepor H, Gregerman M, Crosby R, Mostofi FK, Walsh PC: Precise localization of the autonomic nerves from the pelvic plexus
to the corpora cavernosa: A detailed anatomical study of the
adult male pelvis. J Urol 133:207–212, 1985.
7. Schlegel PN, Walsh PC: Neuroanatomical approach to radical
cystoprostatectomy with preservation of sexual function. J Urol
138:1402–1406, 1987.
8. Walsh PC: Radical prostatectomy, preservation of sexual function, cancer control: The controversy. Urol Clin North Am 4:
663–673, 1987.
9. Young HH, Davis DM: ‘‘Young’s Practice of Urology. Volume
2.’’ Philadelphia: Saunders, 1926:463.
10. Walsh PC, Lepor H, Eggleston JC: Radical prostatectomy with
preservation of sexual function: Anatomical and pathological
considerations. Prostate 4:473–485, 1983.
REFERENCES
11. Walsh PC, Quinlan DM, Morton RA, Steiner MS: Radical retropubic prostatectomy: Improved anastomosis and urinary continence. Urol Clin North Am 17:679–684, 1990.
1. Jewett HJ: The case for radical perineal prostatectomy. J Urol
103:195–199, 1970.
12. Walsh PC, Partin AW, Epstein JI: Cancer control and quality of
life following anatomical radical retropubic prostatectomy: Results at 10 years. J Urol 152:1831–1836, 1994.
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