Two hands in one glove The “discovery” of the cavernous nerves Prof. Rob Pelger Department of Urology, Leiden University Medical Center Leiden (NL)
r.c.m.pelger@lumc.nl In the past, the anatomy of the pelvis has been described in several anatomical atlases in detail, but before the 1980s this “old” anatomical knowledge had not contributed to the (radical) surgical approach of the prostate. This procedure was unpopular because of the abundant, sometimes life-threatening, blood loss from the plexus of Santorini (the dorsal vein complex of the prostate). Radical prostatectomy was therefore performed with little enthusiasm. This hurdle, as I will explain later, was only overcome after modifications of this procedure by, among others, Patrick C. Walsh, professor at the James Buchanan Brady Institute of Urology at Johns Hopkins in Baltimore (US). The next hurdle was another problem of the procedure, the injury to the neurovascular bundles. Intact bundle(s) are a prerequisite for normal erections (nervi erigenti). This is what Pieter Donker, emeritus professor of urology at the University of Leiden (NL) at that time, should be credited for. Who was this Pieter Donker. Donker was born on March 2, 1914 in Schellinkhout, a small village in the province of North-Holland (NL). After completing secondary school in Hoorn, he studied medicine at the Municipal University of Amsterdam and began his surgical and internal training in 1938 at the Maria Foundation in Haarlem, interrupted by the mobilization of WWII in 1939. In 1942, Donker continued the training in the “Johannes de Deo” in Haarlem. He then went to the St. Franciscus Gasthuis in Rotterdam to complete his training (under the supervision of the surgeon P.A. de Vos). In 1945, Donker left for Indonesia (a Dutch colony at that time) as a volunteer doctor. He was initially stationed in Jakarta as head of the surgical department. Then in 1946, he was stationed in Surabaya in the Marine Hospital as head of the surgical department. In 1948, he returned to the Netherlands but was unable to practice his profession for a year due to an illness. Since the profession as a general surgeon was probably too arduous, fortunately, Donker decided to specialise in urology. In 1949, Donker started training at J.A. Weijtlandt in Amsterdam. In 1951, he obtained his doctorate with Prof. Dr. I. Boerema in Amsterdam on the thesis “The treatment of perforating abdominal injuries”. In the same year, he established himself as a urologist at the St. Franciscus Gasthuis (1951-1965) and Eudokia Hospital (1951-1962) in Rotterdam and became a member of the Dutch Urological Association (DUA), which had 19 members at the time. In the 1950’s he became a trainer in urology. On April 1, 1962, Donker started as an extraordinary lecturer in Leiden. Three years later, he became an extraordinary professor of urology. In 1968, he was appointed full professor of urology. Donker retired in 1979 and presented his farewell lecture “Cost control in clinical medicine” on September 21 of the same year. This was not the end of his interest in urology and anatomy. Since then, Donker devoted himself to the dissection of the small pelvis in the laboratory for Embryology and Anatomy in Leiden. At this stage, Walsh, whom Donker was already in contact with, visited Donker and used his findings to develop the nerve-sparing radical prostatectomy.
Drawing of dissection of left pelvic plexus in male newborn
How something small can result in big consequences is clear from the landmark article in the Journal of Urology of 2007, in which Walsh described how he came to his ground-breaking technique of nervesparing prostatectomy.
Image of transverse section through male foetus in the Walsh-Donker publication (1982)
For his services to the Dutch urology, the DUA has honoured Donker posthumously by instituting the Pieter Donker lecture which is held annually under the auspices of the Scientific Committee, on topics related to the experimental or clinical urology.
Due to space constraints, the entire reference list can be made available to interested readers upon request by sending an email to: communications@uroweb.org.
Drawing of dissection of caudal and ventral part of left pelvic plexus in male newborn
Professor Pieter Donker (1914-1999)
In 1977, Walsh had already adapted his technique (the binding of the dorsal vein complex of the prostate) in such a way that it became possible to perform a radical prostatectomy without too much blood loss. That same year, Walsh entered the American Association of Genitourinary Surgeons for the first time. The night before a convention, Walsh went to a restaurant with his wife and “Standing in the shadows behind the maître d’, I spotted an older man. Impetuously I asked if he was also attending the meeting and whether he would like to join us for dinner.” The older man was Donker. This meeting was the beginning of a friendship. A few years later in February 1981, Walsh attended a Boerhaave symposium in Leiden by invitation. The symposium was quite intensive for Walsh due to lectures and demonstrations in the OR. Nonetheless, he still wanted to see a bit of Leiden. Professor Udo Jonas, professor of urology in Leiden at the time, asked Donker, if he would show Walsh around but it never came to that; Walsh wanted to know what Donker was doing in his spare time instead.
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Donker worked in the anatomical laboratory trying to map the innervation of the bladder in male foetuses. Upon learning this, Walsh was eager to see Donker’s work and asked him if he also prepared the innervation of the corpora cavernosa. Up until then, Donker had not looked for it. Three hours later, both saw that these nerve pathways (contrary to what had been claimed) which laid outside the capsule and fascia of the prostate, an essential find for future nerve-sparing procedures! Armed with this knowledge, Walsh returned to the United States and laid the foundation for his well-known nerve-sparing technique of radical retropubic prostatectomy. In his articles, Walsh has always credited Donker for his contributions. The drawings used for the original publication in the Journal of Urology in 1982 were considered lost. In 2010, thanks to Donker’s son, these beautiful pencil drawings of the male pelvis were discovered behind a cupboard when Donker’s widow moved out of their house! What is less known is that Donker also mapped the innervation of the pelvic floor and internal genital organs of women. The surgical anatomy of the innervation of the female pelvis was not well known in the 1980s. At that time, the then unknown drawings of the female pelvis were a great find and fortunately, these were fully appreciated when these were discovered during the cleaning of the old anatomical laboratory. These exquisite drawings were printed in 2008 in the anniversary book of the DUA when the association celebrated its 100th anniversary.
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Drawing of male foetus 11 cm. crown-rump length, composition of microscopic sections
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Drawing of male foetus 20 cm. crown-rump length, composition of microscopic sections
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