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Lodewijk (Louis) Jans Denis January 20, 1933 - July 28, 2021 Antwerp, Belgium

The Canadian Journal of Urology, Int. is sad to report that the urological world has lost one of its giants. Professor Lodewijk (Louis) Jans Denis (January 20, 1933 - July 28, 2021) passed away from a lengthy Illness. Just a few months before his passing, Louis Denis submitted his autobiographical Legends-in-Urology article to the CJU with the expectation that it will serve as learning and inspiration for the future generations of urologists. The CJU wishes to express our deepest sympathy to his beloved family and friends and we are honored to publish his legacy in his own words.

Gabriel P. Haas, MD Clinical Professor of Urology
Loyola University School of Medicine
and
Medical Director, Onoclogy Clinical Sciences,
Astellas Pharma Global Development

Leonard G. Gomella, MD, FACS
Editor-in-Chief
Canadian Journal of Urology International

I am very honored to be invited to write this article. The reasons are clear: An interview by CancerWorld (November 2004) called me one of Urology’s foremost free thinkers in Europe. My international peer-reviewed clinical and research world has been based on evidence-based principles or the objective, unbiased reality by my respected teachers, mentors and scientific boards. My existence on Planet Earth can be divided into my early years at the university, my military career; urological activities at the Antwerp City Hospitals 1958-1998; and my retirement activities from 1998 till the present. The early years cover my birth in January 1933 till my first year as a medical student at the state university of Ghent in 1950. As the first and only son born into a working class family we lived in a quiet suburb of the city missing most of the turmoil caused by demonstrations and social violence of the different ideologies against the conservative governments and institutions, 1933, was a start of conflicting powers by the election of Roosevelt as the American President and the nomination of Hitler as German Chancellor. The 1930’s witnessed a reaction in Europe against the consequences of the industrial revolution coupled to the scars of the Great War (WWI) and the crash of the global financial system. The invasion/occupation of Belgium by the German army, 1939-1945, changed the course of everyday life. With my father held in Germany and mother working more than fulltime I spent these years with my grandparents. My grandfather, a devout Catholic and union man supervised the printing presses of the Gazette of Antwerp and travelled on Sundays around Flanders to educate his fellow union members. He took me along to enjoy the hospitality of the small towns. Here I learned to feel at ease with strangers and their debates. Sports and youth organizations were encouraged and I played on our high school basketball team. I learned the discipline and value of team play and joined the Youth Corps of the Belgian Red Cross. The high school board supported my hope to enter the Royal Military Academy for Health Services (SOGD) which was possible after passing the first year of medical studies.

It was no problem to keep my conviction after entering the army as a cadet. We were lodged in the main barracks of the city, received military training during vacation periods and lived a normal student life attending cultural events, debates and concerts. First as secretary and in the final year as president of the medical student organization, I was given the honor to pledge the Hippocratic Oath at the graduation of my class. My journey to become a urologist continued in the Military Hospital in Colon, Germany followed in 1958 by an appointment as assistant surgeon in the Antwerp City Hospitals. By 1960 a brand-new military hospital was planned in Brussels and the army allowed overseas training programs in all specialties of medicine. I passed the test with the highest recommendation and received an appointment to the Medical College of Virginia (MCV), as a senior assistant resident. I was invited to join the transplant and research program founded by Dr. David Hume that performed the first 50 renal transplants worldwide.

Richmond, as capital of Virginia, was and still is a proud city of a state that provided four of the first five US presidents. At the time of my appointment it was still segregated. The Centennial of the civil war brought some upheaval to the excluded segments of the population but potential conflicts were mostly avoided by polite evasion. Three days after my arrival I bought an expensive ticket to attend a concert by Ella Fitzgerald in the opera. A great surprise to find myself alone with three other white persons in an audience full of colored people. The enthusiastic audience showed appreciation and friendliness to the lone Belgian.

The training was tough but rewarding. MCV controlled about 1,300 beds in four hospitals on the same campus and collaborated with the local VA hospital. Six-hundred beds were available for surgical training. The final test in urology was the performance of TUR prostate as chief resident. One was given access to a TUR room where the future urologist had to give spinal anesthesia, take care of the patient, perform the resection and get him safely to the Recovery room. All this had to be done alone. In a usual year about 100 patients went through this routine. For BPH the Millin procedure was chosen for glands over 60 grams. This experience was great but the chief resident was permanently on call and could not leave town. No better way to foster collaboration if you ever wanted to catch a full night’s sleep. A good physical condition was needed to keep up the routine. First rounds at 06:30, report 07:30, surgery 08:00-16:00, library 17:00, lab work 19:00 and last rounds 21:30. The next year when I practiced in the Antwerp City Hospitals the head of surgery called me after 3 months and said “Denis, I understand I will never operate on a prostate again”.

During my last year I received an NIH grant to join the Prostate Cancer Group led by W.W. Scott with participation of the 15 most important cancer centers of the USA. In this high level urological circle my task was usually to serve coffee and drinks but hearing the discussions, views and plans brought me perception and wisdom in prostate cancer and urology. The fact that I received the first prize in the AUA exhibition on laboratory research and the prestigious James Ewing resident award in 1962 brought me attention, and invitations to the big institutes (Brady, Cornell, Memorial, MD Anderson). In 1966 I wrote a report for the Belgian Society of Urology on “L’homotransplantation rénale humaine”, describing my US experience.

I returned home in 1963 as an assistant professor. Great time to pay back for this education. The army put me in charge of urology in the Military Hospital in Antwerp and as a urologist in the Antwerp City Hospitals. This smooth start-up ended abruptly on November 15, 1964 celebrating Dynasty Day. Around 3 AM the director called me to his office to tell me that I was flying to Zaire (previously Belgian Congo) to join our surgical team for a rescue mission to free hostages kidnapped by rebels in Stanleytown, Congo. The operation called Red Dragon was a joint Belgian – US humanitarian mission of Belgian paratroopers and C130 US military planes that saved the lives of about 2,000 hostages. Called a success for the relative few casualties, it was not the end but the beginning of a human nightmare, unresolved UN interventions and genocide in Rwanda. As an anecdote, few people knew that Che Guevera was present in the region in 1964 to direct the rebellion with Soviet support. He failed in his mission due to the lack of collaboration and coordination with the local politicians and tribal chiefs.

The Oath of Hippocrates applies to the concept of human rights. There are rights and responsibilities for both doctors and patients. The best treatment and holistic care requires collaboration and solidarity. Basic in the quality of teamwork is freedom of opinion and speech, respect to others, equality in treatment, care for all and last but not least, respect and love for all life-forms including yourself. The ultimate test is the mirror in the morning. Know yourself and don’t be afraid to stand by your values.

I left the army in 1973 to become chief of the urologic department in AZ Middelheim, a newly built hospital complex. From this 60 bed unit we founded urological sections in the other city hospitals: AZ Stuivenberg, AZ Jan Palfijn, AZ St. Elisabeth, AZ Hoge Beuken and the Diagnostic Centre to end up as a Coordinated Urological Centre in 1983. The time had come to put words into deeds. After refusing to accept academic offers to chair a university department I finally agreed to groom Dr. F. Keuppens to become a urologist and prepare him to become professor and Head of Urology at the UZ Brussels. I had to accept to become professor in urology and consultant to the clinical department in 1978. My partner since 1973, Dr. P. Nowé, was more interested in clinical work and blessed with administrative abilities. He ran the first Dornier lithotriptor in Belgium as well as the stone clinic. I expressed my thanks to both of them when I received the Life Time Achievement Award from the EAU.

The support, equal respect and trust to all personnel, including the cleaning ladies, brought a strong team spirit and territorial wellbeing. Students and residents were warned to heed and obey the unique expertise of the nursing staff. The simple fact that we limited the income of the senior staff (in these days we paid up to 70% of income tax) shared it with the young staff and paid for our updates and new instruments freed us from envy and dependence on the politicians of the Antwerp town council. This is a fortunate policy as long as you show reciprocal respect, without any shade of arrogance to the authorities.

Our urological activities focused on cancer prevention, the correct diagnosis, treatment of the individual rather than just the cancer, and we relied on evidence-from phase 2 and 3 clinical trials. Our work on the use of ultrasound technology, screening, chemotherapy and clinical trials was recognized by the EAU and international urological associations.

In Antwerp we focused on the renovation of the Royal Medical Society, the second oldest in the country, by raising the standards of scientific communication in the Antwerp Medical Days and literally by restoring its historic building. We founded a Professional Union of Physicians working for the Public Welfare Center of Antwerp. Prof. K. Griffiths, Tenovus Institute Wales, wrote a biography of my professional life in Prostate Cancer (2006) at the occasion of my honorary presidency of the fourth International Consultation on Prostate Cancer in Paris. This event started as a farewell party in the House of Commons, Westminster Palace went through a number of gastronomic events to end-up in the UNESCO building in Paris.

I served as Chairman of the Flemish Advisory Council for Cancer Prevention (VACK) from 1983 till 1997. We brought all university oncological departments together with the general physicians and the health authorities where the available funds were openly discussed and divided based on merit and collaboration. This laid the groundwork for the screening programs on cervix, breast and colon cancer.

Rather strange that the screening for prostate cancer that we started with European grants in 1991 in the European Randomized Screening Study for Prostate Cancer (ERSPC) was taken off the regional grants as too scientific. These funds are under control of the prime minister and screening was not on their list of support. Still the ERSPC was first joined by the Erasmus MC (Prof. Schröder, Rotterdam) and recently published a 16 year follow up in European Urology which demonstrated the benefits of screening. This study is now on cruise control by M. Roobol and her associates with equal representation of the council. V. Nelen is the veteran hero of the Antwerp section. I am still honored to be chosen as co-founder by the European School of Urology, a Phoenix in its continuous fight against cancer.

My career as urological oncologist started as a founding member of the GU group of the European Organization for Research and Treatment of Cancer (EORTC). I served in a number of functions including President from 1988 till 1991. I am still proud of getting a two million Euro grant from the Belgian government for a new building in Brussels and an educational grant to launch the European Journal of Cancer where I served as founding managing director.

I also like to remember the culture and lifestyle that resides permanently in our cultural heritage. In 1977, the 400th birthday of Rubens was celebrated by our Collegium Medicum Antverpiensis, founded in 1620. The publication of Medicine and Rubens details the friendship and gratitude of the artist for his medical treatment.

My pet-projects in this busy phase of my life was the launch of the International Prostate Health Council (IPHC) and the International Consultation on Urological Diseases (ICUD). The IPHC, launched in 1989, was an educational grant from MSD to study all aspects of prostate diseases for medical education. The grant was generous and I was allowed to pick my own team. As any successful coach knows, I picked the players that were far better than myself: Griffiths, Algaba, Boyle, Schröder, Aso, Altwein, Hald, Kirby, Pagano, Steg joined the Belgian non-profit organization as members. These efforts were recognized worldwide and 10 years later we counted 39 national associations, hundreds of publications and a smooth transition to the International Society of Urology (SIU).

The ICUD started in 1996 as a concept of Prof. Kuss and Prof. Gregoir, both SIU leaders, to meet each year to look for consensus and multidisciplinary participation in a single meeting supported by the International Agency on Cancer Research (IARC – WHO), the International Union against Cancer (UICC) and the American Cancer Society. Soon it became clear that consensus was rare and that consultation was more appropriate. The support of the major urological associations (AUA, EAU, CAU, AAU and SIU) and the enthusiastic response of the leadership in urological sciences and practice made it an instant success story for medical and nursing organizations, other scientists and health workers as well as patients. The organization is still alive in different areas of cancer treatment. Personally I became involved in the leadership of most European initiatives against cancer and its burden on our populations through my EORTC and ESO activities. I became council member of the UICC via its TNM committee serving as secretary general and treasurer until 2006.

However happy one is to accept the relativity of all this glory, most creative work and practice is possible only through the efforts of hundreds of unknown staff, officials and social citizens and one becomes famous on the shoulders of his colleagues. As an anecdote, at my 50th birthday celebration, the City of Antwerp commemorated my urological surgery on the only male okapi (Atabu) in the Antwerp zoo as my specific contribution to the city. He became the proud father of seven in an European breeding program.

Despite retirement, I continued to organize international meetings in Antwerp on cancer global organization, education, evidence-based trials, breast cancer and artificial intelligence. I managed to support a European grant for collaboration with the Netherlands on digitalization of medical data, palliative care and patient participation in medical personal decisions. Together with Prof. Schröder, Prof. Pinedo and the German institute of cancer research we managed to receive a European grant of some 450 million Euro to direct and stimulate research called European Cancer Research Initiative (ECRI) From 2006 I tried to retire but was kept into the overall intense communication to facilitate interaction between all organizations engaged in the sciences and practice of medicine in our changing society. The collaboration between global associations explains the long list of honors, medals, publications and meetings. My efforts brought me friends for life. An example is the successful transition of the Asian Association of Urology (AAU) into a strong, collaborative group of national organizations. It also explains the number of monographs and books (70) as each meeting before the digital revolution, as far as possible, was followed by a report for the younger colleagues at home.

Last but not least I spent my energy and time working for the underdog, the patient, in our medicalized world. Ideally a medical doctor is part scientist part Shaman working in a team where most threats against a balanced, happy, productive life could be cured or prevented in a safe, peaceful society. Here I got involved in support for general (founder of the Flemish Cancer League) or specific (US TOO, Europa Uomo) organizations that raise their voices to bring freedom, equity and solidarity to the weakest members of our society.

I would like to pay honor to Prof. Saad Khoury as a real legend in his overall effort to increase the standards of urological sciences and practice. With the support of the La Pitié Hospital and the French urological association, he dedicated his career and life, with his wife Mimi at his side, to serve these goals successfully thanks to a good mix of intelligence and caring nature.

Much work remains to be done but that will be left to the next generations of urologists!