2008 Whitmore Lecture: Radical prostatectomy-where we were and where we are going

We have the following major challenges for the future: (1) Imaging: accurate techniques to estimate the extent and location of tumor within the prostate; (2) cohort studies: for comparison of cancer control and quality of life with competing forms of treatment; (3) adjuvant trials: to improve cancer control in men who are not cured by surgery alone. What would Willet Whitmore say today?: Although I never trained with Dr. Whitmore, I had the privilege of having him as a friend. There are few individuals in the field of urology whose advice I trusted more. To give you insight into what I think Dr. Whitmore would say today, I would like to share with you some letters that he wrote to me over the 10 years prior to his death. These letters will tell you what kind of man he really was-his intellect, honesty, and humility. On November 17, 1983, a little more than a year after I developed nerve-sparing radical prostatectomy, I received this letter, "Hopefully one day in the not too distant future, I will be able to break away from this cancer center long enough to come down to 'The Hopkins' and, with your permission, look over your shoulder while you do one of your classic dissections for the preservation of sexual potency during a radical retropubic prostatectomy! From those who have watched you do it, from reports of those who are doing it, and from your own elegant publications on the subject, you appear to have made one of the few real 'breakthroughs' that I can remember.". Not long thereafter, in June 1984, we found ourselves together at the Karolinska Institute in Stockholm, where I performed two radical prostatectomies for the Swedish urologists. In the first one, Dr. Whitmore assisted me, and in the second, he moderated the session. Shortly thereafter, we produced a monograph in which Dr. Whitmore made the following comment, "I enjoyed the privilege of assisting Dr. Walsh in the performance of such a nerve sparing radical prostatectomy in Stockholm in 1984 and was impressed by the controlled anatomical exposure and technical precision possible with the procedure. I also realized that in doing literally hundreds of radical cystectomies over many years, I had seen the neurovascular bundles countless times, but had not recognized them!" Unfortunately, the publishers of this monograph removed the last sentence because they were afraid that Dr. Whitmore might be subject to medical legal action. His next letter was written on November 6, 1986, where he describes performing a radical prostatectomy, "After a lapse of 17+ years, I finally accomplished a radical prostatectomy August 7, 1986! I did a Walsh 'nerve sparing' radical retropubic operation with bilateral pelvic lymph node dissection. The excisional part of the operation was uneventful but the urethro-vesical anastomosis gave me a hard time. Under the influence of sedatives, the patient removed his catheter on the evening of the first operative day but he had the good sense to deflate the balloon before doing so, and a catheter was reinserted without difficulty and left in place for a total of 3 weeks. On removal of the catheter, his urinary control was apparently normal. On follow-up examination on October 29th his urinary control was perfect, his urinary stream like a "fire hose", and his sexual function normal! I may close my 'series' while my results are better than yours! Finally, I should add that the operation spared the patient's nerves, but not mine!". He wrote the final letter on December 2, 1992. Here he spoke about Dr. Hugh Jewett, the famous professor of urology at Hopkins who was the torch bearer for radical prostatectomy after Hugh Young. He and Dr. Jewett frequently were called upon to debate the relative value of surgery. Dr. Jewett died from metastatic prostate cancer in 1990 and sadly Dr. Whitmore succumbed to the same fate 5 years later. In his letter from December 1992, he added the following P.S., "You will be interested in this anecdote. When I last visited the Brady three or four (?) years ago, Don Coffey took me to see Dr. Jewett, who was in the nursing home. Almost as white as the sheets between which he lay, Dr. Jewett said "Whit, we haven't done a damned thing for this disease." My reply was (and I remember it so well), "Dr. Jewett, you were responsible for keeping radical prostatectomy alive long enough for Pat Walsh to develop an operation acceptable to patients, referring physician, and surgeon." That is certainly true and I'm confident that molecular biology will one day (no predictions!) provide the sorely needed precision in case selection.". I believe that these letters give great insight to what Willet Whitmore would say today. Thank you for the honor of giving this lecture.