History Session - 2010 Meeting, Antalya, Turkey

Article Index

Abstracts which were presented during ESPU History session of the Pediatric Urology Meeting on 28th April 2010.

17.40 - 17.45 OPENING REMARKS C.Büyükünal

17.45 - 18.05 Turkish Medicine in History
                         N. Sarı (Dept History of Medicine and Medical Ethics, Cerrahpasa Medical Faculty,Istanhbul University)

18.05 - 18.20 Development of Pediatric Urology in Anatolia
                        C. Buyukunal

18.20 - 18.25 The Older History of Nonmedical Circumsicion
                        Mikko Reunanen Mehilainen Turku, Pediatrics, Turku, Finland

18.15 - 18.20 Discussion

18.20 - 18.35 The history of injection therapy of vesicoureteric reflux
                        G. Läckgren

18.35 - 18.50 Voiding Dysfunction Classification; According to the Rhazes’s (854-914, Iran) first textbook of Urology
                         A.M. Kajbafzadeh, S.M. Tabatabaei

18.50 - 19.00 Discussion   

1. Turkish Medicine in History

Nil Sarı
Cerrahpasa Medical Faculty,Dept. MedicalHhistory and Ethics,
Istanbul University

Turkish tribes and states of Eurasia had relations with a cultural area extending from northern China in the east to the north of the Black Sea in the west throughout their history, hence Turkish people carried medical knowledge and practice from one civilization to another over a large geographical area. Turks also carried their traditions with them during their journey from the Central Asia to Anatolia. Seljukians were heirs of the Central Asian Turkish culture.  Stylized animal motifs and figural reliefs of Seljukian  hospitals’ gates reflect the pre-Islamic cult of Central Asia. However, several pre-Islamic features continued to be shaped in the context of Islamic culture during the Ottoman period.  On the other side, from the 11th century on, Galenic and Hippocratic medicine of the Western world came to be a basic part of Turkish medicine through integration with the Islamic medical world of which Turkish medical professionals were a main population. A second period of Westernisation started during the 18th century and accelerated in the 19th century. The transition of medical knowledge this time was attained directly from European medical professionals. During late 19th and early 20th centuries, Turkish physicians educated on contemporary medicine contributed to the field. However, it is possible to find traces of archaic practices amongst traditional circles in rural areas, that attract tourists. Festivities during the scattering of the trational drug mesir and visits to mausoleums praying for spiritual treatment are examples of it. But, as Turkish people today search for the latest medical treatment methods, traditional practices have now come to be either entertainments reminiscent of the past rituals or a means of hope for the incurable.

 2. Development of Pediatric Urology in Anatolia

S.N. Cenk Buyukunal 
Cerrrahpasa Medical Faculty,Section of  Pediatric Urology,Department of  Pediatric Surgery,
Istanbul University

AIM: The aim of this presentation is  to give a brief information to the audiance ,about the development of  pediatric urology  in this historical area  called:Anatolia

MATERIAL AND METHOD: Various materials on medical history such as translation of Sumerian Clay tablets,an old surgical textbook from 15th century: Cerrahiye-i Ilhaniye,Annals of  Sisli  Children’s Hospital (Hamidiye-i Etfal),informed concent texts for pediatric operations from  15th and 16 th century, documents and materials related with 19 th and 20th century are investigated

RESULT AND DISCUSSION: Translation of  a clay  tablet from Sumerian period(a scientific work of  Prof Mrs Canan Agartan) mentions  us the first pediatric urological abnormalities such as :urinary incontinance and sexual development disorders.
Galen was the first phsician in this part of the world who mentioned the name  “hypospadias” and gave description of the abnormality.Sabuncuoglu Serafeddin (mid 15th Century from North Anatolia) was the first  surgeon  who has given the detailed operative pictures of  pediatric urological and surgical  procedures  : hypospadias, circumcision, intersex,inguinal  hernia,fused labia minora.This manuscript written by Sabuncuoglu(3 volumes,1460,Amasya)can be accepted as the  first pediatric surgical and urological atlas with its informative  and descriptive  pictures.
The children rights was very important in Ottoman Empire and  since 15th century,before every pediatric operation, an informed concents has been prepared and  signed by the  judge,surgeon and parents as well. During the presentation some examples from informed concents, related with bladder stone extraction operations will be shown.In these concents ,the type  and risk of operation,surgeon’s skills,parent’s rights and surgeon’s fee were all mentioned in detail.
First Children’s Hospital  called  Hamidiye-i Etfal in Istanbul founded in late 1890s and this was one of the most modern  and well equipped children hospitals of Europe.Many pediatric urological operations mainly urinary stone exstractions ,hydroceles and hernias has been  performed with successful results.
In this study  the names and efforts of leading persons as well as the names of  some  unknown heros will be mentioned. Turkish Pediatric Urologists are grateful for leading surgeons,  from both sides, pediatric surgery   and  adult urology background , for the foundation and development of this  specific  branch .

3. The Older History of Nonmedical Circumsicion

Mikko Reunanen, MD
Hospital of Mehilainen, Turku, Finland

About 10.000-6.000 BCE aboriginal tribes in deserts of Australia and tribes in north-eastern Africa  practised circumcision as puberty rite.

Some believe also that in mummies you can sometimes see circumcised men. It may also be that they have had only dorsal incision on medical reasons. In Egyptian relief (for example from sixth dynasty) you can see the circumcision or shaving of the pubic hair. In later dynasties the Pharaoh Ahomse and Pharaoh Amenhotep I were not circumcised.

The first description of circumcision is in The Holy Bible (about 600 BCE), in Genesis 17:10-12 or 1st part of Tora: God said to Abram (Abraham): ”For your part you must keep my covenant… every male among you must be circumcised at his 8th day…you shall cut off the flesh of your foreskin, and that will be the symbol of the covenant between us”. According to this the Jewish people circumcise their sons at the age of eight day.

In the Greek literature and sculptures the men are not circumcised, the long foreskins are admired, the circumcised men being slaves, Egyptians and Semites as well as Jews (Herodotus, 485-420 BCE). The apostle Paul argued that ”in Christ Jesus neither physical circumcision nor uncircumcision count for anything” ( Gal 5:6). So in the apostolic council at Jerusalem, 49 CE, it was not seen necessary to circumcise the Christians. thereafter even the Jews decided that circumcision has value if you observe the law (of Moses).

Circumcision is an old Arab tradition (dated before CE), and in The Holy Coran (Qur´an) it is not mentioned at all. In old traditions (of Abraham) it is under the Tahara (=hygiene) in Hadith (sayings of Muhammad), with cutting of the nails and shaving of the beard.

Ecumenical Council of Florence, 1438-1445: A person making a circumcision has risk for loosing eternal salvation.


4. The history of injection therapy of vesicoureteric reflux

Göran Läckgren MD PhD,
Professor of Pedaitric Urology, University Children´s Hospital , Uppsala Sweden

The first  work on the endoscopic injection therapy  of  vesicoureteral reflux (VUR) was published by  Matouscheck in 1981  :  “Die Behandlung des vesikorenalen Refluxes durch transurtehrale  Entspritzung von Teflon Paste” (Urologe A)  .  However, even earlier this idea was brought up by Victor Politano  (J Urol, 1974) , who introduced teflon injection for the treatment on urinary incontinence, when he mentionned that subureteral injection of teflon may be used to cure VUR. 
The pioneer, experimental and clinical work  by  Barry O´Donnell and Prem Puri on teflon injection was published in 1984  and made this treatment popular among pediatric urologists/surgeons over the world.  Since then the endoscopic correction of VUR  has proved to be a successful, minimally invasive treatment. 
In the 1990-ties increased concern was raised against the use of Teflon based on a risk for small particle migration to other organs.  Polydimethylsiloxane (Macroplastique) , that contained larger particles seemed to be a good alternative, but  distant particle migration have been seen even after silicone injection.  There are also other non-biological materials as Calcium hydroxyapatite in use today.    
Because of the potential risk for migration and life-long persistence of these substances more biological materials came into use .  Bovine  Collagen was used for long time , but with less successrate and a higher recurrence rate and is now more or less abandonned.  Chondrocytes was injected , but the complex procedure of this method prevented it from routine use.
The search for new “biological” material continued during the 90-ties and in 1994 the first presentation of a new material ,Dextranomers in Hyaluronic Acid (Deflux®) was made in “Dialogues of Ped Urology “ .  Particularily after the approval by FDA in 2001,  Deflux®  has been the substance of choice for the endoscopic treatment.  The technical improvement  of the treatment  over the last decade (Kirsch et al.) have increased the successrate and many publications have demonstrated this  in most grades and types  of VUR . The endoscopic treatment may therefore often be a first- choice treatment to avoid long-term antibiotic prophylaxis and is, thus, an established treatment of most children with  urinary tract infection and VUR.


5. Voiding Dysfunction Classification; According to the Rhazes's (854-914, Iran) first textbook of urology

A.M. Kajbafzadeh MD 1, S.M. Tabatabaei 2 MD
1Professor of Pediatric Urology, 2Professor of Psychology,  Pediatric Research Center, Pediatric Center  of Excellence, Tehran University of Medical Sciences, Tehran, Iran

Abu Bakr Muhammad ibn Zakariya al-Razi, known in Latin as Rhazes was born near Tehran, Iran (854AD). Rhazes eventually became the caliph’s personal physician and director of the largest hospital in Baghdad. He is credited with writing 273 manuscripts, most of which are now lost. The clarity of his writings did much to bring Greek medicine, especially Hippocrates and Galen, to the Persian and Arabic world. He wrote more than 24 textbooks in different aspects of medicine, surgery and pharmacology called Al-Hawi.We could find three volumes textbook of urology from these series. His classification on voiding dysfunction was basically the same as the recent classification. He classified voiding dysfunction as follow: Dribbling, defined as constant dribbled micturation.  The etiology was divided in 7 main groups: A. Failure of storage. B. Infection of the kidney or bladder and some diseases of genitourinary tracts presenting with hematuria. C: Pelvic floor, uterine or perineal infection and inflammation. D: Sphincter failure E: Bladder tumor. F: Urinary chemical changes. G: Overstretch of the detrusor muscles due to voluntary holding of micturation. Urgency:  due to bladder or urethral inflammation/ ulcer. Difficulty on urination due to: A: Advance hemorrhoid. B: Anal inflammation or infection. Urinary retention: A- Muscular failure. B: Neurogenic voiding dysfunction due to spinal cord injuries. He noticed that the bladder is constructed from different circular muscles fibers. Nerves dividing from the spinal cord innervate these fibers.
Rhazes’s was a pioneer in the use of bladder catheter and provided many details about the urethral catheterization in the first textbook of genitourinary diseases (1).

1.    Ira M. Rutkow: Islamic and Jewish surgery, In; Surgery an Illustration History Mosby – Year Book, Inc. PP 53-57, 1993