GIANTS OF UROLOGY: The Contributions of Leonard Zinman, MD
By: Alex J. Vanni, MD, FACS | Posted on: 01 Oct 2022
Leonard N. Zinman (1931–2021), was a graduate of Boston University and Tufts University School of Medicine. He completed his surgical training at the Boston Veterans Administration and urology residency at the Massachusetts General Hospital, where he was inspired by both Drs. Wyland Leadbetter and W. Hardy Hendren to pursue a career in genitourinary reconstruction. He joined the Lahey Clinic in 1964 before embarking on fellowships in reconstructive urology with Mr. Richard Turner-Warwick at the Institute of Urology in London, England from 1967–1968, and renal transplantation at Middlesex Hospital from 1973–1974 with Mr. David Innes Williams at Newcastle Royal Infirmary, New Castle, England.
At Lahey, Dr. Zinman was instrumental in creating one of the finest urological reconstructive centers in the country. Dr. Zinman, whose career at Lahey Hospital and Medical Center exceeded 50 years, founded the Center for Reconstructive Urologic Surgery at the Lahey Clinic in 1973. Recognizing the importance of reconstructive urology as a distinct subspecialty, Dr. Zinman cofounded the Society of Genitourinary Reconstructive Surgeons with Drs. Gerald Jordan, Charles Devine, and Charles Horton in 1987, and served as president in 1992.
During his long and distinguished career, Dr. Zinman made significant, innovative contributions to the field of reconstructive urology. Never satisfied with the way things had previously been done, he was always looking for innovative ideas to improve the lives of his patients. Dr. Zinman’s intellectual curiosity and passion for medicine led to numerous new techniques and approaches for the most challenging issues facing reconstructive urologists. Although space precludes discussing all of Dr. Zinman’s contributions, I will highlight several of his most innovative reconstructive concepts in hopes of inspiring current and future surgeons.
Prior to the modern endovascular approach to renovascular hypertension, surgical renovascular reconstruction was the gold standard treatment. In 1976, Drs. Zinman and Libertino described the hepatorenal bypass as the first viable alternative to aortorenal bypass in patients with renovascular hypertension.1
Drs. Zinman and Libertino began using cecum in the 1970s as an alternative to ileum or sigmoid colon for augmentation cystoplasty. This technique was shown to have low complication rates and serves as an excellent alternative to ileum in reoperative cases or in previously radiated fields.2
Bladder Neck Contracture/Vesicourethral Anastomotic Stenosis
Recurrent bladder neck contractures are a challenging entity often requiring repeat urethrotomy, indwelling catheter, complex reconstruction, or urinary diversion. In 2011, Dr. Zinman presented the first data of using an anti-fibrotic medication (mitomycin-C) as an adjunct to bladder neck urethrotomy to improve the outcomes to urethrotomy alone.3
Rectourethral Fistula (RUF)
Dr. Zinman is perhaps best known among reconstructive urologists for his transformative approach to RUF repair. He performed the first transperineal RUF repair with a gracilis muscle interposition flap in 1971.This technique selectively uses a buccal mucosa graft (BMG) to close the urethral side of the fistula and is supported by a gracilis muscle flap. By separating suture lines, supporting a BMG, and filling dead space, this technique has been shown to have 98% success rate in surgically induced RUF and 86% success rate in radiated RUF.4
In 2016, Dr. Zinman described a novel approach to prostatosymphyseal fistulas. In patients with a viable bladder, he demonstrated that patients who underwent pubic symphysis debridement, fistula closure (with or without a BMG), with an interposition rectus abdominis muscle flap could be successfully reconstructed.5
Dr. Zinman was the first to describe using extragenital flaps for complex genitourinary reconstruction. In 1997, Zinman described multiple approaches for complex urethral reconstruction.6 These included the first description of a prefabricated skin graft on a gracilis muscle and pudendal fasciocutaneous medial thigh flaps for particularly complex urethral strictures with a poor graft bed. In 2015, he demonstrated an 80% success rate in patients with long segment radiation urethral strictures with his technique of a ventrally placed graft BMG supported by a gracilis muscle flap.7
Always looking for solutions for his most complex patients, Dr. Zinman pioneered the minimally invasive retrieval of rectal mucosa grafts for urethral reconstruction. In patients with long urethral strictures in whom oral mucosa was either insufficient or contraindicated, rectal mucosa is a viable alternative. Applying the transanal endoscopic microsurgery technique colorectal surgeons use to resect low-grade rectal tumors and polyps for rectal mucosa graft harvest allowed for the safe retrieval of an alternative graft for urethral reconstruction.8
Dr. Zinman was also the first to describe urolume stent removal without segmental urethral resection. In 2006, he described the technique of dorsal urethrotomy, removal of individual urolume tines, and BMG onlay.9 This concept has been further validated both at Lahey by Dr. Zinman and Buckley in 2012 and in 2018 by an international multicenter group.
Dr. Zinman’s innovative academic work includes over 130 peer-reviewed published manuscripts, multiple textbooks, and numerous visiting professorships. Dr. Zinman won numerous awards during his career, including election to the American Association of Genitourinary Surgeons (1994), Honorary Fellow of the Royal College of Surgeons (2010), AUA Lifetime Achievement Award (2015), Society of Genitourinary Reconstructive Urologic Surgeons Lifetime Achievement Award (2019), and the Frank Lahey Award (2019).
Dr. Zinman was kind, caring, and a collaborator. He was always quick to give credit to his mentors who influenced him, and we are fortunate he left such an indelible legacy to inspire our current and future reconstructive urologists. His thirst for knowledge and inquiry never wavered, no matter the changes in the health care landscape. This latter characteristic truly defined his love for medicine. We are grateful for his service and contributions.
- Libertino JA, Zinman L, Breslin DJ, NW Swinton. Hepatorenal artery bypass in the management of renovascular hypertension. J Urol. 1976;115(4):369-372.
- Zinman L, Libertino JA. Technique of augmentation cecocystoplasty. Surg Clin North Am. 1980;60(3):703-710.
- Vanni AJ, Zinman LN, Buckley JC. Radial urethrotomy and intralesional mitomycin C for the management of recurrent bladder neck contractures. J Urol. 2011;186(1):156-160.
- Kaufman DA, Zinman LN, Buckley JC, Marcello P, Browne BM, Vanni AJ. Short- and long-term complications and outcomes of radiation and surgically induced rectourethral fistula repair with buccal mucosa graft and muscle interposition flap. Urology. 2016;98:170-175.
- Kaufman DA, Browne BM, Zinman LN, Vanni AJ. Management of radiation anterior prostato-symphyseal fistulas with interposition rectus abdominis muscle flap. Urology. 2016;92:122-126.
- Zinman L. Extragenital muscular myocutaneous and fasciocutaneous flaps in urethral reconstruction. Urol Clin North Am. 1997;24(3):683-698.
- Palmer DA, Buckley JC, Zinman LN, Vanni AJ. Urethroplasty for high risk, long segment urethral strictures with ventral buccal mucosa graft and gracilis muscle flap. J Urol. 2015;193(3):902-905.
- Palmer DA, Marcello PW, Zinman LN, Vanni AJ. Urethral reconstruction with rectal mucosa graft onlay: a novel, minimally invasive technique. J Urol. 2016;196(3):782-786.
- Zinman LN, Stoffe JT, Malone M. 124: Simplified urolume stent removal with urethral preservation and dorsal buccal graft onlay. (or without segmental urethrectomy). J Urol. 2006;175(4S):40.