Prostate

Dr. Patrick Walsh explains his achievements in prostate surgery and why he is honest with his patients.

00:00: Charlie Rose: He is a professor at Johns Hopkins School of Medicine. In 1982, he devised a procedure to remove the prostate while preserving sexual function. A quarter century later, he has performed that operation more than 4,000 times. His achievements in the world of prostate surgery are remarkable. It has been pioneering. And what he has done has changed the way prostate cancer is treated. So it`s especially an honor to have him here. And I know having -- not ever had cancer in my life, but having known a lot of people who do, what you have done is remarkable for them. Let me go back to the `80s. Tell me what the status of prostate cancer was in terms of treatment, in terms of consequence, in terms of death.
00:51: Patrick Walsh: It was pretty dismal. In the 1980s, in the early 1980s, virtually every man diagnosed with prostate cancer came because his cancer was palpable or he had symptoms.
01:02: Charlie Rose: Right.
01:04: Patrick Walsh: Essentially, most men were not curable. And almost -- and of the men who were curable, almost none of them received curative therapy. Radiation in those days was underpowered to cure the disease, and surgery had so many complications that only 7 percent of men with localized prostate cancer underwent surgery. So, essentially, the men that were diagnosed usually were not curable, and the ones who were curable did not receive curative therapy.
01:29: Charlie Rose: And tell me about the dilemma of surgery.
01:32: Patrick Walsh: Well, the problem was, although radical prostatectomy had been developed at Johns Hopkins by Hugh Young in 1904, and had been used, and people believed that it was -- that it was curative, there were so many side-effects -- excessive bleeding, 100 percent of men were impotent. And --
01:47: Charlie Rose: A hundred percent?
01:49: Patrick Walsh: A hundred percent. It was inevitable. People believed the nerves ran through the prostate, and it was inevitable. And about 25 percent of men had severe incontinence. Essentially, the side-effects of the surgery to many people seemed worse than the disease itself.
02:08: Charlie Rose: And how did you go about determining where the nerves were? What was your indication? What was your insight? And how did you get there?
02:18: Patrick Walsh: Well, I tell my residents, who teaches the professor? His patients. And a patient came back to me after the operation and told me he was fully potent.
02:29: Charlie Rose: Right.
02:30: Patrick Walsh: I removed his prostate. And so I knew that the dogma that the nerves ran through the prostate was incorrect. But where were they? Well, at that time, 1977, when that happened, my wife and I went out to dinner one night with an elderly doctor from Leiden and befriended him at an international meeting. And four years later, when I went to Leiden, after five days of lecturing he was assigned to show me around. And I said, "What are you doing now that you are retired?" And we went down to the anatomy laboratory and he took out an infant cadaver, a dissecting microscope, and his drawings. I said, "What are you doing?" He said, "I`m dissecting out the nerves to the bladder." I said, Why hasn`t that been done? Well, it wasn`t done because in the adult cadaver you just can`t see them.
03:13: Charlie Rose: Right. You can`t because tissue covers them or --
03:16: Patrick Walsh: Well, exactly what happens in the adult cadaver is that they use phenol and formalin --
03:20: Charlie Rose: Right. Right.
03:23: Patrick Walsh: -- to fix the cadaver, and that dissolves away the fat planes (ph).
03:26: Charlie Rose: Got it.
03:27: Patrick Walsh: And in the post-mortem state, the pelvic viscera are compressed into a thick pancake.
03:31: Charlie Rose: Right.
03:33: Patrick Walsh: In the infant cadaver that doesn`t happen. And I looked down and I said, "Where are the branches of the nerves from the bladder that are responsible for erection?" He said, "I`ve never looked." And three hours later, there they were, outside the prostate, outside the capsule of the prostate.
03:46: Charlie Rose: So, the next day what did you do?
03:47: Patrick Walsh: Well, that was February 13, 1981, my 43rd birthday actually.
03:51: Charlie Rose: Yes?
03:53: Patrick Walsh: And the problem was, it was like having this schematic for the television. We knew where they were on a schematic, but where were they in the adult male pelvis?
04:00: Charlie Rose: Right.
04:03: Patrick Walsh: So I went back to Hopkins, and as I had done with other steps in this operation, like controlling bleeding, which was a major one, I used the operating room as an anatomy laboratory. And I saw some vessels that ran in that same location. And so a year later, I got together with Peter Donker (ph), who I made the discovery with, and I said, "Peter --"
04:20: Charlie Rose: Peter Donker (ph) is a physician?
04:22: Patrick Walsh: Peter Donker (ph) was the retired professor of urology at the University of Leiden.
04:26: Charlie Rose: OK. Right.
04:30: Patrick Walsh: And he was a neurourologist. And I said, "Peter, I think that these vessels and these nerves make a neurovascular bundle, and I can use that as the indicator, the macroscopic landmark interoperatively."
04:39: Charlie Rose: Now, is that the way it is generally in the body, that the nerves and the blood vessels there sort of -- whatever the term you used was?
04:47: Patrick Walsh: Neurovascular bundle.
04:49: Charlie Rose: Neurovascular bundle.
04:51: Patrick Walsh: Yes. It is in many places, and so it made sense that these microscopic nerves needed some kind of scaffolding to hang onto. So, I came back, and I removed the bladder on a 67-year-old man. You remove the bladder and prostate. And I had never had a patient ever potent after that. And 10 days --
05:06: Charlie Rose: After you had done that operation. In all previous operations, the nerves had been destroyed, and therefore --
05:11: Patrick Walsh: Always. And that man woke up 10 days later with a normal erection in the morning.
05:17: Charlie Rose: Now, what had enabled you to do that to make sure you didn`t cut the nerves?
05:20: Patrick Walsh: I was able to see the neurovascular bundle. And so I used --
05:23: Charlie Rose: And so you set it aside? Is that what you did, pushed it aside?
05:27: Patrick Walsh: That`s right. Identified it and moved it away. Previously, those nerves were cut and left in place. And then on April 26, 1982, we had the 25th anniversary, the first patient came back. And he was 52 years old in those days. He came back last year for the anniversary. I told him before the operation -- and he had been told by everyone that he was going to be 100 impotent -- that I could preserve his nerves. And here he is today, 25, now almost 26 years later, cancer free, with a normal quality of life.
05:52: Charlie Rose: He`s in the book.
05:53: Patrick Walsh: He`s in the book.
05:55: Charlie Rose: Yes. Why prostate cancer for you? Why has that been the obsession?
06:01: Patrick Walsh: Well, there are many reasons why.
06:02: Charlie Rose: I mean, you`re a urologist.
06:04: Patrick Walsh: I`m a urologist.
06:06: Charlie Rose: And a surgeon.
06:07: Patrick Walsh: And prostate cancer is a major problem. I became fascinated by it.
06:11: Charlie Rose: Right.
06:13: Patrick Walsh: Also, an uncle who was instrumental in my scientific development died of the disease when I was in my formative years, my uncle Harry.
06:18: Charlie Rose: Most people face a choice. What is the choice, surgery or something?
06:23: Patrick Walsh: There are three choices. And, you know, the trick question is, what is the best form of treatment for prostate cancer? There is no one best choice. There are many options. One of them for a man who is too old or too ill to live longer than 10 years is to keep an eye on it, what we call expected management. For the young --
06:38: Charlie Rose: In other words, at some level for some people, just live with it.
06:43: Patrick Walsh: Yes. If you are older or ill, and you are not going to live 10 or 15 years, it`s unlikely that that cancer will progress to the point that it will kill you. And if you are followed carefully and it appears to be progressing, intervention can occur at that time. And that makes a lot of sense. For a man in his 40s and 50s, who is going to be alive potentially for 40 or 50 years, surgery makes great sense because we know, number one, the long-term outcome. And number two, if the operation is done by someone who is skilled in it, the quality of life is excellent. And then the large majority of men are in their 60s and early 70s. And for them there are options. Radiation therapy is a good option. Surgery is a good option. I`ve written this book for lay people for the very purpose of giving them a detailed understanding of the options. And so when they see the their urologist, there`s an even playing field. And the two of them, the urologist, or the radiation oncologist, and the patient, can decide, based upon facts, what they want to do.
07:45: Charlie Rose: So, you don`t always advise surgery?
07:47: Patrick Walsh: I absolutely don`t, because for many people that`s not the right form of treatment.
07:53: Charlie Rose: And what about what some people call seeds?
07:56: Patrick Walsh: Yes, interstitial radiotherapy.
07:59: Charlie Rose: Right. That`s the word I was looking for, interstitial radiotherapy.
08:04: Patrick Walsh: Now, the trick is this -- and that is, there are side-effects to all forms of treatment for prostate cancer. And if you are going to be treated, therefore, you want to have an expert do it. Experience, experience, experience. If you are going to have seeds, that is very hands on. You want someone that can be able to distribute that radiation very well throughout the prostate. If you are going to have surgery, you want someone who gets out all the cancer and preserves quality of life. With external beam radiotherapy, it`s a little bit more like lasik surgery, where there`s a computer that lines you up and radiates you. But for those two extremes of seeds versus surgery, you really want to have someone who is an expert in that field.
08:45: Charlie Rose: And in fact, I think I`m correct in this -- you have some reservations about people who think you can do this in terms of some kind of minimally invasive surgery, because you believe that you need a skilled, experienced hand there watching over the particular nerves and the particular physical anatomy of the person.
09:04: Patrick Walsh: There`s been great commercialization of a thing called the "robot," robotic prostatectomy. And many hospitals spend $1.5 million. They advertise it in their community. Many people well-meaningly say, well, the robot is going to do the operation. No, it`s the person behind the robot. And the problem with the robot is you really cannot feel exactly where you are and whether or not you`ve removed all the cancer.
09:29: Charlie Rose: PSA screening --
09:31: Patrick Walsh: Yes.
09:33: Charlie Rose: -- tell me what your opinion -- and where judgment about it is changing or not.
09:38: Patrick Walsh: OK. It`s a controversial area. I`ll put it this way -- 25 years ago, 30 years ago, men that presented with prostate cancer, 90 percent of them weren`t curable. Today, 90 percent of them are curable. In the last 10 years, deaths from prostate cancer in the United States have fallen 33 percent, more than any other cancer in men and women. If you go to Scandinavia and you looked at countries that introduced surgery and PSA testing early, within a couple of years, death rates that were going up 2 percent began to fall. But in one Scandinavian country in Denmark, where they did not do surgery and did not do PSA testing, death rates from prostate cancer continued to go up 2 percent. I can give you any number of examples. PSA testing is the right thing to do for someone who is going to live long enough that need to be cured from prostate cancer. I tell an 80-year-old man who wants to have it, fine, but bring both of your parents to the appointment. So you have to be careful that not everyone is a candidate for it. But in the right circumstance, interpreted the right way, it saves lives.
10:43: Charlie Rose: And it`s accurate for determining that you do not have prostate cancer at the time?
10:48: Patrick Walsh: No, it isn`t. It is like any other test. But let me give you an example. If a 50-year-old man has an elevated PSA, his chance of having prostate cancer is 25 percent. If his 50-year-old wife has a positive mammogram, her chance of having breast cancer is less than 10 percent. It`s not a perfect test. If your PSA is up, you have prostate disease, and you need to see a urologist to see whether it`s cancer, inflammation or enlargement.
11:19: Charlie Rose: But my question was, how many people who don`t have a high PSA might have prostate cancer?
11:24: Patrick Walsh: It is -- a recent study suggested that 15 percent of men with PSAs less than 4 have cancer.
11:28: Charlie Rose: Fifteen percent?
11:30: Patrick Walsh: Fifteen percent.
11:31: Charlie Rose: What about less than 2?
11:33: Patrick Walsh: There is no -- I was just going to say, there is no absolute cut-off point.
11:38: Charlie Rose: Right.
11:40: Patrick Walsh: And so one of my associates, Dr. arter, has made a great contribution in what is called PSA velocity. If your PSA is less than 4, it should not go up more than 0.4 per year. And so if you have a low PSA -- say your PSA is 1 and it stays around 1. Your chance of having cancer is very low. But if it goes from 1 to 1.4 to 1.6 to 2.0 in a consistent way --
12:05: Charlie Rose: The velocity is --
12:07: Patrick Walsh: If the velocity is increasing, then you need to be evaluated to see whether or not that signifies that you have cancer.
12:14: Charlie Rose: How often do you operate today?
12:16: Patrick Walsh: I operate the same amount. I do around 200 cases a year. As I left this morning, I went and saw the two patients I operated on yesterday.
12:23: Charlie Rose: So that`s my question. So how do you choose? I mean, you are the most famous prostate surgeon in the world. And you are recognized for being the best. I`m sure there are people who -- I`m saying you`re recognized. There are many people out there who have learned from you and are approaching as good as you are, but we may not know about them. How do you decide who you will take as a patient?
12:42: Patrick Walsh: Well, the first thing is, when you work at John Hopkins, you work for a salary.
12:46: Charlie Rose: Right.
12:47: Patrick Walsh: So, you take the financial considerations out.
12:49: Charlie Rose: It`s gone, off the table.
12:50: Patrick Walsh: And I take care of everyone the way I would want to be taken care of. I see them myself, I do their entire operation. I give them my home telephone number --
12:58: Charlie Rose: Right.
13:00: Patrick Walsh: And I talk to them every three months until everything is working well. So you can`t operate on everybody. So, you know, I operate on people from all walks of life. And I have associates that treat people the say way. I don`t have to do every operation in the world.
13:13: Charlie Rose: Talk to me about mindset of a surgeon, because I`ve heard this about you. And I can`t remember, and it wasn`t recent, but someone said, the thing about Walsh is that when he walks in there, he sits you down and he tells you the stark reality, and he tells you, I can take care of this. Give me a sense of what it is that you feel is the imperative for a surgeon talking to someone, in this case with prostate cancer.
13:41: Patrick Walsh: To be honest, I`ve been given gifts. And I don`t take credit for them. But if I see someone and I know from the tables we`ve developed that they have curable disease, and I tell them honestly that they have curable disease, that they are a candidate for surgery because they are curable and are going to live long enough to be need to be cured, and I give them the results of the likelihood that they will have complications, and I tell them, just like I just mentioned, that if they want me to take care of them, I will lift them up, I will make them well, and put them down.
14:11: Charlie Rose: OK. But is this a charming conversation, or is this kind of matter of fact, this is the way it is, I`m the guy here, I know what I`m doing?
14:21: Patrick Walsh: It`s a very -- it`s a humble conversation.
14:22: Charlie Rose: It really is.
14:24: Patrick Walsh: It`s a humble conversation.
14:26: Charlie Rose: Yes.
14:28: Patrick Walsh: I see new patients on Friday. My wife will tell you on Friday night I`m exhausted when I come home, because I put my heart and soul into those conversations. And some of those conversations aren`t rosy. Some of those conversations say it`s touch and go.
14:37: Charlie Rose: Touch and go as to whether we can?
14:38: Patrick Walsh: Cure you.
14:39: Charlie Rose: Cure you.
14:41: Patrick Walsh: That`s right. So you tell people the truth. You speak to someone the way you would speak to yourself or your brother.
14:49: Charlie Rose: Let me push beyond prostate cancer to cancer in general. People feel like we have failed -- failed in terms of whatever metaphor you use, "a war on cancer," that somehow cancer remains a terrible killer, and that we should have been further along than we are. Do you buy that?
15:12: Patrick Walsh: No, I don`t buy that. First of all, we`ve been successful in reducing deaths from heart disease. And for that reason, people are living longer and they are more likely to get cancer. A man in the United States today has a 45 percent chance of getting cancer. He didn`t have that 25 years ago because he was dead from heart disease a long time ago. So we`ve had more success in heart disease than we have in cancer. But the Human Genome Project is opening up a vast new understanding of what causes this disease. I mean, if you want to say -- look to the future. You know, we`re going to have all these men. The baby boomers now are over 60. Prostate cancer is the most common cancer after age 60.
15:51: Charlie Rose: Oh, in other words, the most common newly discovered cancer, or the most common cancer?
15:55: Patrick Walsh: The most common newly discovered cancer over the age of 60 is prostate cancer.
16:02: Charlie Rose: Is that when most men find they have it? Does the majority of men figure out they have it, or diagnosed with it after they`re 60?
16:08: Patrick Walsh: The average age is 68 of diagnosis.
16:11: Charlie Rose: Wow.
16:13: Patrick Walsh: But the point is, is unless we find some way to do something about it -- I`m coming back to prostate cancer as the example. Over the next 40 years, there will be twice as many new cases, and maybe three times as many men dying from the disease. So, we have to really focus on, I think, trying to find a way to prevent these cancers. And to understand that, we need to understand their root cause. And that`s where the Human Genome Project I think is going to be so important in helping opening up those doors. That wasn`t available before. So, we cannot be called a failure for something -- a technique that wasn`t available before. And if you look to other areas of science, it was only when new avenues of basic science came in that we had new clinical approaches to curing those diseases.
16:56: Charlie Rose: We know that smoking contributes to cancer.
16:58: Patrick Walsh: Yes. And prostate cancer.
17:01: Charlie Rose: We know that -- OK. That`s what I`m asking. What contributes to prostate cancer?
17:06: Patrick Walsh: OK. It`s age. It`s family history. It`s race. African-Americans have the highest incidence. Asian men that live in Asia have the lowest incidence.
17:16: Charlie Rose: Does it have anything to do with diet, or does it have to do with some other ethnic concern?
17:21: Patrick Walsh: For Asians it`s very interesting. When a man in rural China who has a 2 percent risk of prostate cancer moves to the western culture and lives here for 25 years, his risk begins to approach but not equal Caucasian men.
17:32: Charlie Rose: Why?
17:35: Patrick Walsh: It has something to do with our environment. In China, when I speak to a Chinese man that lived there previously, I said, "How has your diet changed?" He said, "Dr. Walsh, when I lived in China we starved." So, number one, it was few calories.
17:47: Charlie Rose: Didn`t have enough to eat.
17:49: Patrick Walsh: No animal fat. Fat in red meat and dairy products. The availability of sunlight is very important. A good healthy weight and exercise.
17:57: Charlie Rose: What does sunlight have to do with it?
17:59: Patrick Walsh: Vitamin D. Vitamin D is protective. If you take --
18:03: Charlie Rose: Maybe we should spend time in sunlight.
18:05: Patrick Walsh: Fifteen minutes maybe every day.
18:08: Charlie Rose: OK.
18:10: Patrick Walsh: Ninety percent of the Vitamin D in our body is manufactured in our skin from cholesterol from the influence of ultraviolet light.
18:17: Charlie Rose: Ninety percent?
18:20: Patrick Walsh: Over the last 25 years, the highest deaths from prostate cancer in the United States have occurred north of 40 degrees latitude -- Philadelphia, Columbus, Ohio; Provo, Utah; where three months of the year there is not sufficient ultraviolet exposure to produce sufficient Vitamin D.
18:35: Charlie Rose: Some general questions about surgery.
18:37: Patrick Walsh: Yes?
18:39: Charlie Rose: What makes a great surgeon? I`m reading a biography of Harvey Cushing.
18:43: Patrick Walsh: Yes.
18:45: Charlie Rose: Tell me about what makes a great surgeon.
18:47: Patrick Walsh: It`s a wonderful biography. My own feeling, it`s someone who likes to fix things. When I talk --
18:52: Charlie Rose: Like a plumber?
18:53: Patrick Walsh: No, not like a plumber. It`s like someone who wants to solve a problem.
18:56: Charlie Rose: A mechanic?
18:58: Patrick Walsh: Like a mechanic. When I come home at night, if there`s something broken in the house, that`s my best day. And that`s what you are as a surgeon. You are constantly solving problems. You`re trying to figure it out. And that`s a real --
19:11: Charlie Rose: So, that`s the kind of mindset you need.
19:13: Patrick Walsh: That`s right.
19:15: Charlie Rose: Somebody who likes to fix things.
19:17: Patrick Walsh: That`s right.
19:19: Charlie Rose: What do you need in terms of -- tell me about eyesight, hand-eye coordination, all those kinds of things that we somehow want to imbue great surgeons with.
19:26: Patrick Walsh: You have to have the right stuff. And there`s --
19:30: Charlie Rose: What is the right stuff?
19:32: Patrick Walsh: Well, it`s -- when you see it you know it. We have an intern right now in our service. And I operated the other day and watched him, and he has the right stuff.
19:40: Charlie Rose: What did you see?
19:42: Patrick Walsh: Well, he has the right reflexes in the operating room. He is a natural. And so the finest surgeons are naturals.
19:51: Charlie Rose: You can see it?
19:53: Patrick Walsh: You can see it.
19:54: Charlie Rose: Of all the residents you`ve trained --
19:56: Patrick Walsh: That`s right.
19:57: Charlie Rose: -- at what point could you say this one will be a very good physician, a very good doctor, and a good surgeon? This one is going to be a great surgeon?
20:03: Patrick Walsh: When they are a medical student.
20:05: Charlie Rose: Can you really?
20:06: Patrick Walsh: You can see it. That`s right.
20:10: Charlie Rose: But it`s not the grades they make, it is something else?
20:13: Patrick Walsh: No, it is -- it`s like a sport. It`s like being an athlete. You know? I always wondered if they would have an Olympic event called radical prostatectomy.
20:20: Charlie Rose: So you referred earlier to yourself has having a gift. What was the gift you had other than this notion of wanting to fix things?
20:28: Patrick Walsh: I have the gift of the insight and intuition, and I have the manual dexterity to be able to carry it out.
20:31: Charlie Rose: Ever known a great surgeon that didn`t have maximum manual dexterity?
20:35: Patrick Walsh: Yes. But they had to work at it.
20:38: Charlie Rose: Yes.
20:39: Patrick Walsh: We`re talking about the people who are not naturals.
20:42: Charlie Rose: Right. Right.
20:45: Patrick Walsh: And there are people that are not naturals, but if you train them, they can be good.
20:49: Charlie Rose: All right. Is what you have learned about prostate cancer and all about the bundling of the nerves and the vessels, is it applicable to other aspects of the body? In other words -- I mean, I`m just stunned by the fact that it was in 1982 we were living under a false assumption about --
21:03: Patrick Walsh: About everything.
21:05: Charlie Rose: About everything.
21:07: Patrick Walsh: We didn`t know where the veins were --
21:09: Charlie Rose: Right.
21:11: Patrick Walsh: -- that bled, we didn`t know where the nerves were. And we didn`t know the mechanism that made people`s urinary control good. And we solved those problems.
21:21: Charlie Rose: So, in terms of incontinence and in terms of impotence, 95 percent of your patients are not affected?
21:25: Patrick Walsh: Today, if you take a man under the age of 60 who has normal sexual function --
21:30: Charlie Rose: Right.
21:32: Patrick Walsh: -- his chance of ever wearing a pad is 2 percent, and his chance of having recovery of sexual function is 95 percent.
21:37: Charlie Rose: Ninety-five percent, because you know where those nerves are?
21:40: Patrick Walsh: That`s right.
21:42: Charlie Rose: Thank you for coming.
21:44: Patrick Walsh: Thank you for the opportunity, Charlie.
21:46: Charlie Rose: It`s a pleasure to meet you.
21:47: Patrick Walsh: It`s wonderful to meet you.
21:48: Charlie Rose: Thank you. Dr. Patrick Walsh. He -- he`s the best. That`s what everybody says. And he has trained a lot of people who are very good as well. And there are people who have gone to school literally on what he does. "Dr. Patrick Walsh`s Guide to Surviving Prostate Cancer," there`s more here than simply surgery and surgical technique. There`s a lot here with an overview about prostate cancer, which is the leading cancer in men over a certain age or --
22:18: Patrick Walsh: It`s the number one cancer in men, and it`s the second most common cause of cancer death in men. One out of six chance of developing the disease.
22:24: Charlie Rose: Thank you again.

Prostate BPH, or benign prostatic hyperplasia, is a condition where the prostate gland becomes enlarged and causes urinary problems. Some studies have shown a possible connection between sex, or more specifically ejaculation, and prostate health. According to [Cleveland Clinic], frequent ejaculation may lower the risk of prostate cancer by clearing out potentially harmful carcinogens from the prostate. However, sex may not prevent or reverse prostate enlargement, which is a natural part of aging.

Squirting

Squirting refers to fluid expelled from the vagina during orgasm. Not all people with vaginas squirt during orgasm, and those who do may only do it some of the time. This type of orgasm includes a rapid ejection of urine, along with other fluids, from the bladder.

Squirting sometimes also involves secretions from the Skene's glands. Skene’s glands are two glands located on the lower end of the urethra in women. Women has two glands located on the lower end of the urethra. The Skene's glands are sometimes called the female prostate because they function similarly to the male prostate.

WebMD: What Is a Squirting Orgasm?