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In medical school, I did stereotaxic neurosurgery, inserting penicillin crystals in the lateral geniculate body of cats to induce secondary epileptogenic foci. I was a huge fan of the TV show "Ben Casey" and its brilliant, angry eponymous neurosurgeon. At least I had the anger part down pat. When medical school was over, the Vietnam war was still raging.
I went into the Air Force and became a rated Flight Surgeon, training at the School of Aerospace Medicine as well as flight school. I was one of the lucky few who got assigned to a tactical reconnaissance squadron and I flew the F-4 Phantom (RF-4C) for 3 years (Figure 1). Instead of guns, we had cameras. I flew between 50 and 500 feet at 500 knots and took pictures. Appropriate to my profession, I never killed anyone. I jokingly tell patients now that the hand-eye coordination involved in doing microsurgery is very similar to the hand-eye coordination involved in flying high-performance aircraft. The biggest difference is: back then it was my butt on the line, and now it's their balls.
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During urology residency in the late 70s, clinical andrology was still in its relative infancy. The surgical aspects of it were quite crude by today's standards. Operating microscopes were unknown to the field. One day, I saw an article by Italian microsurgeons who had microsurgically transplanted a testicle from one man to his identical twin, who had lost both testicles. The recipient of the transplant fathered a child with his brother's testicle. The transplant required anastomosis of the tiny testicular artery, testicular vein, and vas deferens. Simultaneously, Dr Sherman Silber reported an identical case in the United States. Around the same time, Dr Earl Owen, in Australia, and Silber, his former fellow, reported successful reanastomosis of the vas deferens for vasectomy reversal. My Chairman, Dr Keith Waterhouse, sent me to Saint Louis to learn from Silber, the only urologic microsurgeon in the world at that time.
Silber's enthusiasm and innovative thinking were infectious. I came back from that visit intent on making a career in urologic microsurgery. The only microscope in the hospital was in neurosurgery, and I practiced microsurgery in the closet where the microscope was kept, using pieces of fresh human placenta to practice vascular anastomoses. This resulted in my first publication (Goldstein, 1979). There were no fellowships in andrology or microsurgery at that time. After residency, I decided that I would learn microsurgery by transplanting testicles from one rat to another (Figure 2). I figured there had to be some way to use this model for research. I met Larry Ewing at a meeting of the American Society of Andrology and he invited me to come to Johns Hopkins and do the research in his lab. I asked Larry if there was anybody in New York to whom I could speak to about doing research in this area. He sent me to see Wayne Bardin at the Population Council's Center for Biomedical Research at The Rockefeller University.
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When I got to Wayne's lab, I didn't even know one end of a pipette from the other. I ordered a Zeiss Opmi I operating microscope. I ordered jeweler's forceps at $5 apiece from Dumont & Sons, who made instruments for watch repair (the same forceps ordered from a surgery catalogue cost over $200). I polished the tips to the right shape with a metal Revlon nail file. I used an iris scissors for cutting. The only microinstrument I had to buy was the microneedleholder. Thus, with two jeweler's forceps, an iris scissors, and a microneedleholder, I set off to learn science and microsurgery. I packed crystalline testosterone into silastic tubing and sealed the ends with wooden applicator sticks and crazy glue.
There were no textbooks on urologic microsurgery at that time. I consulted Rand's Microneurosurgery. I stayed up late every night studying plastic surgery textbooks on free flap transfer. For the first 6 months in the lab, I couldn't get a single transplant to work. I lost a lot of animals due to anesthesia. The surgery took so long and the animals were so precious that, if they stopped breathing, I did everything I could to resuscitate them. I used a 12-inch length of rubber tubing. I put one end over the rat's nose and I would blow into the other end. I was using this technique for many months until one day, Dr Kalyan Sundaram, in whose lab I was working, saw me resuscitating a rat. He picked up the rubber tube and asked, "Which end is yours and which end is the rat's?" I said, "I don't know." From then on, I labeled one end "rat" and the other end "Marc."
After months of fumbling and failure, one day I took a microvascular clamp off the aorta after completing the anastomoses in the recipient. I saw a line of blood race through the serpiginous arteries on the surface of the testis. Then I saw the end of the vas bleed. Eureka! I then had several more failures and then another few transplants worked. Finally, I was able to get the transplants to work 2 out of 3 times. Each transplant took over 6 hours (Goldstein et al, 1983).
Those 2 years in the lab were among the most exciting of my life. For the first year, I was doing the surgery entirely alone and devised numerous gadgets to allow me to do such microsurgery by myself. I had a little pump with a foot peddle that allowed me to squirt water onto the anastomosis to clear it of blood. I designed a little frame to put the microsutures around. Originally, my intent in going to the lab was to acquire microsurgical skills and then apply them clinically, but I became entranced with the science.
I joined the faculty of Cornell when I completed my fellowship, but kept my lab at the Population Council, which I maintain to this day. I applied the microsurgical techniques that I learned on rats to clinical andrology, first to vasectomy reversals, then to the much more difficult vaso-epididymostomies, and finally, to varicocele, which previously had been done nonmicrosurgically.
I was lucky to have fabulous role models and mentors for the rare academic triple threat of clinician/scientist/teacher throughout my career, including Wayne Bardin, Stuart Howards, Arnold Belker, Anthony Thomas, Richard Sherins, and Darracott Vaughan. Our Society is a rare, unique entity that brings together basic scientists and clinicians in an exciting environment of intellectual exchange which promotes cross-fertilization of ideas.
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Today I run a fellowship designed to train young urologists to be surgeons/scientists/teachers. Although the pressure to bring in clinical income has made this an ever more difficult goal, the ability to collaborate with basic scientists and get young people as excited about our field as I am is still my greatest joy. I jokingly tell my residents that our field is a fertile one for investigation. On the clinical side, every time I get a phone call, "We're pregnant," I feel like it's one of my children. Although I have only 1 son, when people ask me how many children I have, I tell them 1500.
We are blessed to have chosen a field that is exciting and challenging. Most important, however, it is a field filled with some of the friendliest, funniest, and most talented people in all of science and medicine.
References
Goldstein M. Use of fresh human placenta for microsurgical training. J Microsurg. 1979; 1: 70 -71.[Medline]
Goldstein M, Phillips DM, Sundaram K, Young GPH, Gunsalus GL, Thau R, Bardin CW. Microsurgical transplantation of testes in isogenic rats: method and function. Biol Reprod. 1983; 28: 971 -982.[CrossRef][Medline]
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