History The History of Urology in Cleveland, Ohio - Cleveland Clinic

History
The History of Urology in Cleveland, Ohio
Kamran P. Sajadi and Howard B. Goldman
INTRODUCTION Urology in Cleveland, as in the rest of the country, has evolved greatly over the past century.
The recent passing of Resnick and Novick warrants a review of Cleveland’s rich urological
history.
MATERIALS AND We reviewed historical and scientific literature and interviewed Cleveland urologists.
METHODS
RESULTS Lower joined his cousin Crile as professor at Case Western Reserve University (CWRU) before
they cofounded the Cleveland Clinic (CC) in 1921. Goldblatt at CWRU discovered renovascular
hypertension, leading Poutasse at CC to develop renovascular arteriography and bypass
surgery. Kolff brought his greatest invention, dialysis, to the United States when he joined CC.
Straffon put CC’s renal transplant program on the map through his success with deceased donor
transplants. Persky, renowned at radical prostatectomies, chaired urology at CWRU for nearly 30
years and trained 6 future university department chairpersons. Resnick succeeded him and
became one of the eminent figures in urology; an authority on numerous subjects, president of the
American Urological Association and American Board of Urology (ABU) and Editor of the
Journal of Urology. Novick, who became chairman at CC in 1985, was the consummate renal
surgeon; he was adept at renal revascularization and transplantation, but his greatest surgical
innovation was the partial nephrectomy. He likewise held many positions, including president of
the ABU.
CONCLUSIONS Cleveland has been a driving force in the evolution of urology in the last century. Resnick and
Novick led a golden age of urology for several decades until their recent untimely
passings. UROLOGY 76: 1293–1297, 2010. © 2010 Elsevier Inc.
Urology in Cleveland, as in the rest of the country,
has evolved greatly over the past century.
Toward the end of the 19th century, open surgeries
of the kidneys, bladder, and prostate were initially
the province of certain general surgeons. 1 With the development
of endoscopic techniques and the formation
of the American Urological Association (AUA) in 1902,
the specialty of urology grew exponentially over the next
100 years. In the last 3 years, however, the urological
community has lost 2 giants in Andrew Novick and
Martin Resnick, two Clevelanders whose contributions
to the field are incalculable. Their recent passing warrants
a review of Cleveland’s rich urological history.
MATERIAL AND METHODS
We reviewed historical references covering urology and those
covering medicine in the Cleveland area. Some were obtained
by literature search and others based on recommendations from
local urologists. Pertinent publications by urologists were reviewed.
We interviewed several prominent Cleveland urolo-
From the Glickman Urological and Kidney Institute, Cleveland Clinic Foundation,
Cleveland, Ohio
Reprint requests: Kamran Sajadi, Glickman Urological and Kidney Institute, Cleveland
Clinic Foundation, Q10–1 9500 Euclid Avenue, Cleveland, OH 44195. E-mail:
kpsajadi@gmail.com
gists, among them Dr. Sanford Luria, Dr. D. Karl Montague,
and Dr. Anthony Thomas, for their personal perspectives.
RESULTS
Frank Weed and George Crile, Sr. are credited with
performing the first nephrectomy in Cleveland in 1890 at
St. Alexis Hospital. 1 Crile went on to join the faculty at
Case Western Reserve University (CWRU) and was later
joined there by his cousin, William Lower. 1,2 Lower spent
a year in Berlin and Paris to learn urology, which he
brought back to Cleveland in 1910, as an associate professor
at CWRU and staff physician at Lutheran and
Mount Sinai hospitals. Lower—whom Will Mayo later
called “the leading American urologist of that day”—was
active in the AUA in its early years and would go on to
serve on its board. 2 After WWI, Lower, Crile, and their
partners Frank Bunts and John Phillips founded the
Cleveland Clinic (CC) in 1921. After a fire destroyed the
Clinic in 1929, killing 123 people, including Phillips,
Crile and Lower rebuilt, and Lower went on to become
the CC’s first urology chairman. Both CC and CWRU
established urology resident training programs in 1939,
and the first graduate of CC’s program, Charles Higgins,
went on to become its second department chairman.
Harry Goldblatt emigrated from Canada and, after
serving in the American armed forces, joined the faculty
© 2010 Elsevier Inc. 0090-4295/10/$36.00 1293
All Rights Reserved doi:10.1016/j.urology.2010.05.039

in the department of pathology at CWRU in the 1920s. 3
Goldblatt’s primary interest was the role of renin in
hypertension, which he explored through animal models.
4 In his dog experiments, he used a clamp he fashioned
on the renal arteries to produce hypertension. Our
modern understanding of renovascular hypertension
(RVH) is based on Goldblatt’s now-famous “two kidney,
one clip” and “one kidney, one clip” models in the 1930s
and early 1940s. 4,5 His later work purifying renin for
experimental activities led other scientists to elucidate
the remainder of the renin-angiotensin-aldosterone pathway.
3,5 One such scientist was Irvine Page, who in 1939
had wrapped a dog’s kidney in cellophane to produce
hypertension, producing a model of what is now called
“Page’s Kidney.” 6 He established a hypertension research
program at CC in 1945, where he extensively researched
and described the role of angiotensin. 7
There remained a significant gap between the groundbreaking
basic science work of Goldblatt and the successful
surgical management of patients with RVH. At CC,
Higgins hired renal surgeon Eugene Poutasse, a man
whom William Kiser of CC would later describe as “a
fearless guy ...Hewould just blindly stick a needle into
the aorta at the level of the kidney. Most people in those
days thought that this would kill a patient ...” 2 With his
translumbar aortography, Poutasse reported a large series
of renal arteriograms in 1957. 8 He performed the first
renal endarterectomies and became a pioneer in renovascular
bypass surgery. 2,8 At the time, Higgins had become
nationally known. He performed the first transureteroureterostomy
in a human, advocated for and performed
many ureterosigmoidostomies for children with exstrophy,
and, most famously, promoted the “acid-ash” diet for
patients with nephrolithiasis. 2 He would later go on to be
president of the AUA. 2
Dutch physician Willem Kolff initially became interested
in renal failure after watching a patient die of
uremia and worked for many years on developing an
“artificial kidney.” 9 He developed many hemodialysis machines
and ultimately performed the first successful dialysis
in 1943, in German-occupied Holland. After the
war, he performed dialysis on a woman in a uremic coma
who awakened and lived. 9 He came to the United States
in 1950 and became the director of the CC Department
of Artificial Organs. 2 With the development of the Quinton-Scribner
Teflon Silastic shunt, chronic dialysis became
a reality, and Dr. Kolff’s work is credited with
helping countless patients.
The 1950s saw the first human kidney transplants, but
renal transplantation boomed in the late 1950s and early
1960s after the introduction of azathiaprine and other
immunosuppressive agents. 10 Ralph Straffon (Fig. 1) became
chairman of urology at CC in 1963 and initiated
the first renal transplantation program in Cleveland, initially
with living donors. He recruited 3 more urologists
to join his transplant team, each of whom would later
make their names in different ways. Bruce Stewart was a
Figure 1. Ralph A. Straffon.
technically gifted surgeon who would later specialize in
male infertility and remain at the clinic until his untimely
death from prostate cancer at age 53. 2 Clarence
Hewitt was an expert on testis tumors who at the time
had the largest series of retroperitoneal lymphadenectomies
in the country (Sanford Luria, oral communication,
September 2009). William Kiser would later become the
CEO of CC. 2
Transplant surgeons at the time were disappointed with
the results of deceased donor renal transplants (DDRT).
Straffon, however, was frustrated by the lack of living donors
and sought to resuscitate the role of DDRTs in transplantation.
Straffon’s team published the largest successful
series of DDRTs at the time. 2 Dr. Kolff, one of the key
nephrologists of the team, performed dialysis on the recipients
until their grafts became functional. 9 Today, CC remains
a high-volume renal transplant center, having performed
nearly 4000 renal transplants.
George Austen, Jr. trained under J. Hartwell Harrison
at Brigham Hospital in Boston. 1 He stayed on as faculty
urologist at Harvard until he came to CWRU in 1952. 11
For the 7 years he stayed at CWRU, he developed the
first successful series of radical prostatectomies in Cleveland,
performing them through a perineal approach. 1
Lester Persky (Fig. 2) was also renowned for his radical
perineal prostatectomy skills and became chairman at
CWRU when Austen returned to Boston. 1,11 A Cleveland
native, Persky gained brief fame as a football star at
the University of Michigan until a hip injury cut his
athletic career short (D. Karl Montague, oral communication,
September 2009). 12 He received his medical degree
from Johns Hopkins and his surgical and urology
training in Boston before joining the faculty of CWRU in
1951. 12
1294 UROLOGY 76 (6), 2010

Table 1. Sample of awards bestowed on selected cleveland urologists
Urologist Awards
Charles C. Higgins AUA, Ramon Guiteras Award, American Association of Genito-Urinary Surgeons
(AAGUS) Keyes Medal
Ralph A. Straffon AUA Hugh Hampton Young Award, AUA Gold Cane Award, AUA Certificate of
Achievement Award
William Kiser AUA Presidential Citation
Lester Perksy AUA Distinguished Service Award, AUA Gold Cane Award, AUA Certificate of
Achievement Award
Martin I. Resnick AUA Gold Cystoscope Award, AUA Distinguished Contribution Award, AAGUS Spence
Award, American Foundation for Urologic Diseases Russell Scott Education Award
Andrew C. Novick AAGUS Barringer Medal, AUA, Roman Guiteras Award, Honorary Fellowship in the Royal
College of Surgeons of Ireland and in the Canadian Urological Association, and the
St. Paul’s Medal from the British Association of Urological Surgeons
Figure 2. Lester Persky (Courtesy James M. Persky).
Persky served as Chair of Urology at CWRU for nearly
30 years. During his tenure, he was notoriously hardworking
and a nationally well-regarded speaker, educator,
writer, and surgeon (D. Karl Montague and Sanford Luria,
oral communication, September 2009). 12 He was
known for having a hand in every aspect of the field, and
was one of the most published urologists of his time, with
more than 200 scientific papers to his name (D. Karl
Montague, oral communication, September 2009). 12 He
maintained a busy practice, and throughout most of the
1960s was the only urologist in Cleveland performing
radical prostatectomies, because Straffon at CC was not a
believer in the operation (Sanford Luria, oral communication,
September 2009). One of his many legacies was
the quantity and quality of residents he trained during his
tenure. Persky was a hard worker and expected the same
of his residents (D. Karl Montague, oral communication,
September 2009). He was known to tell trainees on his
service, “The good news is that call is every other night.
Figure 3. Andrew C. Novick.
The bad news is you’re going to miss half the learning
opportunities.” Many of his former students and residents
have gone on to chair urology departments, including
Robert Flanigan at Loyola, Jean DeKernion at UCLA,
Mark Soloway at the University of Miami, Steven Selman
at the University of Toledo, W. Scott McDougal at
Massachusetts General Hospital, and Patrick Walsh at
Johns Hopkins University.
In the early 1970s, Straffon, Stewart, Hewitt, and Kiser
were the only urologists at the CC, but over the next few
decades the department would expand exponentially (D. Karl
Montague and Anthony Thomas, oral communication, September
2009). 2 Straffon recruited two of his resident graduates
to join the faculty: D. Karl Montague in 1973 and
Andrew C. Novick (Fig. 3) in 1977 (D. Karl Montague,
oral communication, September 2009). At the time,
there was little to no subspecialization in urology, and all
the urology faculty were adept in all areas of the field, but
each began to develop his own niche (D. Karl Montague,
oral communication, September 2009). 2 Stewart began
UROLOGY 76 (6), 2010 1295

focusing on male infertility and his accomplishments
continue to be recognized by the American Fertility
Society, which has maintained a Bruce H. Stewart Lectureship
since 1972. 2 Lynn Banowski joined the CC in
1972 to direct renal transplantation (D. Karl Montague,
oral communication, September 2009). D. Karl Montague,
who also trained in prosthetics with Brantley Scott
in Houston, remains on the faculty as one of the world’s
experts in urological prosthetics.
Andrew C. Novick emigrated from Montreal in 1972
and joined the faculty upon completion of his residency
at CC in 1977. 13 Novick was widely regarded as one of
the world’s most accomplished renal surgeons (D. Karl
Montague, oral communication, September 2009). 2,13
He began his career in renal transplantation and renovascular
surgery, continuing the CC’s strong tradition in
these fields, which continued well into an era where
these operations are largely the domain of vascular and
general surgeons (D. Karl Montague, oral communication,
September 2009). 2 In the 1980s, he developed a
keen interest in nephron-sparing surgery for renal cell
carcinoma, and reported excellent results for both in vivo
and extracorporeal or “bench” partial nephrectomies. 14
His experience with partial nephrectomies in solitary
kidneys later demonstrated a relationship between the
amount of renal mass lost and development of proteinuria
and glomerulopathy, validating Barry Brenner’s hyperfiltration
theory. 15 Straffon became the chair of the Division of
Surgery at CC in 1983, and urological oncologist James
E. Montie chaired the Department of Urology until Novick
was named chairman in 1985. 2 Novick at the time
was chair of a department with 7 staff urologists. His
23-year tenure saw the department grow into the Glickman
Urological and Kidney Institute, currently home to
43 staff urologists. 13 A product of the residency program
himself, he oversaw the program as it developed from a
regional to a nationally renowned academic powerhouse,
recognized as one of the top two programs in the country.
16 By recruiting basic science researchers, he elevated
the role of laboratory research in the department and
incorporated a research year into the residency program.
Novick himself authored more than 500 peer-reviewed
research articles and 104 book chapters, and served on
the American Board of Urology (Table 1). 13 His “proudest
professional achievement,” however, was his development
of and success with Glickman Urological and Kidney
Institute. 13 Unfortunately, shortly after the Institute
moved to its present location in the Glickman Tower,
Novick died of complications of lymphoma. 13 His passing
on October 18, 2008 was a shocking and distressing
surprise to many, because he had maintained his vigorous
work ethic and clinical stamina until the end (Anthony
Thomas, oral communication, September 2009). 15
In 1981, CWRU recruited Martin I. Resnick (Fig. 4)as
chairman to succeed Persky, a position he would hold
until his passing 26 years later. His areas of expertise were
broad. He wrote extensively of the role of ultrasonogra-
Figure 4. Martin I. Resnick.
phy in urology and was politically active in maintaining
the role of the urologist in the performance of these
procedures. 17 He had an interest in nephrolithiasis that
began as a medical student at Bowman Gray School of
Medicine and he later published on the biochemical
profiles of stone-formers and the role of macromolecules
in renal stone formation. 17,18 In the past 30 years, the
management of stones has moved from large, open surgeries
to endoscopic, extracorporeal, and percutaneous
approaches, and Resnick recognized the importance of
defining renal and renovascular anatomy in obtaining
access for the latter. 17 In the management of prostate
cancer, Resnick was well-regarded as an expert in the
perineal approach to radical prostatectomy (D. Karl
Montague and Anthony Thomas, oral communication,
September 2009) . 14,15
Resnick maintained an impressive presence on the
national urology scene. He served as secretary and then
as president of the AUA, president of the ABU, and
editor of the Journal of Urology. 17 He had an enthusiasm
for urological education early on and he established a
resident exchange program between CC and CWRU,
and later, nationally, he developed the AUA’s “Young
Leadership Program.” 11,17 In early 2006, he was diagnosed
with acute myeloid leukemia, but despite his illness
and treatment regimen, he remained active in practice
and with his editorial duties at the Journal. 19 Sadly, Dr.
Resnick passed away on June 24, 2007.
CONCLUSION
Cleveland urology has been not only a microcosm of
American urology, but one of the major driving forces for
1296 UROLOGY 76 (6), 2010

the evolution of the field in the 20th and early 21st
centuries. The growth, specialization, and subspecialization
of the field have been echoed in Cleveland, especially
at CC and CWRU. Moreover, many contributions
to and milestones in the understanding and management
of genitourinary disease occurred in Cleveland. Renovascular
hypertension, hemodialysis, renal transplantation,
nephron-sparing surgery, and surgical management of
prostate cancer were either introduced or excelled at by
physicians in Cleveland. In particular, Resnick and Novick
led a golden age of urology for nearly 30 years, and
urology—both locally and nationally—is better for having
had them.
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