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Objectives Surgical techniques to repair a ureteral stricture may depend on the stricture’s etiology, length, and location. Options may range from primary ureteral reimplantation for short, distal strictures, buccal mucosa onlay ureteroplasty for complex proximal or mid ureteral defects, to Boari flap or even autotransplantation for longer mid to distal ureteral defects. Replacement of the entire ureter with a segment of ileum is rare but may provide durable results when indicated. Our objective was to illustrate how the history and evolution of the ileal ureter entered the contemporary surgical armamentarium. Methods A comprehensive literature review was performed in conjunction with library resources in the History of Medicine section at the University of Rochester. We used PubMed to identify contemporary medical literature, ILLiad to access archived texts and historic surgical and urological textbooks to obtain additional historical information and references. Results We documented perhaps the first description of the ileal ureter in a canine model by Guido Tizzoni and Alfonso Foggi in 1888. Adaptations of ileal ureters over the next century, and beyond, have increased the safety, feasibility, and reproducibility of thre procedure for replacement of the ureter rendered unsalvageable by strictural disease, trauma, or malignancy. Conclusions Tizzoni and Foggi described the first ileal ureter in the canine model in 1888.

Objectives Infectious diseases have tormented humans for thousands of years, and severe outbreaks have led to the devastation of entire communities. Even before globalization, parasites and pathogens traveled along trade routes with their human hosts. The protective clothing worn by physicians during epidemics serves as a powerful historical record chronicling accepted theories of disease transmission and treatments. The materials and designs of modern-day protective equipment reflect the contributions of surgeons to the ways doctors protected themselves and their patients during epidemics. Methods Historical texts and journal articles were reviewed regarding the history, epidemiology, and pathophysiology of epidemics of plague, influenza, and coronavirus. Results The Justinian Plague of the 540s CE was the first pandemic to be fully documented and began the long history of plagues through the Black Death of the Middle Ages. Believing that the etiology was foul-smelling bad air (miasma), doctors protected themselves by wearing dramatic head-to-toe coverings. Heavy boots, pants, long coats, gloves, and brimmed hats were made of leather sealed with animal fat. Most important was the infamous face mask with glass eye coverings and a long beak filled with aromatics intended to purify disease-causing vapors. An appreciation of droplet theory in the 19th century made beaked masks obsolete, replacing them with cloth face masks. Surgeons continued to pioneer the development of gloves and gowns, initially to protect themselves and later to protect their patients. Their outfits were worn by healthcare workers during the epidemics of the 20th century. Similar to the plague doctors, present-day physicians treating patients suffering from COVID-19 don themselves in head-to-toe protective outwear, although heavy leather and beaked-masks have long since been replaced by disposable fabrics and the N95 respirator. Conclusions The evolution of physicians’ protective clothing from the iconic beaked mask of the 17th century plague doctor to the hazmat-esque suits of the COVID-19 pandemic doctor reflects the substantial advancements in the detection, treatment, and containment of communicable diseases. Much of this is due to the dedicated efforts of surgeons to better safeguard their patients as well as protect themselves against diseases contained in bodily fluids.

Background Necrotizing soft tissue infections (NSTI) are characterized by fulminant tissue destruction and high mortality rates. Primary treatment is surgical debridement and antibiotics; hyperbaric oxygen therapy (HBOT) may be considered as adjuvant therapy. HBOT for NSTI remains controversial given the lack of quality evidence. HBOT is frequently used for NSTI at our institution; however, the early COVID-19 pandemic forced a significant decrease in its utilization. This practice change created an unusually high proportion of NSTI patients who did not receive HBOT at our institution and thus provided an opportunity to compare outcomes amongst NSTI patients who received HBOT against those who did not. Methods We performed a retrospective cohort study of patients aged 18 years and older admitted with the diagnosis of NSTI between January 2018 and December 2020, a period that included the first 6 months of the pandemic (Figure 1). We collected data on patient demographics, comorbidities, infection location, pathogen, severity of illness (APACHE II score), whether HBOT was provided and number of dives. Outcomes included 90-day mortality, amputations, inpatient antibiotic days, ventilator days, and hospital length of stay. Figure 1Proportion of NSTI patients admitted to R Adams Cowley Shock Trauma Center who received HBOT between January 2018 through December 2020. Proportions were averaged over six month blocks. Results 253 patients were included of whom 143 (56%) received HBOT and 110 (43.3%) did not. Baseline characteristics were similar between the groups except for Wound Surface Area (WSA) and APACHE II score (Table 1). Length of stay was significantly longer in HBOT patients (15.3 days vs 11.7 days p=0.005, Table 2). Fewer HBOT patients had amputations (7.5% vs 21% p=0.007) and fewer died within 90 days of admission (6.3% vs 14.5% p=0.029). When stratifying patients by APACHE II score, HBOT patients with APACHE II scores > 18 had significantly lower mortality than non-HBOT patients (9.7% vs 32.4% p=0.035). Conclusion In this population of NSTI patients who underwent surgical debridement, HBOT was associated with lower incidence of amputation, and lower mortality. Patients with APACHE II scores >18 who received HBOT had lower mortality than those who did not. A prospective study should further evaluate the impact of HBOT on mortality and amputations. Disclosures All Authors: No reported disclosures.

Philipp Bozzini, a German army surgeon, in 1807 invented the Lichtleiter, the predecessor of the modern cystoscope. By the mid-1800s, several new instruments were created including one, a variation on Bozzini's instrument by Antoine Desormeaux in Paris. The William P. Didusch Museum of Urologic History acquired the Wales endoscope, a rare and unique cystoscope that was invented around the same time in the United States.We researched the life of Philip Wales and the description of his cystoscope as well as Horatio Kern, the instrument maker that produced Wales' instrument. We examined the Wales cystoscope acquired by the William P. Didusch Museum.Philip Skinner Wales (1837-1906) was a surgeon who entered the United States Navy in 1856 and served throughout the Civil War. He organized and held charge of the Naval Hospital at New Orleans during the operations of Admiral Farragut's fleet in the Mississippi River. He was one of the first surgeons to attend President Garfield when he was shot. He was Surgeon General of the Navy (1879-1884) and founded the Museum of Naval Hygiene in Washington D.C. which later, combined with the naval laboratory and Department of Instruction, became the prototype of the Naval Medical School. In 1868 he published a series of papers in the Philadelphia Medical and Surgical Reporter on "Instrumental Diagnosis," with a paper entitled "Description of a New Endoscope." The instrument contained a metal shaft with an acute beak and used an ophthalmologic mirror to reflect light down the channel. The surgeon peered through the center hole to look into the bladder. Wales used his instrument multiple times in his private practice. Wales writes that the advantages of his cystoscope were that it was simple to produce and cheap compared to Desormeaux's endoscope. Furthermore it was light, weighing approximately 2 pounds. The main drawbacks of Wales' cystoscope were the inadequate illumination, as the light source was external and projected from the outside through a narrow channel into the bladder, and that without an optical system the image appeared relatively small. Horatio Kern, a well-known instrument maker in Philadelphia, that also supplied surgical sets and instruments for the U.S. Army during the Civil War, produced Wales' cystoscope. While he was Chief of the Bureau of Medicine, a subordinate embezzled Navy funds and Dr, Wales was court-martialed. Though he was eventually exonerated, he lived the rest of his life in disgrace in France.The Wales endoscope is unique in that it had an American inventor, was simple in design and cheap to produce. It is an important historical artifact and is one of the earliest and rarest cystoscopes developed.

Introduction: The 2020 American Urological Association (AUA) Retrospectroscope Award winning presentation investigated the history of war trophies. Included was Life magazine’s May 22, 1944 “Picture of the Week” showing a young American woman gazing at a skull sent by her boyfriend serving in the Pacific theater of WWII. The caption claimed the skull was from a Japanese soldier “picked up on a New Guinea beach.” The displaying of human remains so casually in a magazine brings up the ethical considerations behind how we use human remains in medicine, art, museums, and collections. Identification and interpretation of bony characteristics and injuries from skeletonized human remains can help demystify medical history, reconstruct battles, and bring identity back to the faceless. We investigated what forensic and paleopathology techniques can tell us about battlefield human remains including the Life skull. Sources and Methods: We reviewed the literature for information about the Life skull and characterization of physical traits and traumatic injuries that can be assessed from skeletal remains. Results: Taking ‘trophies’ from human remains has occurred throughout human history. Anatomical trophy taking by US troops in the Pacific during WWII was fueled by rampant jingoism and anti-Asian racism of the time. Battlefield methods to remove soft tissue from bone included boiling, skinning, scrubbing, lye, and ants. Similar techniques are used by modern medical examiners. The tropical Pacific climate and lack of burial would have hastened natural decomposition of a fallen soldier. The bony pelvis and the skull are the two most useful parts of the skeleton for assessment of human remains. The pelvis is the most reliable bone in the human body for determining sex, followed by the skull. The pelvis and skull also aid in the determination of age at death. Estimation of likely ancestry primarily relies on the skull but is a challenging and increasingly controversial practice. Skeletal remains may show evidence of trauma to the pelvis and skull, providing clues as to cause of death. Pelvic injuries are associated with high rates of mortality from hemorrhage and disruption of the genitourinary system, and evidence of genital mutilation may be present. Forensic methods suggest the Life skull is consistent with male sex. Ancestry, age at death and age of the remains are unable to be determined from the photo. Publication of the Life skull led to public disapproval and an Army memorandum condemning the practice of taking enemy remains. Conclusions: The pelvis and the skull provide useful, objective evidence when studying victims of past wars. Accurate determination of age at death, sex, and likely ancestry may be established from skeletal remains. Forensic methods and paleopathology can help restore the humanity lost by the faceless victims of war.

Introduction: Approximately 16.5% of the U.S. population is estimated to have overactive bladder (OAB), significantly impacting their daily life. Sacral nerve stimulation (SNS) has been a successful method of treating urge incontinence, urgency, frequency, and non-obstructive retention since its development. This article reviews the development of SNS from its inception to the procedure we know it as today. Sources and Methods: We conducted a literature review using the PubMed database, Google Scholar, and JSTOR regarding the history of SNS and the discoveries leading to its development. Results: As our ability to incorporate electricity into medical practice improved in the mid-1900s, the pressing question in urology was whether it could be used in treatment of the neurogenic bladder. Initial efforts focused on direct detrusor stimulation and pelvic nerve stimulation, with limited efficacy. In the 1970s, Drs. Emil Tanagho and Richard Schmidt found that stimulation of sacral nerves in dog models resulted in a detrusor contraction response, resulting in the voiding of urine. They focused on improving these techniques and published a paper in 1989 on the first use of SNS on human subjects, paving the way for our modern-day procedure. Eventually, Medtronic developed the InterStim system, which received FDA approval in 1997 for the treatment of urge incontinence. The basic SNS technique has since remained largely the same. In 2019, the Axonics Sacral Neuromodulation System was also approved for treatment of OAB symptoms as an alternative to the InterStim system. Given the efficacy of SNS in the treatment of OAB, further iterations of SNS devices were recently developed, such as devices with rechargeable batteries and prolonged battery life. Conclusions: Since Tanagho and Schmidt first described its use, SNS has been and continues to be a successful method for treating OAB. Going forward, SNS will remain a viable option for the treatment of urge incontinence and retention.

INTRODUCTION AND OBJECTIVES:Homo sapiens have suffered from stone disease since ancient times with the earliest evidence dating to the Stone Age (Mesolithic period). The history of urolithiasis has...

Introduction: The struggle to treat male stress urinary incontinence (SUI) dates back centuries, with descriptions of male urinary incontinence (UI) in Egyptian manuscripts as early as 1500 BCE. In this review, we chronicle the history of male SUI interventions that have educated the modern options available today. Sources and Methods: A comprehensive literature review was performed to elucidate relevant historical and clinical information. We used PubMed to identify contemporary medical literature at www.ncbi.nlm.nih.gov and JSTOR, the digital library, to access archived, older texts at www.jstor.org. Results: French surgeon Ambroise Paré is credited with developing the first portable urinals in 1564, which was quickly followed by Hildanus developing the condom catheter and penile clamp in the 1600s. The first documented compression device was developed by Lorenz Heister in 1747. Two hundred years later, Frederic Foley created a urinary sphincter and in 1973, F. Brantley Scott created the first multi-component artificial urinary sphincter (AUS). In the 1960s and 1970s, mesh implants were fraught with complications, including urethral erosion, fistulas, and pain. More recently, the transobturator male sling, which came to market during the 2000s, has become an option for select men. Conclusions: The modern devices we use for the treatment of male UI are evolutionary byproducts of centuries of experimental designs by pioneering surgeons from around the world. While the materials have improved, barrier, storage devices and bulking agents almost identical to the versions first invented remain in use today.

INTRODUCTION AND OBJECTIVE:The 2020 AUA Retrospectroscope Award winning presentation investigated the history of war trophies. Included was Life magazine’s May 22, 1944 “Picture of the Week” showin...

INTRODUCTION AND OBJECTIVE:To present the history of venereal disease during America's wars and the way its rampant spread shaped US armed forces and military medicine.METHODS:In-depth review of pu...

We investigated the history of Resusci Anne, the well-known cardiopulmonary resuscitation (CPR) simulation trainer. The creation of Resusci Anne began with Peter J. Safar, an accomplished anesthesiologist who experimented with resuscitation of respiration and cardiac function. He collaborated with Asmund S. Laerdal, whose early experimentation with soft plastics allowed him to create a human simulator that could be used to teach the skills of resuscitation to both medical care practitioners and individuals of all walks of life. A special face was chosen for the simulation mannequin, one based on a mysterious death mask of a beautiful woman from the late 19th century. The success of Resusci Anne led to the widespread acceptance of CPR and simulation use in medical training.

Introduction Veno-venous extracorporeal membrane oxygenation (VV ECMO) has become a support modality for patients with acute respiratory failure refractory to standard therapies. VV ECMO has been increasingly used during the current COVID-19 pandemic for patients with refractory respiratory failure. The object of this study was to evaluate the outcomes of VV ECMO in patients with COVID-19 compared to patients with non-COVID-19 viral infections. Methods We retrospectively reviewed all patients supported with VV ECMO between 8/2014 and 8/2020 whose etiology of illness was a viral pulmonary infection. The primary outcome of this study was to evaluate in-hospital mortality. The secondary outcomes included length of ECMO course, ventilator duration, hospital length of stay, incidence of adverse events through ECMO course. Results Eighty-nine patients were included (35 COVID-19 vs 54 non-COVID-19). Forty (74%) of the non-COVID-19 patients had influenza virus. Prior to cannulation, COVID-19 patients had longer ventilator duration (3 vs 1 day, p = .003), higher PaCO2 (64 vs 53 mmHg, p = .012), and white blood cell count (14 vs 9 ×103/μL, p = .004). Overall in-hospital mortality was 33.7% ( n = 30). COVID-19 patients had a higher mortality (49% vs. 24%, p = .017) when compared to non-COVID-19 patients. COVID-19 survivors had longer median time on ECMO than non-COVID-19 survivors (24.4 vs 16.5 days p = .03) but had a similar hospital length of stay (HLOS) (41 vs 48 Extracorporeal Membrane Oxygenationdays p = .33). Conclusion COVID-19 patients supported with VV ECMO have a higher mortality than non-COVID-19 patients. While COVID-19 survivors had significantly longer VV ECMO runs than non-COVID-19 survivors, HLOS was similar. This data add to a growing body of literature supporting the use of ECMO for potentially reversible causes of respiratory failure.

The purpose of this study was to evaluate survival to hospital discharge for patients on venovenous extracorporeal membrane oxygenation (VV ECMO) when stratified by age. We performed a retrospective study at single, academic, tertiary care center intensive care unit for VV ECMO. All patients, older than 17 years of age, on VV ECMO admitted to a specialized intensive care unit for the management of VV ECMO between August 2014 and May 2018 were included in the study. Trauma and bridge-to-lung transplant patients were excluded for this analysis. Demographics, pre-ECMO and ECMO data were collected. Primary outcome was survival to hospital discharge when stratified by age. Secondary outcomes included time on VV ECMO and hospital length of stay (HLOS). One hundred eighty-two patients were included. Median P/F ratio at time of cannulation was 69 [56-85], and respiratory ECMO survival prediction (RESP) score was 3 [1-5]. Median time on ECMO was 319 [180-567] hours. Overall survival to hospital discharge was 75.8%. Lowess and cubic spline curves demonstrated an inflection point associated with increased mortality at age >45 years. Kaplan-Meier analysis demonstrated significantly greater survival in patients

The development of renal stones in space would not only impact the health of an astronaut but could critically affect the success of the mission.We reviewed the medical literature, texts and multimedia sources regarding the careers of Dr. Abraham Cockett and Dr. Peggy Whitson and their contributions to the study of urolithiasis in space, as well as the studies in between both of their careers that helped to further characterize the risks of stone formation in space.Dr. Abraham T. K. Cockett (1928-2011) was Professor and Chair of the Department of Urology at the University of Rochester and served as AUA President (1994-1995). In 1962, Dr. Cockett was one of the first to raise a concern regarding astronauts potentially forming renal stones in space and suggested multiple prophylactic measures to prevent stone formation. Many of the early studies in this field used immobilized patients as a surrogate to a micro-gravity environment to mimic the bone demineralization that could occur in space in order to measure changes in urinary parameters. Dr. Peggy A. Whitson (1960-), is a biochemistry researcher and former NASA astronaut. She carried out multiple studies examining renal stone risk during short term space shuttle flights and later during long-duration Shuttle-Mir missions.From the early vision of Dr. Cockett to the astronaut studies of Dr. Whitson, we have a better understanding of the risks of urolithiasis in space, resulting in preventive measures for urolithiasis in future long duration space exploration.

Limited literature regarding the incidence of cannula-associated deep vein thrombosis (CaDVT) after veno-venous extracorporeal membrane oxygenation (VV ECMO) exists. The purpose of this study was to identify the incidence of post decannulation CaDVT and identify any associated risk factors. Forty-eight patients were admitted between August 2014 and January 2016 to the Lung Rescue Unit were included in the study. Protocolized anticoagulation levels (partial thromboplastin time [PTT] 45-55 seconds) and routine post decannulation DVT screening were in place during the study period. Forty-one (85.4%) patients had CaDVT. Of those with CaDVT, 31 (76%) patients were treated with full anti-coagulation therapy. Thirty-four (76%) patients with right internal jugular (RIJ) cannulation had CaDVT at cannula site. Twenty-five (61%) patients had CaDVT in the lower extremity (18 associated right femoral vein cannulation and 7 left femoral vein cannulation). Eighteen (44%) patients had both upper and lower extremity CaDVT. Overall, patients with CaDVT tended to be older, have a higher body mass index (BMI), and on ECMO longer (p = NS). Mean PTT during time on ECMO between patients that did and did not have CaDVT did not differ. No clinical evidence of pulmonary embolism (PE) was seen.

INTRODUCTION AND OBJECTIVES:Marin Marais was the favorite viol player of the Sun King, Louis XIV at Versailles, and an early composer of music depicting a scene (program music). His 1725 Portrait o...

INTRODUCTION AND OBJECTIVE:Walt Whitman (1819-1892) was a visionary American poet who inspired innovation within the literary landscape, choosing to preserve real, complex life with poetic imagery....

INTRODUCTION AND OBJECTIVE:In 1807, Philipp Bozzini, a German army surgeon, invented the Lichtleiter, the predecessor of the modern cystoscope. By the mid-1800s, several new instruments were create...

INTRODUCTION AND OBJECTIVE:An explosive is a device designed to inflict injury through generating either significant thermal injury, projectile debris and/or shockwave force following detonation. T...

The use of veno-venous extracorporeal membrane oxygenation (VV ECMO) has increased over the past decade. The purpose of this study was to evaluate outcomes in adult trauma patients requiring VV ECMO. Data were collected on adult trauma patients admitted between January 1, 2015, and November 1, 2016. Demographics, injury-specific data, ECMO data, and survival to discharge were recorded. Medians [interquartile range (IQR)] were reported. A p value ≤0.05 was considered statistically significant. Eighteen patients required VV ECMO during the study period. Median age was 28.5 years (IQR 24–43). Median injury severity score (ISS) was 27 (IQR 21–41); median PaO2/FiO2 (P/F) prior to ECMO cannulation was 61 (IQR 50–70). Median time from injury to cannulation was 3 (IQR 0–6) days. Median duration of ECMO was 266 (IQR 177–379) hours. Survival to discharge was 78%. Survivors had a significantly higher ISS (p = 0.03), longer intensive care unit length of stay (ICU LOS) (p

Antibiotic management of Fournier's gangrene (FG) is without evidence-based guidelines and is based on expert opinion. The effect of duration of antibiotic therapy on outcomes in FG is unknown.A retrospective review was performed of FG patients from 2012 to 2015 at a single institution. Patients were managed by our institutional practice of complete primary wound closure as possible, with antibiotic duration according to physician judgment. Patients were stratified into multiple durations of antibiotic administration.Overall, 168 patients with FG were included. When examining multiple stratifications of antibiotic therapy of 7 days or less, 8 days to 10 days, 11 days to 14 days, or 15 days or more of antibiotics, there was no significant difference in mortality (p = 0.11), primary closure (p = 0.75), surgical site infection (SSI) (p = 0.52), or Clostridium difficile infection (p = 0.63). There were no cases of recurrent FG in any antibiotic stratification. Mortality was not increased (p = 1.00) and ability to achieve primary closure was not decreased (p = 0.08) with initial antibiotic therapy exclusive of cultured organisms.Shorter antibiotic courses for patients in whom source control is obtained and initial antibiotic selection exclusive of many resistant organisms were not associated with worse outcomes in FG.Therapeutic, level IV.

“Sir, you have a stone in the bladder,” said Thompson with a great deal of certainty. “That is impossible” retorted the patient, “I have been assured by a very rising surgeon that there is nothing of the kind present.” Thompson looked at the patient and said simply, “Sir, I have risen.” Henry Thompson (Fig. 1), born in 1820 in Framlingham, Suffolk, was the son of a strict preacher. Despite his father’s objections, Henry pursued a career in medicine. He graduated from University College Hospital in 1850 and became a house surgeon.