Build And They Will Come

Donald Skinner took a fledgling urology program and built it into a world-respected department filled with experts who pioneer ways to maintain the dignity and independence of their patients.

by Alicia Di Rado

In 1980, America was obsessed with who shot J.R. on the television show “Dallas,” the Rubik’s Cube was about to become everyone’s favorite toy-turned-torture-device, and the United States hockey team beat Russia for the gold in the Winter Olympics.

And USC/Norris Comprehensive Cancer Center’s hospital and research institute were still a mass of steel beams, barrels of concrete and rolls of blueprints.

Enter Donald Skinner.

Seven years after USC/Norris became one of the nation’s first comprehensive cancer centers—with its hospital and institute under construction—Skinner arrived at USC to spearhead a growing urology program. The program’s federal research dollars: nil. Its faculty: one (Skinner himself). Its surgical facilities: at a hospital off campus.

Today, Skinner, M.D., is the Hanson-White Professor in Medical Research, chair of the Catherine and Joseph Aresty Department of Urology at the Keck School of Medicine and chief of surgery at USC/Norris Comprehensive Cancer Center and Hospital. The department boasts 16 specialist physicians who see patients from throughout the world, as well as six laboratory researchers investigating the science behind urology’s medical challenges. Its faculty members hold 10 National Institutes of Health grants worth $2.3 million in direct research funding. And its genitourinary surgeons are the busiest at USC/Norris Hospital, logging more than 850 major operations each year.

Beyond the numbers, Skinner and his colleagues have achieved something perhaps even more impressive. They have not only helped thousands recover from life-threatening diseases such as cancer, they have pioneered ways to maintain the dignity and independence of those patients.

Not bad for 25 years of hard work.

Leading experts

Skinner first considered jumping to USC from UCLA in 1976, but it was not until 1980 that he moved to USC and became chief of the division of urologic surgery. With USC/Norris’ building set to open in 1983, the time was right, he thought.

Perhaps most importantly, the lack of an existing urology department at USC offered the freedom to create one from scratch.

“I had the opportunity for autonomy, control of my own resources and good facilities,” remembers Skinner. “What was attractive here was that we had all the parts for a great organization, and none of the players yet.”

So he hired surgeons such as Stuart Boyd, M.D., and Gary Lieskovsky, M.D., both of whom had trained under Skinner at UCLA, and established the USC Department of Urology in 1990. Boyd specializes in cancer surgery and reconstruction, with unique expertise in erectile dysfunction, urinary incontinence and urologic prostheses. Lieskovsky, the Donald G. Skinner Chair in Urology, offers a highly sought-after surgery that spares the vulnerable nerves of prostate cancer patients.

Boyd and Lieskovsky are examples of Skinner’s strategy: hire experts who each have a unique skill and a proven track record under his own tutelage.

In the years since, Skinner has filled the department with carefully selected physicians and researchers. Only two faculty physicians have left.

The department has become what Skinner had envisioned: a place for the toughest cases, a place for patients with advanced kidney cancer that requires complex surgery, or perhaps troubling incontinence that does not respond to standard therapy.

Community physicians without the specialized experience to handle these tough cases frequently refer their patients to Skinner and his colleagues. Urologists from other states and countries send cancer patients to USC for surgery.

Says Skinner: “We treat the most difficult problems and develop solutions for them.”

Pushing advances

According to the National Cancer Institute, bladder cancer is the fourth most-common cancer in men and the eighth most-common cancer in women in the United States. When they are first diagnosed with bladder cancer, about 20 to 30 percent of patients already have cancer that has invaded the muscle tissue—an indication for cystectomy, or removal of the bladder.

The bladder is a temporary holding tank for urine that has traveled through the ureters from the kidneys. In patients without a bladder, surgeons had to create a different route for urine to drain.

In the first such procedures, surgeons removed a short segment of a patient’s small intestine, moved it into place in the lower abdomen and hooked up the ureters to one end of it. They then created an opening to the outside through the skin of the abdomen, and attached the other end of the small intestine to the opening. A bag placed over the opening collected urine as it continuously drained.

In the 1970s, Swedish surgeon Nils Kock (pronounced coke) envisioned something different—an artificial bladder. He took several feet of small intestine and sewed it together to create a reservoir that could remain inside the patient. In addition, he fashioned valves at either end of the reservoir to control the direction of flow. This allowed patients to empty urine from their abdomen through a catheter several times a day, instead of having to wear a bag under their clothes.

The potential of this idea was not lost on Skinner, who had seen the physical, emotional and social impact of cystectomy among his patients.

Skinner and members of his team, such as urologist John Stein, M.D., soon refined the idea and popularized the concept of continent cutaneous urinary diversion in the United States. Hearing of this creation—which Skinner dubbed the Kock pouch—patients flocked to USC/Norris.

Within a few years, advanced understanding of continence in men allowed the surgeons to take the procedure further. Instead of connecting the pouch to an abdominal opening, they began connecting it to the urethra, where urine ordinarily drains and leaves the body. That procedure was called an orthotopic urinary diversion. Through practice, they believed, men could learn to void conventionally. It proved a success.

In women, however, the urethra is so short that surgeons usually removed it in cystectomies for fear that it could develop cancer. Restoring normal voiding, then, seemed impossible; but Skinner was unconvinced. When he and Stein looked at cancer specimens, he saw that cancer usually did not spread to the urethra—so, in most cases, there was no need to take it out. Further anatomical studies on the location of nerves that provide women’s urinary control confirmed that the procedure could be offered to women—an advance that happened in 1992.

Soon, the pouch itself was further refined. In some of the original Kock pouches, a constriction of the new bladder’s nipple-like valve interfered with urine flow. Restricted urine flow or obstruction could put patients at risk for kidney damage.

So arose the new T-pouch. The team altered the Kock procedure to preserve more of the patient’s original tissue in the valve area, ensuring a better blood supply and eliminating fibrotic growths. The surgeons also refined the way they used staples, reducing the occurrence of stones.

Skinner’s team built on their experience to push advances in other procedures, such as removal of the uterus, cervix, fallopian tubes, ovaries, vagina, bladder, rectum and part of the colon due to sarcomas or advanced colon or bladder cancer. By using the T-pouch and other techniques, “we can reconstruct the pelvis and restore urine and bowel function with no ostomy and no bags,” says Skinner.

Nerve-sparing procedures, combined with new chemotherapies and radiation, also have given thousands of USC/Norris testicular and prostate cancer patients better post-operative quality of life.

Restoring quality

Though recovering from such surgeries is no easy task, patients are thankful to have their quality of life restored while they battle their cancer, Skinner says.

That gratefulness has, in turn, spurred Skinner’s growing group of satisfied clientele.

One grateful patient was Butch Walts, a highly ranked tennis pro whose career was curtailed by testicular cancer. Treated successfully at the Keck School, Walts wanted to give back to the urology department. The Butch Walts Foundation was set up in 1982, and soon after, three of his charity tennis tournaments, featuring stars such as John McEnroe, Chris Evert, Jimmy Connors and Martina Navratilova, raised more than $400,000 for urology research.

Those funds served as the seed for an endowment that still grows today. With a funding base, and the support of then-USC/Norris Director Brian E. Henderson, M.D., Skinner recruited a director of urologic cancer research to lead basic science investigations: Peter Jones, Ph.D., today director of USC/Norris.
Jones, the H. Leslie Hoffman and Elaine S. Hoffman Chair in Cancer Research, advanced the idea of translational research—studies that bridge the gap between the laboratory and the patient.

Keenly aware that survivors wanted to support the work of Jones and others, Skinner kept patients involved by sending them an annual update on research happenings and inviting them to a yearlyreception —practices that continue even 19 years later.

And patients have responded with millions of dollars.

Joseph Aresty, chair of the board of clothing company Alfred Dunner Inc., is an example. He went to Skinner for cancer treatment in 1994; now cured of the disease, he has gone on to donate more than $20 million to USC/Norris—a gift so generous that the urology department has been renamed in honor of Aresty and his wife, Catherine.

Developing strengths

With such generous support, Skinner is confident the urology department will continue to grow, focus on its research strengths and develop better ways to treat patients afflicted with urologic cancer.

For one, the department has gathered a database containing information on more than 2,000 bladder cancer patients and nearly 3,500 prostate cancer patients. USC/Norris maintains tissue specimens from each patient, and together with USC epidemiologists, basic science researchers in urology and pathology have used the database to develop molecular profiles of bladder and prostate cancer that have been used to figure out which patients would be most likely to have recurrent cancer after standard treatment.

From these studies, researchers identified a suspicious gene called p53, a tumor suppressor gene. Stein and Richard J. Cote, M.D., Keck School professor of pathology and urology, are leading a clinical trial to see if patients with a p53 mutation benefit from chemotherapy given in addition to their standard therapy. “This was the first National Institutes of Health-sponsored clinical trial based on molecular markers,” Skinner says.

Now researchers are amassing a similar database on kidney cancer patients. And research continues on all urologic fronts, an effort sure to grow even further when the researchers move onto their floor in the soon-to-be-complete Harlyne J. Norris Research Tower. The current Norris Hospital’s third floor, meanwhile, will be renovated to house a urologic institute for outpatient services, including consultation and examining rooms, a prostate cancer center, extracorporeal shock wave lithotripsy (a minimally invasive kidney stone treatment), fluorodynamics studies and endoscopic suites for minimally invasive surgery.

“There is a lot to offer in this field,” says Skinner. “As a urologist, you not only cure patients’ cancer—you restore their quality of life.”

1980
Donald G. Skinner, M.D., arrives at USC; urology faculty grows to three; NIH funding and endowment non-existent.

1982
Urology team begins using Kock pouch to reconstruct bladder after treatment for advanced cancer.1984
Tennis champions Bjorn Borg and Billie Jean King kick off first of three Butch Walts tennis tournaments benefiting USC urology.

1986
Former patient Sven Idsten donates $1 million from beer distributorship sale; gift goes toward building Dr. Norman Topping Tower.After modification by urology team, the new Kock pouch offers more normal urination to men treated for advanced bladder cancer.

1992
Women begin receiving orthotopic urinary diversion.

1995
Lord Gordon White donates $1.5 million to set up Hanson--White Chair in Medical Research, held by Skinner.

1996
Urology team begins using improved T-pouch for bladder reconstruction.

NIH awards $1.2 million to USC multidisciplinary team to study gene mutation predictors in patients at high risk for recurrence of bladder cancer.

David Cofrin, M.D., gives $1 million to establish David Cofrin Fellowship in Urology; later gives $2 million for Harlyne J. Norris Research Tower.

Catherine and Joseph Aresty give first of what will become more than $20.5 million in gifts, establishing the Catherine and Joseph Aresty Chair for Urologic Research, held byRonald K. Ross, M.D., the Catherine and Joseph Aresty Urologic Cancer Research Laboratory, the Catherine and Joseph Aresty Endowment for Urologic Cancer, the Catherine and Joseph Aresty Department of Urology, and in 2004, the Catherine and Joseph Aresty Conference Center in the Harlyne J. Norris Research Tower.

1997
Topping dinner raises $1.5 million for Donald G. Skinner Chair in Urology, held by Gary Lieskovsky, M.D.

2004
Faculty includes 16 physicians and 6 basic researchers; NIH direct funds reach $2.3 million; endowments surpass $33 million.