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 , 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 . 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’’ . 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 . 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 . 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 : 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 . 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.