Dr. Robert Douglas Jeffs (1924–2006) — A founding father of North American pediatric urology

Background

Dr. Robert Jeffs (Fig. 1) was born in Toronto in 1924 into a medical family, being the son, grandson, and nephew of physicians. With a keen interest in pursuing medicine, his premedical studies were initially put on hold, having graduated from the Upper Canada College in 1941 at the age of 17. Unlike the preceding conflict, Britain’s declaration of war on Nazi Germany did not automatically commit Canada, as had been the case in 1914. However, the public support at that time for Britain and France was unanimous, and therefore, following a parliamentary debate, Canada declared war on Germany on September 10, 1939. Prime Minister William Lyon Mackenzie King promised that only volunteers would serve overseas.¹ With a fervent desire to serve his country, Robert Jeffs joined the Canadian Air Force following his graduation as a De Havilland Tiger Moth pilot. Following the end of the war in 1945, he read for a degree in medicine from the University of Toronto (his father’s alma mater). He served an internship in Toronto Western Hospital in 1949 before joining the faculty of the University of Toronto as a demonstrator of anatomy the following year. He served as a resident in both plastic surgery and in neurosurgery in 1952 at Sunnybrook Hospital in Toronto, and as a senior resident in urology at Toronto Western Hospital that same year. In 1953, he was appointed senior resident in general surgery at Toronto Western Hospital. He then held a residency in urology in 1954 and a residency in general surgery in 1955, both at Toronto General Hospital.²

Fig. 1.

Portrait of Dr. Robert D. Jeffs during his time at the Hospital for Sick Children, Toronto.

In 1956, Dr. Jeffs was awarded the McLaughlin Traveling Fellowship, which enabled him to study for nine months with Sir David Innes Williams at the Great Ormond Street Children’s Hospital in London. It was there that he developed a strong interest in pediatric urology.³ Upon his return in 1957, Dr. Jeffs was appointed as the pediatric urologist at the Hospital for Sick Children in Toronto and also joined the staff of Toronto Western Hospital.⁴

The Hospital for Sick Children (Sick Kids), Toronto (1957–1975)

Dr. Jeffs was the first Chief of Pediatric Urology at the Hospital for Sick Children in Toronto, and remained as divisional director for his entire tenure (1960–1975). He was recognized as a team leader, a distinguished educator, and an innovative investigator.⁵ He was also appointed as the Chairman of Urology at the Academy of Medicine in Toronto. In 1962, he was appointed as an Assistant Professor in the Department of Surgery at the University of Toronto, and was subsequently elected as the President of the medical staff at Sick Kids during his last two years in Toronto (1973–1975).

While at the Hospital for Sick Children, he and his colleagues pioneered new surgical procedures for ileal conduits, ureteric reimplantation, and dismembered pyeloplasty. They introduced peritoneal dialysis in collaboration with the division of nephrology and began a large series of pediatric renal transplants. Jeffs was also involved in planning a center for the rehabilitation of children with spina bifida and neuro-urological conditions. He also established one of the first pediatric urology fellowship training programs in North America.

However, it was Dr. Jeffs’ work that began in the late 1950s, when he began to investigate the possibilities for surgically correcting a rare congenital defect (approximately 1/50 000 live births) known as bladder exstrophy — a spectrum disorder caused by a midline fusion failure of mesenchymal folding in the first trimester leading to protrusion of the bladder on the lower abdominal wall and significant associated defects, including genital anomalies and a disrupted pelvic ring. At the time, this was a devastating disorder for parents and families. Dr. Jeffs’ clinical research culminated in a staged approach to the surgical repair of this condition, which at the time was considered experimental but eventually became the standard of care for children born with this condition. The world’s attention became focussed on Toronto, as he and his colleagues became the first to close a bladder exstrophy in Canada.

Johns Hopkins Brady Urological Institute, Baltimore (1975–1997)

Following the departure of both Dr. Charles Tesar and Dr. William W. Scott from Johns Hopkins in 1974 — both pioneers in the hormonal effect of androgens on prostatic tissue⁶ — and with the appointment of Dr. Patrick C. Walsh that same year⁷ (open retropubic nerve-sparing prostatectomy) as the new departmental chairman, Robert Jeffs was head-hunted to join the department and to become the founding chief of the Division of Pediatric Urology at the Brady Urological Institute at Johns Hopkins. Dr. Jeffs made the move to Baltimore in 1975 and was appointed Professor and Director of the Division of Pediatric Urology at the Johns Hopkins University School of Medicine for more than two decades.⁴

It should be noted that Dr. Jeffs was not the first urologist to operate on children at Johns Hopkins. One of his predecessors, Hugh Hampton Young (1870–1945) had already recognized and surgically treated posterior urethral valves, was the first to develop a procedure to correct incontinence in patients with the epispadias-exstrophy complex, and was the first to describe bilateral subtotal adrenalectomy for virilization secondary to congenital adrenal hyperplasia.^8–11 He was, however, the first to establish a formal unit of excellence to allow the high-volume flow of patients with complex congenital genitourinary disorders through the division. In addition to being a master surgeon in dealing with congenital kidney malformations, ureter abnormalities, pediatric testicular tumors, Wilms’ tumor, and polycystic kidney disease, he was a world expert in the surgical and perioperative management of children with primary epispadias, bladder exstrophy, and cloacal exstrophy. He had refined and modified his multistage operative approach during the 1970s, and in 1985, was joined by Dr. John Gearhart, who further strived towards the development of a world-class center of excellence but also in the development of clinical research databases and the publication of high-quality manuscripts. “Robert Jeffs took a major birth defect, which consigned children to a reclusive, dismal existence and devised a three-step technique to repair it, basically altering the lives of thousands of children throughout the world,” said Dr. John Gearhart, who in 1996 succeeded Dr. Jeffs as director of Pediatric Urology.¹²

During his time as divisional director, Dr. Jeffs was also highly regarded as a mentor to both faculty and students, and as a warm, kind, and generous caregiver. He instituted an annual picnic (which exists to this day) to bring together patients and families in an effort to allow them to learn about congenital urological disorders in an open, friendly atmosphere where they would be encouraged to engage with others.³

Academic endeavours

Dr. Jeffs was academically very active. His first available peer-reviewed publication was in 1962 exploring the association between vesicoureteric reflux and infection.¹³ He published five single-author reviews on bladder exstrophy and its variants, and co-authored a further 150 manuscripts, in addition to book chapters and edited textbooks. He was in high demand as a visiting professor and lecturer, was elected chairman of the urology section of the American Academy of Pediatrics (AAP), and in 1999 he was awarded the Pediatric Urology Medal by the AAP for having “significantly and positively influenced the care of children with genitourinary problems throughout the world.”⁵ In 2010, the Brady Urological Institute and the Zanvyl and Isabelle Krieger Fund honored him with the establishment of the Robert D. Jeffs, MD, Professorship in Pediatric Urology.

“Robert Jeffs was the kind of doctor who’d go the extra mile… He’d be the one to take that last phone call, and patients would come back to see him even as adults, and even when their problems had nothing to do with urology.”

– Dr. John Gearhart

“(He was a)…magnificent surgeon and a wonderfully sensitive physician… He single-handedly conquered one of the most severe deformities of the genitourinary tract, one which everyone thought was incurable… Jeffs’ contributions to the field of pediatric urology and to Hopkins as an institution cannot be overstated.”

– Dr. Patrick Walsh

Dr. Jeffs published 155 papers between 1962 and 2008 on over 20 topics in pediatric urology, with his last publication being posthumously (Fig. 2, Table 1). Over one-third of his total publications were on the bladder exstrophy/epispadias/cloacal exstrophy complex (37.4%), with a further 12.3% on genitourinary reconstruction, and 9% on ureteral abnormalities. Interestingly, he featured as a co-author/senior author on 94% of his publications, which demonstrated his leadership and willingness to act as a mentor and teacher.

Fig. 2.

Timeline of publications by Dr. Robert Jeffs (1962–2018). The red line denotes the binomial skew timeline.

Table 1.

Topics and frequency of publications by Dr. R. Jeffs

Topic	Single-author	First author	Second author	Co-author	Senior author	Total
Historical/biographies					1	1
Bladder exstrophy/epispadias complex	5	1	6	21	25	58
Bladder neck procedures				2	5	7
Ureteral abnormalities			5	6	3	14
Urethral abnormalities				1	1	2
Genitourinary reconstruction			3	3	13	19
Undescended testes/scrotal abnormalities				1	5	6
Hypospadias				1	3	4
Basic science			2		2	4
Trauma					1	1
Stones					1	1
Testicular tumors			1			1
Vesicoureteric reflux		2		1	2	5
Rhabdomyosarcoma/neuroblastoma/Wilms tumor			1	4	4	9
Disorders of sexual development			1	2	2	5
Renal abnormalities (non-tumor/stones)			3	2	6	11
Renal transplantation				1		1
Posterior urethral valves				1		1
Prune belly syndrome		1			1	2
Nocturnal enuresis				2	1	3
Total	5	4	22	48	76	155

Conclusions

Dr. Robert Jeffs was a humanitarian with an extraordinary work ethic and infectious energy. “RDJ” loved spending time with his family, staying at his cottage at Georgian Bay, Ontario, listening to Gordon Lightfoot songs, and following Toronto Maple Leafs ice hockey (personal communication, Michael Leonard). He built the division at Sick Kids, Toronto “case by case, referral by referral,” and had a strong appreciation for how excellence could only be achieved through team work rather than by individual efforts. This culture of teamwork and the importance of tackling behavior designed to build one’s one reputation and ego especially holds true in contemporary practice.

He set a grueling pace at work and the urological shadow of excellence he cast as a teacher is felt throughout North America, as generations of surgeons are able to trace their lines of mentors back to him.¹⁴ The alumni of the Pediatric Urological divisions both at Sick Kids and Johns Hopkins went on to grow the field throughout the continent, with the likes of Schillinger, Cook, McLorie, Churchill, Canning, Peters, Leonard, Elder, Diamond, Shapiro, and Docimo providing urological care from Vancouver to Montreal, from UCLA to Hopkins. He died from complications of pulmonary fibrosis at the age of 82 on August 28, 2006 in Baltimore.¹⁵