Page 35 - NEWSLETTER_27

ΣΥΝΈΝΤΈΥΞΗ
Nielsen ME, Schaeffer, et al J. Urol. 2008;180:2557-2564
Figure 7
Tεύχος 27 | Iανουάριος - Φεβρουάριος 2024
order to clip the vessels. One of the major principles of nerve-sparing is avoiding tension. Another one is avoiding cautery. I never used cautery. You should only use clips. These nerves are very delicate. By pushing the neurovascular bundles away, you put traction on them. By releasing the levator fascia up higher, and then carrying out that separation, when you pull the prostate back, there is no traction on the nerves. Figure 7 When I did that, in patients who were fully potent preoperatively, one year postoperatively, 93% of them were potent versus 77% previously.
sensation when releasing the neurovascular bundle. If there was any sense that it was adherent to the prostate, I knew exactly where I could partially excise it more widely. Then intraoperatively, when the prostate was out, I could examine the specimen to see if more tissue had to be removed. So, I believe there are still some advantages in the open operation, but it would be impossible to return to the old days. Every attempt is being made today to make the robotic cases better.
T.S.: In your opinion which are the characteristics that a Director should have so as to lead his Department in excellence, like you did with the Brady Institute?
P.W.: When I came to the Brady, I felt that my major job was not to train general urologists in the community. My job was to train leaders in the field. A couple of years ago I was speaking to one of my former residents, Mark Gonzalgo, who is Professor and Vice Chair in the University of Miami and I asked “Why did you come to Hopkins for your training?”. He said: “You don’t remember? I was an MD-PhD student at USC (University of Southern California) with the great Donald Skinner and there was a show on The Learning Channel (TLC) called “The Operation”. The week I watched it, you were featured and radical prostatectomy was the topic where they actually showed the operation and then you discussed it. Do you remember what you said? If you have been given the privilege to sail in uncharted waters, you have the responsibility to make those charts”. “Doctor Walsh, I came to Hopkins because I wanted to make those charts!”. So, that was the idea. If you came to work with us, your job was to make discoveries. The thrill of discovering something no one else knew before you made that discovery, is so enticing and empowering that it changes your life. For that reason, 87 % of the people I trained went into Academic Medicine and 23% are Chairs. I believe the secret to our success was emphasizing the opportunity and need to make discoveries.
T.S.: Do you believe that young urologists should still be trained in open surgery?
P.W.: Ideally, but it is becoming increasingly difficult to accomplish this. I had three years of surgery before I went into urology: two years of adult surgery and a year of pediatric surgery at Boston Children’s Hospital.
F.N.: What were your thoughts when minimally- invasive surgery (laparoscopic and robotic- assisted surgery) started trending in urology?
P.W.: When this first became popular, I saw a lot of patients coming back to me who had been operated elsewhere who were totally continent and potent, but at three months their PSA was 2.0. Their whole prostate had not been removed. So, initially there was a reckless technique for preserving quality of life without concern for cancer control. I think this has been significantly improved! At least at Hopkins, our surgeons have good results with good surgical margins. Yes, there is less blood loss. However, if you look at the randomized trials of radical prostatectomy, open versus robotic, there is no difference in transfusion rate, but there is a difference in measured blood loss. There is no question that the better your hemostasis is, the better you can see. It’s easier to teach for that reason. You can be more patient. I admit, it took me a long time to develop the technique for the control of bleeding. But today, when I travel and show my videos, people say: “That looked like a robotic case!”. So, I was very good at maintaining hemostasis and I had the added advantage of tactile
35