when Dr. Patrick Walsh pioneered a new technique of prostate surgery a few years ago it was hailed as a major medical breakthrough and earned the 59-year urologist the General Motors-Kettering Award, the highest recognition one can receive for cancer research short of the Nobel Prize.
Since then, Walsh, chief of urology at Johns Hopkins University Medical School, has become something of a medical celebrity. His bestselling 1995 book, "The Prostate: A Guide for Men and the Women Who Love Them," was updated and reissued this year; he regularly makes the rounds on the talk shows, and his practice is booming.
Coming up with a way to preserve a man's sexual potency will do that. By his own estimate, Walsh has performed prostatectomies on more than 2,000 patients, managing to preserve sexual potency in 90 percent of his patients in their 40s, 75 percent of those in their 50s and 60 percent of those in their 60s. These are amazingly high potency rates for an operation that heretofore left men totally limp.
Last month, however, a group of Harvard doctors published a study suggesting what a number of cancer specialists have suspected -- that Dr. Walsh's claims were too good to be true. In the wake of that study, a bitter dispute has erupted between Walsh and his chief critic that could cause many prostate cancer patients to reconsider the benefits of Walsh's technique.
"It's a matter of adjusting expectations," Dr. James Talcott of Massachusetts General Hospital in Boston told Salon. Talcott, an oncologist, was the lead researcher in the study. He says Walsh is misleading prospective patients by suggesting his technique will work for most men, and accused Walsh of "trading on ambiguity."
The study, published in the August Journal of the National Cancer Institute, used a sample of 94 men who had their cancerous prostate glands surgically removed. Whether they underwent Walsh's nerve-sparing technique or not, the results were nearly the same: Most of the men were impotent one year after surgery.
"If, as Dr. Walsh claims, 60 percent of patients in their 60s who have bilateral nerve-sparing surgery can expect full post-operative potency, and our sample shows that the percentage is only 21, then there's a problem," says Talcott.
In an interview, Walsh hit back hard, labeling the report "a two-bit study," and calling Talcott "one of those quality-of-life people who believe no one should ever have a radical prostatectomy. When he gets prostate cancer, I don't know what he's going to do," said Walsh.
According to the American Cancer Society, some 317,000 men were diagnosed with prostate cancer in 1996, and about 41,400 died of the disease. It can be treated with radiation, chemotherapy or surgery. Until Walsh perfected his technique, surgery involved removing the entire prostate and cutting the nerve bundles, leaving the patient impotent and often incontinent.
The prostate gland is located at the neck of the bladder and urethra in men. The nerve bundles that lie on each side of the walnut-sized gland are crucial for achieving and sustaining erections. Walsh says the reason why the earlier surgical method was so drastic was because heavy bleeding prevented doctors from seeing the entire operative field. "So to avoid leaving any cancerous tumors, we took out the whole thing."
Walsh says he was able to track where the bleeding came from and control it, giving him a clear view of the diseased prostate and allowing him to remove only the tumors, leaving the nerve bundles intact. "The operation is performed on men who are curable and who are going to live long enough to be cured," says Walsh. "So if you take men in their 40s or 50s with curable cancer, the side effects of radical prostatectomy are really quite minimal."
Talcott responds that choosing only patients who are "curable" amounts to "cherry-picking" and says the high rates of potency that he claims to have preserved are not really representative of the general prostate patient population. "What we're saying is that if you're in your 60s, don't choose radical prostatectomy because you expect a 60 percent chance of full potency afterward," he said. "We're saying it's a long shot and a much longer shot than Dr. Walsh would have you believe."
"That really tickles me," replies Walsh. "If someone isn't curable, he shouldn't have the operation in the first place. So I try to pick patients who are curable. I don't like to use ages categorically because there are old 50-year-olds and young 60-year-olds," he continued. "But generally, a man in his 70s should not have a radical prostatectomy. He's not going to live long enough to need it, and he's going to have terrible complications. And a man in his 40s should be treated in no other way. I don't consider that cherry-picking."
In questioning the study's methodology, Walsh notes that it monitored only 18 patients who had nerve bundles spared and who were potent before the operation. "Give me a break. There have been over 1,000 patients operated on with the technique and have shown similar results to the ones I have. And these jerks are questioning this operation on the basis of 18 patients and a group of community urologists who operated infrequently? I'm telling you, it's a two-bit article."
Talcott believes such patients are often less than candid. "Generally, patients are not inclined to report problems to doctors. I think it's difficult to report bad outcomes to somebody who has putatively saved your life. And it may be particularly difficult if your doctor happens to be Patrick Walsh, whose most noteworthy claim to fame is having invented an operation for prostate cancer that leaves men potent. It's hard for a man to say to him, 'Thank you for saving my life, but I'm impotent and incontinent.' And it may not be that easy for Dr. Walsh to hear that kind of report."
That sends Walsh ballistic. "The claim that we don't know what happens to our patients is crazy," he said. "We follow our patients. We examine them. We take down their trousers. If they had a big pad on, we would see it."
Talcott acknowledges that the study's sample was small and that more research needs to be done. But he says the study was "on track" and that the "final reckoning" will come in two years, when a larger study he's conducting, involving 400 patients, publishes its results.
"The whole business of trying to choose treatment for prostate cancer is very difficult," he says. "So men need to make a decision based on accurate information. It's in everyone's interest if everybody knows what's at stake."