Prostate surgery debate hits nerve in Hub
by Michael Lasalandra
Sunday, March 16, 2003
When he decided to have prostate cancer surgery, Sen. John Kerry went to Baltimore, choosing the doctor known for developing a technique designed to preserve erectile function even though there are surgeons in Boston who can do the procedure.
Dr. Patrick C. Walsh of Johns Hopkins Hospital reports his ``nerve-sparing'' approach to radical prostatectomy can preserve potency in 91 percent of men under the age of 50 and in 75 percent of those between the ages of 50 and 60.
Kerry's choice highlighted a long-standing medical controversy, one that has left Boston, known to many as the nation's medical mecca, the loser, at least in the eyes of some.
The senator had his operation Feb. 13 and was declared to be cancer-free. He has resumed his presidential campaign, although he bowed out of today's St. Patrick's Day breakfast in South Boston, citing the surgery.
As far as the flap over Kerry's decision to have his surgery in Baltimore rather than Boston is concerned, Walsh said he really doesn't understand it.
``I'm sorry it's caused so much controversy,'' he said. ``I don't criticize them up in Boston. But I've spent my entire life doing this.''
While there are doctors in Boston who perform the nerve-sparing procedure, their results on preserving potency, when they are reported, don't quite measure up to those reported by Walsh.
Walsh says the reason his results are so good is that he does nothing else.
``I do 200 a year,'' he said. ``I did six this week. And I have five associates and that's all they do, too. It's a very complicated operation.''
Walsh said there are no urologists in Boston who devote themselves solely to the procedure - and he said he doesn't know why.
``There ought to be two or three in Boston doing nothing else,'' he said. ``There are two surgeons in Boston who do nothing but brain surgery. There are many more patients with prostate cancer than there are with brain tumors.''
Dr. Jeffrey Steinberg, who heads the Massachusetts Association of Practicing Urologists, said surgeons need not concentrate solely on radical prostatectomies to do a good job, as long as they do a sufficient number.
``There are so many surgeons who do an excellent job,'' he said. ``We've all trained using this technique. The more you do, the better you get.''
One study pegged the threshold number at 40 per year.
Walsh conceded others can do just as well as he does - if they do enough of them.
He cited a recent study in the journal Urology that compared five different surgeons, including himself, and found they got the same results: 75 percent of patients were potent after one year.
The five included surgeons in New York, St. Louis, Minnesota and Tennessee. Three of them were trained by Walsh and all do nothing else, he said.
But some urologists and many patients believe Walsh's statistics may be skewed because he ``cherry picks'' his patients.
When you operate on both the young and the old, the results won't be as good, they say.
``The actual recovery of erectile function will vary from study to study even when the nerve-sparing technique is used,'' said Dr. John Long, urologist at Tufts-New England Medical Center.
``I tell my patients that when I succeed in performing nerve-sparing surgery, the rate will be 50 percent within 12 months. That means 50 percent of patients will have workable erections.''
He said the chances of regaining potency vary with the age of the patient and whether the patient could sustain a strong erection before surgery.
``Selection bias plays a role,'' he said.
According to a 2000 study in the Journal of the American Medical Association, nearly 60 percent of men who had their cancerous prostates removed were impotent a year and a half after surgery.
But a study of 64 patients done by Walsh showed only 10 percent of men in their 50s turned out to be impotent 18 months later.
Stan Klein of Somerville, a prostate-cancer survivor who runs the state's largest support group, says most members of his group have potency problems and must use vacuums, injections or Viagra.
``At any given meeting, the (impotence) rate is about 98 percent,'' he said. ``I don't care if they are in their 40s or 50s.''
He was sharply critical of surgeons for not telling patients the truth before they go in for surgery.
``All the urologists lie,'' he said. ``They don't want their patients to take a chance and refuse treatment.''
Dr. John Libertino, urologist at the Lahey Clinic in Burlington, is among the best at the procedure not only in Boston, but nationally, says the Wall Street Journal.
Walsh agrees. ``John is very, very good,'' he said.
Libertino, who has performed 1,500 radical prostatectomies, said there are others in Boston who do plenty and are good at them.
The procedure involves sparing the two nerve bundles that run along either side of the prostate.
``Before Walsh identified the importance of these nerves, they were routinely sacrificed,'' Libertino said.
Libertino said if he is able to spare both nerves, about 70 percent of his patients under age 65 will still be potent. If only one nerve can be spared, that rate is 50 percent.
As far as concentrating exclusively on the one procedure is concerned, Long said it would not be economically feasible for most urologists to do so.
``It is highly unusual for someone to be in a practice that would allow him to concentrate on a single operation,'' he said. |
