Tuesday, June 10, 2014

Historical Contribution: 1922, Young, Cure of Incontinence with Epispadias


Surgery for epispadias.  An operation for the cure of incontinence associated with epispadias. Young H.H.    J Urol 1922; 7:1. 

In the early 20th century, external procedures could be done to correct the cosmetic appearance but were powerless to cure incontinence.  Dr. Young reviews the existing literature and surgical attempts to provide continence in these patients.  He describes techniques of tubularization, attempts to increase urethral sphincter resistance, and other techniques - none of which achieve adequate social continence for more than a couple of hours.

Then Young describes a case of rectourethral fistula where he was able to restore continence to the patient.  By opening the perineum and reconstitution of the internal and external urethral sphincters, Young restored continence to the patient. From these observations, Young postulated that restoring the internal and external sphincters from an anterior approach could restore continence in young boys and men with epispadias.*

Dr. Young then describes two cases where he was able to restore continence to young men with epispadias. His description of the surgical technique is meticulously detailed.  In addition to creating the surgical technique, Young created surgical instruments to help place the difficult sutures needed for this surgery (as he did for many innovative surgeries).  See the "Boomerang Needle Holder" in the figures below.

In summation, Dr. Young concludes that: 1) continence can be restored during the repair of epispadias, 2) that incontinence is associated with a dilation of the proximal urethra, specifically involving the external sphincter and 3) restoring the external sphincter and "normal" anatomy of the proximal urethra can restore continence perfectly.

Finally, one of the finest aspects of this manuscript are the wonderful medical drawing by William P. Didusch including the abnormal anatomy of the epispadias deformity and methods of penile reconstruction.
Epispadias defect before repair.

Cosmetic appearance after Young's epispadias repair.

*This is reminiscent of the classic story Dr. Patrick C. Walsh tells about discovering the cavernous nerves of the penis.  In a fortuitous event, Dr. Walsh performed a radical prostatectomy and a patient was potent afterwards.  The nerves that innervate the penis, Dr. Walsh postulated, must therefore run outside the prostate and can be spared during radical surgery.  The rest, they say, is history.

To read the entire manuscript follow the link above or click here.

HISTORICAL CONTRIBUTIONS highlight the greatest academic manuscripts from the Brady Urological Institute over the past 100 years.  As the Brady Urological Institute approaches its centennial, we will present a HISTORICAL CONTRIBUTION from each of the past 100 years.  In the most recent experience, the most highly cited article from each year is selected; older manuscripts were selected based on their perceived impact on the field.  We hope you enjoy! 

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