From vision to reality: The foundations of paediatric urology in Austria: A tribute to Dr. Marcus Riccabona

It is with great sadness and dismay that we have to announce the passing of Prof Marcus Riccabona (1946–2022), founder and former head of the Department of Paediatric Urology at the Hospital of the Sisters of Charity in Linz, Austria. Marcus died during the course of a pediatric urologic mission in Asmara, Eritrea due to a sudden and unexpected cardiac event. Marcus Riccabona studied medicine at the University of Innsbruck, he completed his studies as a specialist in urology at the hospital of the Sisters of Charity. Early on, he concentrated on congenital malformations of the urogenital tract in children, having had the chance to treat these children at the general urology department. The conditions that existed in the department gave birth to his vision: to create the best possible therapy in a child-friendly environment for these affected children, the weakest members of our society. Children were treated along the guidelines of adult medicine at that time; both outpatient and inpatient infrastructure were oriented towards adults in those days. For example, only in a few exceptional cases were parents allowed to accompany their children during their hospital stay. Both the diagnostic concepts and the consequent therapy of the child's urogenital tract mimicked the procedures for adult urology. At that time the usual diagnostic and therapeutic concepts were less than appropriate for many urogenital tract malformations. There might have been a lack of awareness as to the fact that diagnostic tests in particular were barely able to provide even a snapshot of a developing organ. In retrospect, many children were prematurely treated according to the lege artis guidelines, dilatations of the upper urinary tract were perceived as obstructions per se and treated. “Natural history” became a new term during this time as we attributed changes to the growth of children with obvious pathologies of the kidneys as well as the draining urinary tract (Fig. 1). Marcus Riccabona evolved a new pathophysiological way of child-oriented thinking and travelled for a short time to the U.S. to acquaint himself with current developments in paediatric urology As a result of this venture, John Duckett in Philadelphia became one of his greatest professional role models. Back in Europe, Marcus Riccabona began to implement his vision of a child-friendly infrastructure, pathophysiologically mandatory diagnostics and minimally invasive therapy concepts. Initially, his efforts at the hospital were viewed with scepticism, however, his persistence in building his own paediatric urology department led to more and more concessions from the administration, which ultimately led to the establishment of the first autonomous paediatric urology unit in Austria in 1992, with a day clinic and an inpatient mother-child unit. The prerequisite for the founding of this department, which was the first autonomous unit for pediatric urology in the German-speaking world, was the generosity of the head of administration at that time, Sister S. Leitner. Also, the former head of adult urology, Andreas Schorn, supported this foundation despite critical voices among his colleagues. Initially alone, later with a resident, special paediatric urology was continuously developed. This professional and human climate as well as the empathetic atmosphere so essential to dealing with children quickly gained awareness beyond the borders of Austria. Thus, it transpired that over the years a continuity evolved, combined with a steady influx of affected children and their parents from all over Austria. (Fig. 2). In addition to the growing medical team including many of today's chief physicians, there was still another special feature of this department: The specific diagnostics focused on the well-being of the child, with the overriding focus directed at further development of ultrasound as well as urodynamic specific examinations, all of which were carried out by the department itself. Another diagnostic milestone was the nuclear medicine diagnostics focusing on the complicated pathophysiology of children's kidneys in their isotope renographic scientific understanding. This diagnostic infrastructure made it possible to assess the entire clinical picture of congenital malformations in one department in an effort to create an individual therapy plan for each child. Furthermore, regular guest professorships and visits of colleagues were an integrative part of the departmental culture that Marcus Riccabona established, holding up a high standard of scientific discussion fostering the further development of his unit, and sustained by his own well-respected international reputation. In the meantime, this department has developed into the national centre for rare paediatric urological diseases and as the only such urological department in Austria is a full member of the European Reference Networks. In retrospect, this paediatric urology department founded by Marcus Riccabona must be regarded as a true success story, launched with a small bed division, a modest operating theatre capacity and 2 staff members, today there are 6 operating theatres per week with 8 staff members and about 1600 patients operated on annually. While in the early days minor operations were on the agenda, large complex reconstructions of bladder malformations (bladder exstrophy, augmented bladders for neurogenic bladders), kidney diseases (tumours) and severe malformations of the external genitals (complex hypospadias, persistent sinus urogenitalis, phalloplasty, etc) are at the centre of indications for today's surgery. Through the expansion and professionalization of the isotope department the functional component of renal malformations was recognized leading to more accurate indication of renal abnormalities and therefore significant reduction of kidney surgery. As of recently, adolescents can be operated minimally-invasive with the aid of the Da Vinci system. Milestones in surgical development have also been achieved in the reconstruction of bladder exstrophies and epispadias; in addition to plastic surgical reconstruction, restoration of the rhabdosphincter is one of the most important objectives today. After establishing paediatric urology in Europe as a separate specialist discipline, the department under Marcus's lead was one of the first to offer an accredited fellowship training position (FEAPU) in 2008. What particularly distinguished Marcus Riccabona was his personality which was not only characterized by his professionalism but also by his humanitarian and human qualities. In addition to his operational activities long after his retirement, his teaching activities at the University of in Munich must be emphasized. Pediatric urological surgery performed with patience and meticulousness was his passion, the transfer of this knowledge, both practically and theoretically on the humanitarian sector was one of his visions, in particular in so-called third world countries. Especially his involvement in Eritrea deserves special mention. With many like-minded colleagues we succeeded in starting a pediatric urological pilot project for sick children in Asmara in 2004. In the capital of Eritrea, the International Operation Centre for Children (IOCCA) was founded and more than 1000 children with congenital malformations have been operated on. In the first few years the logistical and infrastructural basis was built up, hygiene and care standards were the most important pillars of this sensible surgical project. The postoperative healing phase was able to be significantly improved, over time the long-term results of our surgery have become more satisfactory. The indications for pediatric urological interventions have changed dramatically over the last 10 years, including in Eritrea: In the beginning mainly congenital urethral malformations such as hypospadias were treated. Later on, more complex malformations of the kidneys, the efferent urinary tract and bladder malformations e.g., exstrophies were operated on, also the treatment of nephrolithiasis could be implemented increasingly. Altogether unexpectedly, Marcus left us precisely in that country where he had embraced particularly children in his heart. His impact on the care of children with congenital urological malformations in Austria and beyond is immeasurable and is continuing. He will remain unforgotten as a teacher, doctor and as a human being. Marcus, you will forever remain a role model for us!