Videotapes Offer Clues to Variations in Prostate Surgery

aseball pitchers use videotape to perfect their fastball; tennis players use it to get a better spin on their serve. The video camera is a staple for athletes; in fact, no respectable football coach would contemplate next week’s game without spending hours going over this week’s effort on the gridiron play by play.

So why don’t surgeons do the same thing, wondered urologist-in-chief Patrick C. Walsh, M.D.? “How are we ever going to improve our technique if we don’t analyze our own work this way?”

Over the years, Walsh says, he has come to believe that “very small differences in surgical technique can have a major impact on outcome.” In a groundbreaking study, he put his theory to the test, watching his own operations. Using a high-quality, three-chip video camera, Walsh videotaped the operations on 64 men who’d undergone a radical prostatectomy at Hopkins. All of the men had agreed to participate in a health-related quality of life survey after surgery that would evaluate their sexual function and continence.

Eighteen months after the study began, Walsh reviewed the tapes. His goal was to make a good operation even better, by minimizing the operation’s two major side effects—incontinence and impotence: “When a patient is continent and potent immediately after surgery, what made the difference in this man?” Walsh spent his summer vacation examining these videotapes, sometimes stopping them frame by frame looking for insight. It took hours of intense scrutiny to watch a single two- hour operation, but the hard work paid off. He was able to identify four slight variations in his technique—in controlling bleeding from the dorsal vein and dividing the sphincter—that appeared to make the difference in the men who recovered sexual potency the soonest.

But most exciting was that Walsh found that some men had a significant anatomical variation. “Previously, everyone believed that the neurovascular bundle took a rather straight pathway from its origin in the sacrum along the lateral surface of the prostate to the urethra,” explains Walsh. “But I learned that in many patients, the bundle curves around the apex of the prostate, and is tucked just beneath the sphincter and held there by a small group of vessels. And that, if one attempts in good faith to preserve as much of the sphincter as possible, the neurovascular bundle can be damaged, and recovery of sexual function delayed.” Indeed, the eight men who at 18 months had not yet recovered full sexual function all seemed to have this variant curve.

Part two of Walsh’s self-imposed exercise was to make the study “blind.” He went back over the operations yet again—this time without identifying the patient or the outcome—to see if the steps he had identified checked out. They did.

Incontinence is a long-term significant problem for only about 2 percent of his patients, and Walsh was unable to find evidence that anything he did or did not do during surgery would make a difference there. “Clearly, it had nothing to do with preservation of the sphincter,” he says. “There was one man with perfect preservation of the sphincter who was still wearing a pad one year after the surgery.” For this reason, Walsh is working to refine the procedure for reconstructing the bladder neck during radical prostatectomy.

Walsh believes many surgeons could benefit from regularly reviewing their operations in this way: “Because many surgeons use different techniques, it’s likely that each surgeon may be able to identify other important, arbitrary variations that may help patients.” Also, for surgeons whose patients seem prone to more side effects than usual, “the review of early successful cases may help them identify ways to modify their technique, and improve the outcome of future patients.”

—- Janet Farrar Worthington