PRELUDE
Urological diseases are as old as mankind. This is understood from the discovery of a vesical calculus in the pelvis of a mummy from a prehistoric tomb in Egypt, which was approximately 7000 years old. Urological expertise was also well-known in the prehistoric time where the circumcision was clearly described (Figs 1.1 and 1.2).
Ritual circumcision on the 8th day of life was practiced by the ancient Hebrews as evidence of God's covenant with Abraham, a story related in Genesis 17:10–14. A more elegant artistic portrayal of this ancient rite may be seen in Rembrandt's etching of the circumcision of Christ (Fig. 1.3).
The elective operations first performed by man—circumcision and cutting for bladder stone—the last was free from religious or ritual conventions and may therefore be pronounced, the most ancient operation undertaken for the relief of a specific surgical condition.
Fig. 1.1: Prehistoric bladder calculus in the pelvis of a mummy(Courtesy: Murphy Leonard JT. History of Urology Charles C Thomas. Publisher Springfield, Illinois, USA; 1972)
Fig. 1.2: Circumcision in Egyptian era(Courtesy: Shokeir AA, Hussein MI. The urology of Pharaonic Egypt. BJU Int. 1999;84:766-1)
PREHISTORIC UROLOGY IN DIFFERENT PARTS OF WORLD
India
Indian medicine has a long history. Its earliest concepts are set out in the sacred writings called the Vedas, especially in the metrical passages of the Atharvaveda, which may possibly date as far back as the second millennium BC. According to a late writer, the system of medicine called Ayurveda was received by a certain Dhanvantari from Brahma and Dhanvantari was deified as the God of Medicine.
Sushruta is the most celebrated physician and surgeon in India. Though he practiced during the fifth century BC, many of his contributions to medicine and surgery preceded similar discoveries in the western world. Sushruta devotes a complete volume of his experiences to ophthalmologic diseases. In the Uttar Tantrum, Sushruta enumerates a sophisticated classification of eye diseases complete with signs, symptoms, prognosis and medical/surgical interventions. In particular, Sushruta describes what may have been the first extracapsular cataract surgery using a sharply pointed instrument with a handle fashioned into a trough (Fig. 1.4). His ability to manage many common eye conditions of the time with limited diagnostic acids is a testament to his virtuosity.
The “Sushruta Samhita” is a Sanskrit redaction text on all the major concepts of ayurvedic medicine with innovative chapters on surgery attributed to Sushruta (Fig. 1.5). Amongst the eight divisions of medical knowledge, surgery was considered the most important branch. The Sushruta Samhita contains 184 chapters and description of 1120 illnesses, 700 medicinal plants, a detailed study on anatomy, 64 preparations from mineral sources and 57 preparations based on animal sources. Sushruta also described the various urethral bougie for dilatation of the stricture urethra.
Sushruta recognized the four kinds of calculi caused by phlegm, bile, air or semen and he also described the stone prophylaxis in stone disease by prescribing strict vegetarian diet. He described the treatment of extravasation of urine by incision in the perineal region. He practiced urethral installation of medicine for treating gonorrhea.
Greece
In Greek antiquity, medicine was second to mathematics. Ancient Greek civilization was at its peak during the 400's BC. During this period of time, sick people went to the temples dedicated to Asclepius, the Greek god of healing. At this time, a man named Hippocrates began teaching that every disease had only natural causes. He is known as the great ancient Greek physician. In medicine, doctors still refer to the Hippocratic oath instituted by Hippocrates who is also credited with laying the foundations of medicine as a science.
Hippocrates (460–370 BC) is considered one of the most outstanding figures in the history of medicine. He is referred to as the western father of medicine in recognition of his lasting contributions to the field as the founder of the Hippocratic School of Medicine. This intellectual school revolutionized medicine in ancient Greece, establishing it as a discipline distinct from other fields and thereby establishing medicine as a profession.
The Hippocratic physician paid careful attention to all aspects of his practice: he followed detailed specifications for, “lighting, personnel, instruments, positioning of the patient and techniques of bandaging and splinting” in the ancient operating room.5
The Hippocratic school gave importance to the clinical doctrines of observation and documentation. These doctrines dictate that physicians record their findings and their medicinal methods in a very clear and objective manner so that these records may be passed down and employed by other physicians. Hippocrates made careful, regular note of many symptoms including complexion, pulse, fever, pains, movement and excretions. He is said to have measured a patient's pulse when taking a case history to know if the patient lied. Hippocrates extended clinical observations into family history and environment. “To him medicine owes the art of clinical inspection and observation.” For this reason, he may more properly be termed as the “Father of Clinical Medicine.”
He recognized and described stone disease but also stated, “I will not cut persons laboring under the stone but will leave this to be done by practitioners of this work.” Possibly, this was the earliest recommendation for super specialization in medicine. Renal and bladder injuries, and disorders were described by Hippocrates (Fig. 1.6); and reference made to the drainage of renal abscesses. He regarded wounds of the bladder as carrying a very grave prognosis and it may have been this view that held surgeons back from the transabdominal approach of the bladder.
The Hippocratic Oath
The Hippocratic Oath is an oath traditionally taken by physicians, in which certain ethical guidelines are laid out. It is thought to be written by Hippocrates and some scholars. Several parts of the oath have been removed or reworded over the years in various countries, schools and societies but the oath still remains one of the few elements of medicine that has remained unchanged.
Middle East
The “Canon of Medicine” is a 14-volume medical encyclopedia compiled by Ibn Sīnā (Avicenna) and completed in 1025 (Fig. 1.7). The book was based on the writings of the Roman physician Galen and Hippocrates as told by Galen. It presents a clear and organized summary of all the medical knowledge of the time. Originally written in the Arabic language, the book was later translated into a number of other languages including Persian, Latin, Chinese, Hebrew, German, French and English. The Canon is considered one of the most famous books in the history of medicine. The Canon of Medicine was used as a textbook in the universities of Montpellier and Louvain as late as 1650.
For 1000 years, he has retained his original renown as one of the greatest thinkers and medical scholars in history. His most important medical works are the Qanun (Canon) and a treatise on cardiac drugs. The “Qanun” is an immense encyclopedia of medicine. It contains some of the most illuminating thoughts pertaining to distinction of mediastinitis from pleurisy, contagious nature of phthisis, distribution of diseases by water and soil, careful description of skin troubles, sexual diseases and perversions and nervous ailments.
Abul-Qasim, etc. described flexible catheter and uroscopy. Islamic philosophers and the physician Ibn al-Nafis (1210–1288 AD) in Damascus succeeded in finding that the lung circulation was a closed system. Without Islamic science, the European renaissance would not have begun and come to maturity.
Rome
The Greeks brought surgery to Rome and it was Celsus, living in Rome in the first century AD.
Fig. 1.8: Self-portrait of Leonardo da Vinci Red chalk 33.3 × 21.3 cm (13 1/8 × 8 3/8 in) Biblioteca Reale, Turin
He made the description of lithotomy that was to hold good with little change through to the end of the 18th century. In Celsus's time catheters were made of bronze and some of those demonstrating the traditional double curve were found in the excavations of Pompeii.
Leonardo da Vinci
Intuitive surgical systems named its robotic system after Leonardo da Vinci (Fig. 1.8) because he was credited for having drawn and built the world's first robot in 1495. The robot wore a suit of armor, typical of 15th century German-Italian design. It had a flexible neck and a jaw that could open and close. It could sit up, turn its head, wave its arms and make sounds to the accompaniment of automated drums. The hips, knees and ankles operated with 3° of freedom, while the shoulders, elbows, wrists and hands operated with 4° of freedom.
Da Vinci's detailed anatomical drawings allowed him to design pulley systems to emulate the complex joints and muscles of the human body. The range of motion of the wrist presented challenges to robot design but, using da Vinci's principles, engineers were able to construct a suitable model (Fig. 1.9). Although the name, da Vinci has become synonymous with the robotic prostatectomy, ironically, in all of his anatomical drawings, Leonardo da Vinci never identified the prostate.
The Greek physician Galen, living and traveling through Asia Minor in the second century AD, brought together in his writings many of the theories of medicine that were current in his day. He described lower urinary tract obstruction and supported Celsus's technique of lithotomy.
Fig. 1.9: Sketch of urinary tract by Leonardo da Vinci(Courtesy: Murphy Leonard JT. History of Urology Charles C Thomas. Publisher Springfield, Illinois, USA; 1972)
MIDDLE AGES TO THE EIGHTEENTH CENTURY
Lithotomy
Operations to remove bladder stones via the perineum were performed by Hindus, Greeks, Romans and Arabs. Ammonius Lithotomos (200 BC), Celsus (first century) and the Hindu surgeon Sushruta produced early descriptions of bladder stone treatment using perineal lithotomy (Fig. 1.10). Like other surgery before the invention of anesthesia, these procedures were intensely painful for the patient (Fig. 1.11).
In 1000, Abu al-Qasim al-Zahrawi (Abulcasis), in his Al-Tasrif, described a more successful extraction of bladder and kidney stones from the urinary bladder by using a new instrument he invented, a lithotomy scalpel with two sharp cutting edges; and a new technique he invented, perineal cystolithotomy which allowed him to crush a large stone inside the bladder, “enabling its piecemeal removal.”
Fig. 1.11: The image shows the surgeon about to operate with his assistants and with no anesthetic (preanesthetic era)
This innovation was important to the development of bladder stone surgery as it significantly decreased the death rate previously caused by earlier attempts at this operation. With it's origin in the techniques of the Sushruta and later that of Celsus, two types of perineal lithotomy were developed. Hence surgeons were slow to take up this technique.
The first successful suprapubic lithotomy was probably done by Pierre Franco in the early 16th century, removing a large calculus from a child's bladder by this approach. James Douglas, who is famous of pouch of Douglas, described the surgical anatomy of the bladder in 1717.
Special surgical instruments (Figs 1.12 and 1.13) were designed for lithotomy, consisting of dilators of the canal, forceps and tweezers, lithotomes (stone cutter) and cystotomes (bladder cutter), urethrotomes (for incisions of the urethra) and conductors (grooved probes used as guides for stone extraction). The patient is placed in a special position in a lithotomy surgical table called the lithotomy position (which curiously retains this name until present for other unrelated medical procedures).
Endourethral Lithotomy
The origin of this technique goes back to ancient Egypt with attempts to dilate the urethra and primitive procedures to fragment bladder calculi.
Probably the most eminent lithotriptist of his days was the London surgeon Sir Henry Thompson who successfully dealt with stone of King Leopold I of Belgium in 1863.
Fig. 1.12: Heard's acoustic bladder sound(Courtesy: Murphy Leonard JT. History of Urology Charles C Thomas. Publisher Springfield, Illinois, USA; 1972)
Civiale had carried out multiple lithotrities in 1862. Later Sir Henry operated on Napoleon III (Fig. 1.14). Litholapaxy and the evacuating of the stone debris was then pioneered by Henry J Bigelow (1818–1890) in the United States and Sir Peter Freyer in England (Fig. 1.15).
Notable People with Bladder Stones
Notable people who suffered from bladder stones include King Leopold I of Belgium, Emperor Napoleon Bonaparte, Emperor Napoleon III, Peter the Great, Louis XIV, George IV, Oliver Cromwell, Benjamin Franklin and the scientist Sir Isaac Newton.
NINETEENTH CENTURY
Vesalius (1514–1564) corrected their studies in 1543 and can certainly be considered to be the father of urologic anatomy.
Fig. 1.14: Sir Henry Thompson performing lithotrity upon Napoleon III. The anesthetist is Joseph Clover and Sir William Gull is standing behind Sir Henry Thompson(Courtesy: Murphy Leonard JT. History of Urology Charles C Thomas. Publisher Springfield, Illinois, USA; 1972)
Gabriel Fallopius (1523–1562) demonstrated intrarenal anatomy, Bartholomeus Eustachius (1520–1574) took these studies further and Lorenzo Bellini (1628–1704) and Marcello Malpighi (1628–1694) refined them. These and many other anatomic discoveries laid the foundation for the advances in physiology and surgery that contributed to the development of modern urology.
History of Catheters and Urological Instrumentation
The earliest catheters were fashioned from reeds, straws and curled up palm leaves. Hollow leaves of Allium fistulosum, an onion plant coated with lacquer, were used as catheters in China around 100 BCE. The Sushruta Samhital, an early Indian surgical text (circa 1000 BCE), described gold, silver, iron and wood tubes lubricated with ghee (liquid butter) for evacuation of urine, management of urethral stricture disease, instillation of medication and assistance in lithotomy.
Early catheters were usually made of metal, often bronze (Fig. 1.16) and later silver, copper and brass, but other materials including treated paper, cloth impregnated with wax, horn or green bamboo sticks were also used. But only after Charles Goodyear earned in 1851 patent for vulcanized or moldable hard rubber could catheters be custom-shaped. Frenchmen Malecot and de Pezzer laid the groundwork with their “four-winged” and “mushroom” models. Before them (1853), Jean Reybard inflated a bladder bag to create the “grandfather” of retained devices.
In 1860, Auguste N laton (1807–1873), physician to Napolean III, introduced a vulcanized rubber catheter which lives on today as the straight red rubber catheter with a side hole near its tip. Joseph Charri re, a French instrument maker (1803–1876) and contemporary of Nekton, developed a sizing system that is still used today. The system known as the French scale, defines the caliber of each catheter as the diameter in millimeters times three. Thus a 1 mm diameter catheter is 3 French.
Frederic EB Foley (1891–1966), a urologist from St Paul, Minnesota, used newly discovered methods for dipping and coagulating latex on metal forms to devise a one-piece latex self-retaining balloon catheter (Fig. 1.17). Dr Foley's demonstrated the first production model at the annual meeting of the American Urological Association (AUA) in 1935.
No other invention had the staying power of Frederick EB Foley's rubber balloon catheter. With its introduction in June 1935, doctors finally had an indwelling hemostatic device that could be held in place. Nothing matched Foley's single, continuous design in ensuring drainage postoperative or short term. A balloon catheter is still referred to simply as a “Foley” (Figs 1.18A to D).
Fig. 1.16: Bronze catheters used during first century AD by Celsus(Courtesy: Murphy Leonard JT. History of Urology Charles C Thomas. Publisher Springfield, Illinosis, USA; 1972)
University of Michigan's urologist Jack Lapides introduced clean intermittent self catheterization. In 1971, it came to light that germs were not the only cause of persistent urinary tract infections but persistent stagnant urine residuals were also a major contributing factor. It was not understood during that time that the stagnant urine is a favorable growth media for the urinary pathogens. Lapides showed clearly that intermittent catheterization was safer than an indwelling catheter. The refinement of urethral catheter was refined further in the 19th century along with the steady advancement in urologic techniques. Previously, a Malecot or de-Pezzar catheter was inserted into the bladder with an open technique or through a metal cannula. Currently, these have been superseded by the modern silastic balloon catheter fitted with integral trocher.
History of Development of Cystoscopes
The cystoscope (Figs 1.19 to 1.27) is perhaps the most significant of all contributions of urology to medicine (Figs 1.19 to 1.27). The cystoscope is a thin and lighted instrument used to look inside the bladder and remove tissue samples or small tumors. Paving the way for endoscopy and laparoscopy, the cystoscope remains one of the major ways for physician's use to look into the human body.
Since, the earlier days of medicine, physicians and healers have sought ways of looking into the living human body. However, it was not until 1807 that Philipp Bozzini (1773–1809), a young German army surgeon, frustrated by the difficulties of locating bullets in his patients, invented an instrument that was the ancestor of the modern endoscope. The device, the Lichtleiter, was a sharkskin-covered instrument housing a candle within a metal chimney (Fig. 1.19).
A mirror on the inside reflected light from the candle through attachments into the urethra, the vagina or the pharynx. One looked through a viewing window, past the mirror, down the funnel of the attachment. When the instrument was first tested in Vienna, examiners could see stones in a cadaver and were able to identify them as gallbladder stones. However, the instrument was clumsy, difficult to use and grew too hot; in short, it was impractical for clinical use. Bozzini did not live to see the fate of his invention; he died of typhoid fever shortly after demonstrating it.
Antoine Desormeaux (1815–1882), introduced his cystoscope in Paris in 1853. He was the first surgeon to succeed in designing an endoscopic instrument that had both diagnostic and therapeutic value for urology. As a light source he used a so-called gazogene lamp, which burnt a mixture of turpentine and alcohol. His endoscope was made of silver tubes into which he projected light, using a combination of lenses and a mirror set at an angle of 45°.
Francis Cruise, an Irish surgeon in Dublin, collaborated with Desormeaux and demonstrated his first instrument in 1865. He also designed new sheaths for examination of the urethra, bladder and other body cavities, and urologists using a bladder catheter filled with boric solution were able to inspect the greater part of the bladder mucosa.
Figs 1.18A to D: (A) Foley's catheter; (B) Plain urethral catheter; (C) Malecot catheter for suprapubic catheterization (SPC); (D) Pigtail catheter
Fig. 1.19: Cystoscopy candle-fueled Lichtleiter(Courtesy: Developed in the 1800s by Philipp Bozzini American Urological Association)
Fig. 1.21: Porter carrying apparatus needed for cystoscopy(Courtesy: Murphy Leonard JT. History of Urology, Charles C Thomas. Publisher Springfield, USA; 1972)
Inspired by Bozzini's instrument and led by such visionaries as Antonin Jean Desormeaux, Francis Richard Cruise and Joseph Grünfeld, German physician Maximilian Nitze introduced the first direct-vision scopes to view living patient urethras, bladders and larynxes. Premiering his first “kystoskop” on October 2, 1877, Nitze utilized an incandescent platinum wire loop (Fig. 1.23) to illuminate the bladder from inside and a system of lenses to magnify its image for the viewer outside.
Howard Kelly, the chairman of Obstetrics/Gynecology at Hopkins, for instance, used a small speculum-like tube (Fig. 1.24) that was used with the patient in the knee-chest position. Initially, it had neither light nor lens system attached to it.
Endoscopic devices gained widespread appeal only after the development of the incandescent lamp by Thomas A Edison, in 1880. Once Edison's bulb was miniaturized into a low-amperage bulb by manufacturers in the United States, instrument makers around the world could produce simple, inexpensive and easily manageable illuminated cystoscopes.
British scientist John Tindall had established the principle of internal light reflection (Fig. 1.25) inside the glass rods in 1872.
Dr Harold Hopkins (Fig. 1.28) introduced a revolutionary telescope in 1960.
Fig. 1.22: Nitze's opening cystoscope with wire snare for avulsion of tumor or application of cautery-one of several models(Courtesy: Murphy Leonard JT. History of Urology, Charles C Thomas. Publisher Springfield, USA; 1972)
Fig. 1.25: Premitive cystoscope use to see the bladder with a reflected light(Courtesy: Murphy Leonard JT. History of Urology Charles C Thomas. Publisher Springfield, USA; 1972)
Fig. 1.26: Howard Kelly performing ureteric catheterization with aerocystoscopy. Note style of catheter held in teeth(Courtesy: Murphy Leonard JT. History of Urology Charles C Thomas. Publisher Springfield, USA; 1972)
Instead of using tiny order of accuracy and the rod-lens telescopes (Fig. 1.29) had the precision of a microscope. Dr Harold Hopkins' rigid endoscopic “rod lens” was introduced in 1960, first applied in 1967 to a cystoscope by Karl Storz, it produced glasses separated by spaces of air, he used air lenses separated by rods of glass. Needing no tubular metal to keep the lenses apart, the entire width of the telescope was available for the transmission of light.
Fig. 1.27: Brenner's catheterizing cystoscope, 1887(Courtesy: Murphy Leonard JT. History of Urology, Charles C Thomas. Publisher Springfield, USA; 1972)
Fig. 1.28: Dr Harold Hopkins who invented rigid endoscopic 'rod lens'. Introduced in with Karl Storz, 1960
Compared with previous systems, Dr Hopkins’ system provided a total light transmission that was 80 times better. Furthermore, because the rods could be held steady, it was possible to grind and coat their surfaces to a new 12brighter, sharper and larger images than previous prisms, mirrors and lenses.
German Heinrich Lamm confirmed that optic fibers could transmit body images in 1930s. Fiber-optics emerged as a practical medical technology in 1954. By the 1980s, scientists showed that fibers and lenses could be married into fiber-optic coaxial bundles, with one package of whisker-thin strands carrying light and other returning images. These slender parcels allowed greater flexibility in traversing the urinary tract, turning corners without distorting images.
Today, endoscopy is so refined that urologists can probe with slender flexible endoscope into lower urinary tract and upper urinary tract in adult and in children. TV monitor now allows the endoscopist to work via monitor and relay can be made to multiple audiences over any distances. This has proved to be a great advantage as a teaching aid globally.
Resectoscope
The resectoscope is an instrument that is inserted through the urethra and used to cut out tissue while allowing the physician to see exactly where he is cutting (Figs 1.30 and 1.31). Major uses for the resectoscope are the treatment of benign prostatic hyperplasia (BPH) and resection of the bladder tumor.
History of Transurethral Resection of Prostate
Before the development of resectoscope, the retention of urine was treated by using a suprapubic trocar for both temporary and permanent bladder drainage in cases of urinary retention. Use of intermittent self catheterization with catheters made of various materials and using oil or butter as a lubricant, was the standard treatment of those days. This “catheter life,” even in the early 20th century, had a reported mortality rate of 8%.
Fig. 1.30: Punch resectoscope; Gershom Thompson, 1935(Courtesy: Murphy Leonard JT. History of Urology, Charles C Thomas. Publisher Springfield, Illinois, USA; 1972)
Fig. 1.31: Stern-McCarthy Prostatic electrotome or resectoscope, 1932(Courtesy: Murphy Leonard JT. History of Urology Charles C Thomas. Publisher Springfield, Illinois, USA; 1972)
Number of factors was critical to the development of modern transurethral resection of prostate, such as adequate endoscopic, transurethral and intravesical illumination with the incandescent lamp cystoscope (Phillip Bozzini, Antonin Jean Desormeaux, Maximilian Nitze, Josef Leiter), electrical tissue resection using cutting current (Heinrich Hertz, Lee DeForest, Reinhold Wappler, George Wyeth), electrical cauterization using coagulating current (Edwin Beer, WT Bovie, GH Leibel) and wire loop resecting electrode (Maximilian Stern, Theodore M Davis).
Telescopic wide-field visualization and magnification (fore oblique lens by Reinhold Wappler, Hopkins rod lens system by Harold Hopkins), consolidation of instrumentation into a single, practical, workable resectoscope [Maximilian Stern, Joseph F. McCarthy, (Fig. 1.30)], description of proper technique of transurethral resection (Reed M Nesbit, William A Milner), recognition and preventive treatment of postoperative complications, such as dilutional hyponatremia or transurethral resection syndrome, and modern refinements and improvements (Hopkins lens, fiber optics, continuous flow, bipolar technology and video) made the objective of resection of tissue from the prostate or bladder possible, accurately and safely.
History of Laparoscopy in Urologic Surgery
A grandchild of the cystoscope, the laparoscope allows surgeons to perform minimally invasive surgical procedures. The foundation of modern laparoscopy was laid in 1805 when Bozzini developed the first self-contained endoscope (Bozzini, 1806). Although his concept of direct visual inspection of the urethra was fiercely rejected by his peers, other investigators pursued his original concept; among them was Nitze (1877) who was the first to introduce glass optics for magnification (Nitze, 1879).
The shift towards laparoscopy was initiated by Kelling (1901), a surgeon who was the first to apply Nitze's cystoscope introduced through a trocar, in a closed-cavity endoscopic examination of a living dog. During the initial step of this procedure, Kelling insufflated the peritoneal cavity with air using a needle to observe changes to the intra-abdominal organs at pneumoperitoneum pressures sufficient to stop intra-abdominal hemorrhage (i.e. up to 50–60 mm Hg).13
The first experimental laparoscopy was performed in Berlin in 1901 by German surgeon Georg Kelling who used a cystoscope to peer into the abdomen of a dog after first insufflating it with air (Fig. 1.32). Kelling also used filtered atmospheric air to create a pneumoperitoneum with the goal of stopping intra-abdominal bleeding (ectopic pregnancy, bleeding ulcers and pancreatitis) but these studies did not find any response or supporters. Kelling proposed a high-pressure insufflation of the abdominal cavity, a technique he called the “Luft-tamponade” or “air-tamponade”.
In 1938, Janos Veress of Hungary developed a specially designed spring-loaded needle. Interestingly, Veress did not promote the use of his Veress needle for laparoscopy purposes. He used Veress needle for the induction of pneumothorax. In 1939, Richard W Telinde tried to perform an endoscopic procedure by a culdoscopic approach in the lithotomy position. This method was rapidly abandoned because of the presence of small intestine. In 1939, Heinz Kalk published his experience of 2000 liver biopsies performed using local anesthesia without mortality.
Jacobaeus (1910), an internist in Stockholm is credited with transforming Kelling's concept into a clinical diagnostic technique, which he named Koelioskopie. Jacobaeus used a trocar with a trapdoor as a single port of entry, thus allowing for simultaneous insufflation and endoscopy of the abdominal cavity. In the United States, Bernheim (1911) performed a visual inspection of the peritoneal cavity with a proctoscope, a procedure he termed as “organoscopy”, at Johns Hopkins University.
In 1953, the rigid rod lens system was discovered by Professor Hopkins. The credit of videoscopic surgery goes to this surgeon who revolutionized the concept by making this instrument. Kurt Semm, a German gynecologist, invented the automatic insufflator in 1966. Kurt Semm introduced an automatic insufflation device in 1960 which was capable of monitoring intra-abdominal pressures. This reduced the dangers associated with insufflation of the abdomen and allowed safer laparoscopy. Gynecologists had embraced laparoscopy and thoroughly incorporated the technique into their practice from 1070. General surgeons, despite their exposure to laparoscopy remained confined to traditional open surgery.
Fig. 1.32: The first experimental laparoscopy was performed in Berlin in 1901 by German surgeon Georg Kelling
In 1977, Kurt Semm first time demonstrated endoloop suturing technique in laparoscopic surgery. Hasson introduced an alternative method of trocar placement in 1978. He proposed a blunt minilaparotomy which permits direct visualization of trocar entrance into the peritoneal cavity. A reusable device of similar design to a standard cannula but attached to an olive-shaped sleeve was developed by Hasson. Kurt Semm, a German gynecologist, performed the first laparoscopic appendicectomy in 1985. The first documented laparoscopic cholecystectomy was performed by Erich Mühe in Germany in 1985.
History of Robotics in Urology
Leonardo's robot refers to a humanoid automaton designed by Leonardo da Vinci around the year 1495. The design notes for the robot appear in sketchbooks that were rediscovered in 1950s. It is not known whether an attempt was made to build the device during Leonardo's lifetime. Since the discovery of the sketchbook, the robot has been built faithfully based on Leonardo's design (Fig. 1.33); this proved that it was fully functional, as Leonardo had planned.
The robot is a warrior, clad in German-Italian medieval armor that is apparently able to make several human-like motions (Fig. 1.34). These motions included sitting up, moving its arms, neck and an anatomically correct jaw. It is partially the fruit of Leonardo's anatomical research in the Canon of Proportions as described in the “Vitruvian Man”.
In 1985, a robot—the PUMA 560, was used to place a needle for a brain biopsy using CT guidance. In 1988, the PROBOT, developed at Imperial College, London was used to perform prostatic surgery. The ROBODOC from Integrated Surgical Systems was introduced in 1992 to mill out precise fittings in the femur for hip replacement. Further development of robotic systems was carried out by Intuitive Surgical Systems with the introduction of the da Vinci Surgical System and Computer Motion with the AESOP and the ZEUS robotic surgical system (Intuitive Surgical bought Computer Motion in 2003; ZEUS is no longer being actively marketed).
The da Vinci Surgical System comprises three components: a surgeon's console, a patient-side robotic cart with four arms manipulated by the surgeon (one to control the camera and three to manipulate instruments) and a high-definition three-dimensional (3D) vision system. Articulating surgical instruments are mounted on the robotic arms (Fig. 1.35) which are introduced into the body through cannulas. The device senses the surgeon's hand movements and translates them electronically into scaled-down micromovements to manipulate the tiny proprietary instruments. It also detects and filters out any tremor in the surgeon's hand movements so that they are not duplicated robotically. The camera used in the system provides a true stereoscopic picture transmitted to a surgeon's console. The da Vinci System is Food and Drug Administration (FDA) cleared for a variety of surgical procedures including surgery for prostate cancer, hysterectomy and mitral valve repair, and is used in more than 800 hospitals in the America and Europe.
Fig. 1.34: Leonardo da Vinci's drawing of robotic arms moved by pulleys is used by modern da Vinci surgical robots
Shortly after, the ZEUS system (Computer Motion Inc. Santa Barbara, CA) came onto the market in 1998. This system combined an AESOP system with an additional two table-mounted robotic arms. At the time, the ZEUS system came with instruments with 4° of freedom (like standard laparoscopic instruments) but in 2002 their Microwrist instruments gained FDA approval. In 2003, Intuitive Surgical and Computer Motion Inc. the two leaders in robotic surgical technology, merged. As a result, the ZEUS system has been phased out. The da Vinci system provided an array of instruments with 6° of freedom (Endowrist), greatly enhancing the laparoscopic capabilities of the surgeon. Currently the da Vinci is the only commercially available telesurgical robotic system (Fig. 1.36). The da Vinci system was first used clinically for laparoscopic cholecystectomy in 1997 and gained FDA approval the same year.
Capitalizing on the steady 3D vision and improved dexterity provided by the da Vinci system, the original technique was described by Abbou and associates (2001) and more recently, other surgeons, such as Ahlering and Menon and their associates have matured the procedure into a viable alternative to open prostatectomy. By 2005, the da Vinci Surgical System has been used to perform almost every laparoscopic urologic ablative and reconstructive procedure.
It is the single robot actually used clinically in minimally invasive surgery by various subspecialties.
It consists of two entities as illustrated and numbered hereunder: (1) a master-slave-system and; (2) the console at which the surgeon pilots the device; his assistant working next to the robotic arms and the patient (Fig. 1.37).
History of Stone Disease Management
The practice of lithotomy or cutting for the stone dates back to antiquity and appears in records from societies, such as the ancient Greeks, Chinese, Persians and Egyptians.
Frère Jacques Beaulieu, who became a monk and traveled the French countryside performing lithotomy for nominal fee and often proffered those funds to the poor, was the first to practice a lateral approach to perineal lithotomy. Frère Jacques performed more than 5,000 lithotomies in 30 years. Though his mortality rate was quite high, he was one of the most celebrated lithotomists of his time and his name lives on in children's song.
Today new technology, lithotripsy has radically transformed treatment by pulverizing stones with powerful bursts of energy. Yet before it emerged, urologists witnessed an evolution of surgical and other techniques.
While John Jones’ perineal stone procedure (1760) initiated urology's formal history in America, the more fascinating footnote may be Philip Syng Physick's (1831) extraction of 1,000 calculi from Supreme Court Justice John Marshall's bladder. At the age of 76, Marshall returned to the courtroom after his surgery.
By the 1970s, however less invasive techniques overtook open operations with “big” stone surgeries involving gentler percutaneous approaches. Today, kidney stone patients, if they require surgery, experience smaller incisions, shorter hospital stays and smoother recoveries.
While research continues, urologists have ever-evolving techniques to make calculi successfully treatable. Even more comforting is the fact that today's options are light, years better from those early lithotomists and their “cutting for the stone”.
History of Extracorporeal Shock Wave Lithotripsy
The concept of fragmenting stones by using shockwave was noted in 1950 in the Institute of Urology Kiev, Russia, but no significant work was done until only two decades ago. CH Chaussy described in 1980, the first clinical use of extracorporeal shock wave lithotripsy (ESWL) for fragmentation of renal calculi (Fig. 1.38).
In the middle and late 70s, research by E Eisenberger, C Chaussy and Forssmann (son of the Nobel Prize-winning urologist) produced an experimental lithotriptor working on dogs with implanted human kidney stones (Fig. 1.38). The successful animal testing program led to a new prototype, the Human Machine (HM1) lithotriptor and the first patient was treated with this machine on February 20, 1980.
The concept was developed from the unusual patterns of metal fatigue in aircraft and theorized that shock waves produced by supersonic flight could possibly be reflected from one part of the aircraft to others, causing the metal fatigue. Shock waves were then created using an underwater spark discharge; serendipity led to the application of this concept to urolithiasis.
The first commercially produced lithotriptor, HM3 in 1984, launched a dramatic revolution of the urologist's approach to renal calculi. This remarkable success by Dornier quickly stimulated additional research. Generation of shock waves using other modalities, such as electromagnetic membranes and piezoelectric crystals led to a market proliferation with approximately 30 different ESWL devices now available (Figs 1.39A and B).
Stone disease remains one of the most interesting aspects of urology, but noninvasive lithotripsy and endourology have replaced the open techniques for stone removal that dominated treatment from ancient times until very recently.
Fig. 1.38: Chaussy, Eisenberger and Forssman reviewing the prototype of extracorporeal shock wave lithotripsy equipment
Figs 1.39A and B: (A) Sketch showing the principle of extracorporeal shock wave lithotripsy; (B) Extracorporeal shock wave lithotripsy machine
Laser Lithotripsy
Albert Einstein assumed the theoretical existence of light amplification by stimulated emission of radiation (laser) as early as 1917. In 1960, TH Maiman discovered the fact that the ruby laser was capable of cutting and coagulating tissue. The Neodymium-Yttrium-Aluminum-Garnet laser (Nd:YAG) was developed in 1961 by LF Johnson and K Nassau. Research showed that all stones become fragmentable if the energy is absorbed and vaporization of H2O at surface and in pores of stone is achieved. Holmium YAG Laser was developed which functions at 2100 nm near infrared portion of wave spectrum. It worked efficiently independent of color and composition of stone.
History of Treatment of Prostate Cancer
In 1962, Stanford University's Malcolm Bagshaw showed that high-dose, radioactive gold celluloid radiation could be a treatment of choice for men with early (and even advanced) prostate cancers. Charles B Huggins, from University of Chicago (Fig. 1.40), made history by altering the body's hormonal milieu to slow or stop cancer cell growth. He showed that either surgically removing testicles or suppressing their testosterone action with medication could turn off the fuel to hormone-driven malignant cells.
Huggins with Clarence V Hodges, initiated their hypothesis on benign enlarged prostates of dogs, eliminating the testicles to shrink the gland and then injecting hormones before measuring regrowth. Huggins with Hodges, RE Stevens Jr and William W Scott, confirmed that malignant prostate cells had a similar dependence on hormones. Castration and/or doses of the female hormone estrogen could slow or retard tumor growth.17
His epic discovery earned him the Nobel Prize in 1966. Huggins also tried to remove the adrenal and pituitary glands to block testosterone formation completely. Both methods peaked briefly in the 1940s, but disappeared because of too many endocrine complications and very few successes.
Based on its power to counteract testosterone, estrogen therapy emerged quickly after Huggins’ successes. But by the early 1970s, multicenter studies documented that men on high doses had significantly higher non cancer death rate. Fortunately, by reducing dosages, urologists could retard the tumors without risking the accompanying heart problems.
Today, synthetic luteinizing hormone-releasing hormone agonists (which block the production of testosterone) are the medication mainstay for advanced cancer. Since the 1980s, injectable drugs, such as leuprolide acetate and goserelin acetate, are administered every 3 or even 12 months to shut down testosterone production. In the interim, oral androgen-blocking agents, such as flutamide, boost the overall effect by preventing testosterone from attaching to prostate cells. Together, these medications bring dramatic, even miraculous improvements to quality of life.
Physicians soon may have therapies that derail the disease long before Huggins's therapy is necessary. With science shedding new light on this old threat, their patients may bask in the reality, not just the hope of a cure.
History of Radiologic Imaging
With the introduction of X-rays by German professor Wilhelm Conrad Röntgen (Fig. 1.41) on November 8, 1895, physicians had a noninvasive tool to survey the urinary tract.
Fig. 1.42: The first X-ray picture precludes the accidental discovery of X-ray. In 1895, a German physicist named Wilhelm Konrad Rontgen accidentally discovered a form of radiation that could penetrate opaque objects and cast ghostly images on a photographic plate. Rontgen called his discovery X-radiation (the X was for “unknown”), and to prove its existence he took a picture of his wife's hand by exposing it to a beam of its rays. The result showed the bones of her hand and a ring on her finger as dark shadows on the photographic plate. It was the first X-ray image ever deliberately recorded
Other technologies, such as ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI), would eventually shine in their ability to delineate organs, diagnose disease and determine treatment, but nothing changed the medical landscape quite like the notion of a penetrating invisible ray that could show the body's interior. Röntgen called them “X-rays” (Fig. 1.42) because of their unknown origins; others identified them as high-energy electromagnetic radiations.18
Physicians eagerly embraced the discovery and set out to shed light on the body, particularly the urinary tract. Curiously, a Scottish otolaryngologist, John Macintyre would make the first radiograph of a kidney stone in a patient on April 2, 1896.
While Röntgen had demonstrated that dark and light areas on photographic film were caused by differential absorption of rays passing through various densities, it was obvious that additional contrast would be needed to distinguish kidneys, ureters or bladder.
But not until 1906, when German surgeons Alexander von Lichtenberg and Fritz Voelcker reported success instilling silver solution, Collargol, through the bladder up into the kidneys, would physicians have a way to evaluate specific urinary tract areas. Retrograde pyelography made previously undisclosed genitourinary disorders vulnerable to disclosure. Swick's intravenous pyelogram heralded a new era in urologic diagnosis. Finally, doctors had a less invasive and more comprehensive method of imaging stones, cysts and tumors with a relatively nontoxic medium.
In time, other sophisticated imaging techniques, such as ultrasonography, CT and MRI scanning, would dramatically reduce the need for excretory urography by providing views it could not impart. Doctors could now diagnose any urinary tract disorder with greater speed, depth and accuracy using tests that were noninvasive, painless and safe.
Ultrasound, which uses the same Doppler sonar that quietly detects submarines and which dolphins use for echolocation, emerged as a gentle diagnostic tool when it debuted in the 1950s. By measuring the acoustical delays of high-frequency sound waves pulsating through the body, sonography enjoys an indispensable role assessing, differentiating and evaluating many problems in the urinary tract.
History of Computed Tomography Scan
Computed tomography was discovered independently by a British engineer named Sir Godfrey Hounsfield and Dr Alan Cormack. It has become a mainstay for diagnosing medical diseases. For their work, Hounsfield and Cormack were jointly awarded the Nobel Prize in 1979. Computed tomography scanners first began to be installed in 1974. Currently, because of advances in computer technology, CT scanners have vastly improved patient comfort because they are now much faster (Fig. 1.43). These improvements have also led to higher resolution images, which improve the diagnostic capabilities of the test.
Computed tomography scanning added a dramatic, high-resolution dimension to uroradiology when it appeared in 1972. By capturing exquisite image slices of tissue, it became essential in evaluating the entire spectrum of urological diseases. The “spiral CT” has only reinforced its position by producing volumes of real-time data in just seconds.
In the early 1900s, the Italian radiologist Alessandro Vallebona proposed a method to represent a single slice of the body on the radiographic film. This method was known as tomography. The idea is based on simple principles of projective geometry: moving synchronously and in opposite directions the X-ray tube and the film, which are connected together by a rod whose pivot point is the focus; the image created by the points on the focal plane appears sharper, while the images of the other points annihilate as noise. This is only marginally effective, as blurring occurs only in the “x” plane.
There are also more complex devices which can move in more than one plane and perform more effective blurring. The first commercially viable CT scanner was invented by Sir Godfrey Hounsfield in Hayes, United Kingdom at EMI Central Research Laboratories using X-rays in 1967.
History of Magnetic Resonance Imaging
Magnetic resonance imaging, as with all medical imaging techniques, is a relatively new technology with its foundations beginning during the year of 1946. Felix Bloch and Edward Purcell (Fig. 1.44) independently discovered the magnetic resonance phenomena during this year and were later awarded the Nobel Prize in 1952. Until the 1970s, MRI was being used for chemical and physical analysis.
Then in 1971, Raymond Damadian (Fig. 1.45) showed that nuclear magnetic relaxation times of tissues and tumors differed in motivating scientists to use MRI to study disease.19
With the advent of CT (using computer techniques to develop images from MRI information) in 1973 by Hounsfield and echo-planar imaging (a rapid imaging technique) in 1977 by Mansfield, many scientists over the next 20 years developed MRI into the technology that we now know today.
Magnetic resonance imaging technology provided unique structural and biochemical information when it emerged in the 1980s. By measuring the absorption of high-frequency radio waves beamed into a body subjected to magnetic fields, it takes the assessment of complex masses and many urological diseases to a new precision level. Edward Purcell of Harvard University and Felix Bloch of Stanford University were awarded the Nobel Prize in physics in 1952 for magnetic resonance studies beginning in 1946. While magnetic resonance was being studied in the 1940s and 1950s, it was not until the 1980s that an MRI scanning machine (Fig. 1.46) was available as a diagnostic resource on humans.
These technologies have given urologists a great versatility, but they are also a harbinger of future developments as scientists search for more effective ways to diagnose and screen patients. Urologists may soon add “digital” and “virtual reality” to their daily lexicon, reading filmless “real-time” images on hand-held computer devices and rehearsing “virtual” surgeries before touching the patients. With such possibilities illuminating its future, uroradiology's next 100 years promise to be brighter than the past. Yet nothing has ever enlightened urologists quite like the inventive genius of Röntgen and the first radiologic milestone—the X-ray.
History of Treatment of Urinary Incontinence
Leaking urine are often the most neglected, especially by women who make up 85% of incontinence sufferers. In both male and female, the condition appears in various forms, involving the bladder, urethra or the sphincter, as well as the central nervous system, and triggered by various causes. Stress incontinence is common to women; postsurgical incontinence is most frequent in men who have undergone prostatic surgery.
Civilization's earliest physicians first postulated that sphincter breakdown or bladder weakness caused leaking, but it wasn't until the 1970s, when urodynamic equipment became sophisticated that urologists began to understand the mechanisms that control voiding.
Johns Hopkins's gynecologist Howard Kelly introduced the first plication or tucking, operation for women in 1914. This colporrhaphy, surgical repair of the vagina secured the area of the bladder neck with stitches on either side of the urethra.20
In 1949, a group of specialists, led by urologist Victor F Marshall, produced the Marshall-Marchetti-Krantz (MMK) procedure, a retropubic suspension of the bladder neck that used an incision in the lower abdomen. Through the incision, urologists stitched the tissue surrounding the bladder neck to the bone or supporting structures.
Both the MMK procedure and JE Burch's 1961 minimally invasive variation (urethropexy) yielded easy access to immobilize the junction. Another version is the transvaginal approach to bladder suspension—pioneered in 1959 by AJ Pereira and since modified by other urologists, including Thomas Stamey, Shlomo Raz and RF Gittes. The transvaginal approach involves elevating the bladder neck with sutures placed in the abdominal or pelvic walls.
Yet the bigger milestones involved the use of internal and external devices to compress the urethra or sphincter. The forerunners of today's Cunningham and Baumrucker penile clamps were crude devices that emerged circa 1750 that were used outside the penis to clamp it and constrict the urethra.
Nearly two centuries later, in 1947, Minneapolis urologist Frederick EB Foley introduced the first artificial sphincter. Patients controlled the artificial sphincter by compressing a pocket device to inflate a pneumatic cuff positioned around surgically segmented portions of the urethra to control the flow of urine.
In 1961, a Veterans Administration urologist in Albany, New York, John Berry, became the first to restore continence by compressing the urethra with implanted acrylic and Silastic blocks. While early results were encouraging, these devices proved disappointing because they shifted out of place and eroded into the urethra (Fig. 1.47). In 1978, Joseph J Kaufman, of the University of California, Los Angeles, introduced an implantable silicone-gel “pillow” to cause urethral resistance, based on earlier versions, but implanted artificial sphincters, the surgical brainchild of Baylor College of Medicine's F Brantley Scott, soon surpassed the prosthesis. First introduced in 1973, this device would become a viable solution for post-prostatectomy patients suffering from incontinence. Today's model works by keeping the urethra closed until necessary. To empty the bladder, the patient squeezes and releases a scrotum pump, which empties fluid from a sphincter cuff (positioned around the urethra) into a pressure-regulating balloon (Fig. 1.48). With pressure relieved from the urethra, urine flows freely. As the bladder empties, the fluid of the balloon automatically moves back into the cuff, squeezing the urethra shut and preventing leaks.
The vast majority of patients suffer from bladder function-related incontinence. Surgery is rarely needed in these cases. Urologists have medications to tap for both genders to improve urine storage, improve bladder emptying or increase sphincter closure and relaxation. Oxybutynin chloride (Ditropan XL) and tolterodine tartrate (Detrol LA) reduce overactive bladders by blocking acetylcholine, the chemical that causes muscle contractions. These drugs are hardly the end-all. As urologists look forward, they anticipate more effective drugs delivered in patches or implantable devices. A bladder pacemaker is used to control overactive bladder.
At the University of Pittsburgh Medical Center, Michael Chancellor and his colleagues are researching the effects that stem cells can have on the growth of new tissue in denervated rat sphincters. In the future, it could 21be possible to rehabilitate “worn-out” sphincters and other organs to restore urologic health without implants, pharmaceuticals or surgery.
History of Management of Female Sexual Dysfunction
Not since William Masters and Virginia Johnson described vaginal changes during sexual arousal in 1966 has so much attention been paid to female physiology as it relates to sexual function or the lack thereof.
In 1997, more than 30 years after Masters and Johnson published their groundbreaking book, Human Sexual Response, Boston University's Kwangsung Park suggested that diminished blood flow reduced arousal in the clitoris and vagina, just as it did in the penis. With animal models, he was the first to show that a woman's problems could be physiological.
The lack of consensus on definitions of what female sexual dysfunction was clinically and the fact that psychologists and physicians had been working independently up to that point laid the ground for a 1998 international meeting that delivered a roadmap for female sexual dysfunction. For the first time, a multidisciplinary panel sponsored by the American Foundation for Urologic Disease, standardized existing disorders of sexual arousal, desire, orgasm and pain for women, confirming that they could be triggered by physiological and psychological causes—the need for additional research in the area.
Yet, despite the accelerated pace in recent years, research on female sexual dysfunction still lags behind that of men who, for centuries, have taken desperate measures to recapture their sexual vigor. In 2000, the FDA approved the first female prosthesis, the EROS clitoral device.
History of Management of Male Sexual Dysfunction
There was no practical solution for the management of sexual dysfunction in male. Herbal and traditional medicine was available, but with no practical impact. In 1973, F Bradley Scott and his Houston colleagues had succeeded in implanting a device into the penis that could be pumped with saline to achieve erection. Shortly thereafter, Michael Small and Hernan Carrion introduced an implantable, rigid rod as prosthesis. While others added silver wire and hinges, these models were the prototypes of today's prosthesis, but the introduction of the penile prosthesis (Fig. 1.49) paled in comparison to British physiologist Gile Brindley's dramatic demonstration at the 1983 Annual Meeting of the AUA. Brindley closed his lecture by dropping his pants to reveal a perfectly-erect phenoxybenzamine-induced erection.
During the same period, French vascular surgeon Ronald Virag introduced the intracavernosal self injections (Fig. 1.50) with injectable phentolamine and papaverine. In the meantime, two functional tests for penile circulation were developed: one was a duplex ultrasound test by Tom F. Lue at the University of California, San Francisco, and the other was dynamic cavernosometry and cavernosography by Irwin Goldstein at Boston University.
Moreover, at the University of California, Los Angeles, Jacob Rajfer and Louis Ignarro (a Nobel laureate) identified nitric oxide as the principal neurotransmitter for penile erection. Their work led to the development of PD5 inhibitor. Sildenafil citrate appeared in market in the name of Viagra from Pfizer in the late 1990s. Since the advent of sildenafil citrate, two other drugs vardenafil and tadalafil have also entered the erectile dysfunction (ED) arena.22
GREAT MIND AND PHILOSOPHERS IN UROLOGY
Philipp Bozzini (1773–1809)
Philipp Bozzini (Fig. 1.51) born in Frankfurt, Germany on May 25, 1773, went to school in Mainz where he began to study medicine. In 1794, he went to the University of Jena in Germany and eventually returned to Mainz where he received his doctorate in 1796.
Bozzini was fascinated with creating an instrument that would allow a physician to look into the inner cavities of the human body. He first presented his idea, the Lichtleiter or “Light Conductor” to the public in 1804 and officially on February 7, 1805. In July of 1806, the instrument was demonstrated at a scientific session in Frankfurt and it was noted that the application of his instrument for the inspection of the pharynx and the nasal cavities was indeed remarkable. Bozzini presented his first publication in 1806 in Hufeland's Journal of Practical Medicine, Volume 24, under the title “Light Conductor, an Invention for the Viewing of Internal Parts and Diseases with Illustration.” Bozzini's invention was honored and it was mentioned as the first laryngoscope. After saving 42 of his patients suffering from typhoid fever, Bozzini succumbed to it himself on April 4, 1809.
Sir Alexander Fleming
Sir Alexander Fleming (Fig. 1.52) was born at Lochfield near Darvel in Ayrshire, Scotland on August 6, 1881. He attended Louden Moor School, Darvel School, and Kilmarnock Academy before moving to London where he attended the Polytechnic. Early in his medical life, Fleming became interested in the natural bacterial action of the blood and in antiseptics. He was able to continue his studies throughout his military career and on demobilization, he settled to work on antibacterial substances which would not be toxic to animal tissues.
In 1921, he discovered that in tissues and secretions, an important bacteriolytic substance exists, which he named lysozyme. About this time, he devised sensitivity titration methods and assays in human blood and other body fluids, which he subsequently used for the titration of penicillin.
In 1928, while working on influenza virus, he observed that mould had developed accidently on a staphylococcus culture plate and that the mould had created a bacteria-free circle around itself. He was inspired to further experiment and he found that a mould culture prevented growth of Staphylococci, even when diluted 800 times. He named the active substance “penicillin”. Sir Alexander Fleming was awarded the Nobel Prize in Physiology or Medicine in 1945.
Frederic Eugene Basil Foley, MD (1891–1966)
Frederic Eugene Basil Foley (Fig. 1.53), born in St. Cloud, Minnesota in 1891, Frederic Eugene Basil Foley, MD started out as a language major, teaching English, as he earned his bachelor's degree from Yale in 1914. He received his medical degree from “The Johns Hopkins School of Medicine” in 1918 and worked for the next 2 years with William Halsted, MD in the general surgical wards. He then spent some time with Harvey Cushing, MD and from 1920–1921, was a member of the surgical house staff of the Peter Brigham Hospital in Boston.
Dr Foley is best known to modern urologists as the man whose name is attached to the self-retaining balloon catheter.
Dr Foley was one of a number of urologists who had worked with various types of catheters to develop a self-retaining instrument.
Dr Foley also invented a hydraulic table and was probably the first to describe an artificial sphincter, an inflatable pneumatic cuff that was placed around the urethra, partially isolated from the penile shaft by creating a “suitcase handle.” A few years later, he presented his rotatable resectoscope that was somewhat bulky and like most others of its kind, did not survive the test of time. Dr Foley died in 1966 of lung cancer.
Harold Hopkins, MD (1918–1994)
Harold Hopkins, MD was born on December 6, 1918 in the United Kingdom and won a scholarship to the Gateway School. He went on to Leicester University where he studied physics and mathematics and obtained his degree in June 1939. At the beginning of the war, his military service was deferred and he was sent to work for a firm of optical instrument-makers in Barnet who were developing a variety of instruments for the war effort. Upon entering the army, he rapidly rose through the ranks, becoming Lance Corporal.
After the war, Dr Hopkins became the research fellow at Imperial College, London in 1947 and quickly became lecturer and reader. Influence from Nairs Craig and another friend, Hugh Gainsborough, MD, directed him towards optical physics. Dr Gainsborough pushed Dr Hopkins to create new instruments for performing gastroscopies.
Between 1954 and 1970, three inventions introduced by Dr Hopkins changed the face of endoscopy and paved the way for minimally invasive surgery. First, came the flexible light guide made up of bundles of glass fibers, each coated with glass of a different refractive index, along which light of unlimited brightness could be guided into any body cavity. This innovation addressed the problem of a century of rigid metal tubes that were used as endoscopes.
The second invention was Dr Hopkins’ revolutionary telescope. Instead of using tiny glasses separated by spaces of air, he used air lenses separated by rods of glass. Needing no tubular metal to keep the lenses apart, the entire width of the telescope was available for the transmission of light. Compared with the prewar systems, Dr Hopkins’ system provided a total light transmission that was 80 times better. Furthermore, because the rods could be held steady, it was possible to grind and coat their surfaces to a new order of accuracy and the rod-lens telescopes had the precision of a microscope. The powerfully illuminated images amazed the older generation of endoscopists.
The third invention was to coil the glass fibers on a wheel and glue them together at one point at which they were cut. At this point, the fibers were enclosed in a loose sheath so that they were entirely flexible. Where they were cut, the fibers coincided with each other so that an image put at one end came out at the other in dots, like an image of a newspaper photograph. A new family of flexible endoscopes quickly emerged, making it possible to perform gastroscopy, colonoscopy, bronchoscopy, cystoscopy and laryngoscopy without danger or great discomfort. The instruments made it possible to take biopsies, cut strictures, remove stones, destroy small tumors and stop bleeding with diathermy or laser.
Dr Hopkins first filed a patent application for the rod-lens system in 1959. However, the English and American companies to whom he offered the system displayed little interest. The situation changed in 1965, when Professor George Berci informed Karl Storz, a manufacturer of precision medical instruments, about the principle of the rod-lens system. Storz immediately recognized the potential of the rod-lens system even though the first laboratory sample of the rod-lens telescope that he examined was still inferior to the conventional lens systems of the time in terms of optical quality. Thus, two talented individuals, a scientist and a precision instrument maker, enabled urology to make tremendous advances in the science of endoscopy and cystoscopy. Dr Hopkins died in 1994.
Joseph Francis McCarthy, MD (1874–1965)
Joseph Francis McCarthy (Fig. 1.54), MD, born on June 12, 1874 in Yonkers, New York. Dr McCarthy studied and worked at the urologic clinics of Berlin, Vienna and Paris. After his return to the United States, he worked at the New York Postgraduate Medical School and Hospital and was appointed as the professor of urology in 1917.24
He also became a clinical professor at the Columbia University College and in 1938 accepted the directorship of the department of urology at the New York Polyclinic Medical School and Hospital until 1940.
Dr McCarthy had an avid interest in diagnostic procedures and instruments. Among his best known instruments are his foroblique lens that he designed with Reinhold Wappler of ACMI and a pan endoscope for this lens system. His other instrument is based on the developments of Maximilian Stern and TM Davis and is still known as the Stern-McCarthy resectoscope. In 1941, Dr McCarthy was awarded the Francis Amory Prize by the American Academy of Arts and Sciences for the development of such urologic instruments. His resectoscope led to the development of numerous modifications, all based on his design. It is still used in many places. Dr McCarthy died on January 21, 1965.
Charles Brenton Huggins, MD Nobel Laureate in Urology (1901–1997)
Nobel Prize winner Charles B Huggins, MD (Fig. 1.55) was born on September 2, 1901 in Halifax, Nova Scotia where he went to public school and college. He then went to Harvard Medical School, where he was the youngest student in his class and graduated in 1924. He subsequently moved to the University of Michigan where he did his internship and began his specialty training.
He continued this training at the University of Chicago where he was offered a position as a research assistant and shortly thereafter, the directorship of the division of urology.
Dr Huggins was known for his curiosity, creativity and almost old-fashioned hard work, frequently coupled with his delicate humor. His first major research dealt with induced transformation of one cell type into another, transforming fibrous tissue into bone by implanting bladder epithelium in a different host site. Dr Huggins wrote about this: the actual value of this spectacular experiment was to lead a young practitioner into the delights of discovery in the exciting world of research.
His next research activity dealt with the relation of body temperature to hematopoiesis in bone marrow. This work, based on transplantation of bone marrow from a rat tail into the abdomen, resulted in one of the three gold medals he received from the American Medical Association.
In the late 1930s (with his students Clarence V Hodges and William W Scott), he studied the relationship between the endocrine system and function of the prostate gland, and later the control of inoperable prostate cancer. Until then, metastatic pain had been treated by a radiation of nerve roots and through successively larger doses of alkaloids.
Hormonally-induced regression of prostatic carcinoma and particularly the resolution of pain were many times quite spectacular. “Humanity owes a great debt to Charles Huggins,” said Paul Talalay, Director Emeritus of the pharmacology department at The Johns Hopkins University and a previous student and collaborator of Dr Huggins.
In October 1966, Dr Huggins received the highest decoration in the scientific world, the Nobel Prize for Physiology and Medicine, jointly with the virologist Peyton Rous. It honors the importance of Huggins’ work and research that influenced other scientists and their research relating to the behavior of cancer cells. His discovery opened an era of rational chemotherapy of 25malignant diseases through manipulation of the endocrine regulation.
He was able to demonstrate in 1951 that breast cancer was, like prostate cancer, dependent on specific hormones and that advanced breast cancer could be influenced positively through hormonal manipulation. However, only 30–40% of women with breast cancer responded positively to this treatment. Huggins, searching for a method to predict positive responses, convinced his colleague Elwood Jensen at the Ben May Laboratories in Chicago to develop a method to identify estrogen receptors. This has led to today's classification of breast cancer as estrogen-receptor positive or negative, an important prognostic and therapeutic marker.
Dr Huggins received numerous awards and honorary degrees and in addition to the Nobel Prize received the “Pour L’Merit Order of the Federal Republic of Germany” in 1958. The AUA awarded Dr Huggins the Ramon Guiteras Award in 1966. He was the last of the original eight faculty members of the University of Chicago and died on January 12, 1997 at the age of 95.
Jack Lapides, MD (1914–1995)
Jack Lapides, MD (Fig. 1.56) was born in 1914 in Rochester, New York. His entire academic career was spent at the University of Michigan where his urologic training was under the aegis of Dr Reed Nesbit. He later became the chief of the section of urology from 1968–1984.
Dr Lapides published extensively and concentrated on topics pertaining to bladder physiology and the neuropathic bladder. His greatest contribution was simple but revolutionary development of clean, intermittent catheterization. In 1987, the AUA awarded Dr Lapides the Ramon Guiteras Medal. He died on November 14, 1995.
Terence Millin, MD
Terence Millin, MD (Fig. 1.57) was born in County Down, Ireland in 1903. After studying at St. Andrew's College in Dublin and Trinity College, he studied medicine at Middlesex Hospital and Guy's Hospital in London.
Dr Millin held the position of senior house surgeon at the General Hospital in Northampton and assistant surgeon at Sir Patrick Dun's Hospital in Dublin. He then went to London and became a specialist in genitourinary surgery. Dr Millin created an operation for urinary incontinence in men and by the early 1940s he was well versed in the technique of transurethral resection.
In 1945, Dr Millin published a paper in “The Lancet” that introduced the retropubic approach to prostatectomy, the first alternative to the perineal approach promoted by American surgeons.
Hugh Hampton Young, MD (1870–1945)
Hugh Hampton Young, MD (Fig. 1.58) was born in San Antonio, Texas in 1870. He attended the University of Virginia where, in 4 years, he received a bachelors, masters and medical degree by 1894. He returned to San Antonio to begin a surgical practice but realized his limitations very quickly and decided to go to “The Johns Hopkins Hospital” for postgraduate education. Working in the surgical dispensary, he eventually obtained a position as a resident on the surgical wards. By 1897, three years after graduating from medical school, Dr Halsted, the chief of surgery asked Dr Young to take charge of the “genitourinary surgery division.”
Thus began the career of the individual who is considered the “Father of American Urology.”
Dr Young remained at Hopkins and developed a number of innovative instruments and techniques. His first new instrument was the “punch” for blind resection of obstructing bladder neck and prostatic tissue, which led to the development of numerous others.
Dr Young was president of AUA in 1909 and became president of the International Association of Urology in 1927. While recuperating from a herpes zoster infection in 1940, Dr Young dictated his last major book: “Hugh Young: A Surgeon's Autobiography.” He died after several heart attacks in 1945 in Baltimore.
Maximilian Carl-Friedrich Nitze, MD (1848–1906)
Maximilian Carl-Friedrich Nitze, MD (Fig. 1.59) was born in September of 1848 in Berlin, Germany. He studied medicine in Heidelberg, Würzburg and Leipzig. Nitze obtained his medical degree in 1874 and made it his life's task to develop endoscopes with new properties and a new range of applications. On October 2, 1877, Nitze used a cadaver to demonstrate his “Kystoskop” and “Urethroskop” in Dresden. On May 9, 1879 he and an associate demonstrated the instrument in Vienna on a living patient.
Nitze returned to Berlin, where he opened a private institute for bladder and kidney disease and also gave special cystoscopy courses for colleagues from Europe and abroad.
Initially striving for improvements, Nitze eventually became so rigid that he would not tolerate any change in the optics of his instruments.
In 1889, he published the first textbook of cystoscopy. The year 1887 had seen the development of the Edison light bulb and the continuation of improvements in endoscopic instruments. It was several years before Nitze agreed to incorporate the small new light bulb of Henry Koch and Charles Preston into his cystoscope. He continued to develop the irrigation cystoscope, the photocystoscope and the operating cystoscope in collaboration with the instrument makers Hartwig, Loewenstein, Hirschmann and Heyneman. In 1894, he published the first atlas of cystoscopy. In 1902, the AUA was founded and Nitze became an honorary member. Two years later, on the silver anniversary of the first live demonstration of the cystoscope, he was showered with letters of recognition from around the world. He died from a stroke in 1906.
Wilhelm Conrad Röntgen (1845–1923)
Wilhelm Conrad Röntgen was born on March 27, 1845, at Lennep in the Lower Rhine Province of Germany. In 1862, he entered a technical school at Utrecht where he was however unfairly expelled, accused of having produced a caricature of one of the teachers, which was in fact done by someone else.
In 1869, he graduated PhD at the University of Zurich, was appointed assistant to Kundt and went with him to Würzburg in the same year, and 3 years later to Strasbourg. In 1874, he was qualified as a Lecturer at Strasbourg University, and in 1875 he was appointed as Professor in the Academy of Agriculture at Hohenheim in Württemberg. In 1876, he returned to Strasbourg as Professor of Physics, but 3 years later he accepted the invitation to the Chair of Physics in the University of Giessen. In 1900, he accepted the chair in the University of Munich by special request of the Bavarian government, as successor of E Lommel. Here he remained for the rest of his life. On the evening of November 8, 1895, he 27found that if the discharge tube is enclosed in a sealed, thick black carton to exclude all light and if he worked in a dark room, a paper plate covered on one side with barium platino-cyanide placed in the path of the rays became fluorescent even when it was as far as 2 m from the discharge tube. During subsequent experiments he found that objects of different thicknesses interposed in the path of the rays showed variable transparency to them when recorded on a photographic plate. When he immobilized the hand of his wife in the path of the rays over a photographic plate for a few minutes, he observed after development of the plate an image of his wife's hand which showed the shadows thrown by the bones of her hand and that of a ring she was wearing, surrounded by the penumbra of the flesh, which was more permeable to the rays and therefore threw a fainter shadow. This was the first “röntgenogram” ever taken. In further experiments, Röntgen showed that the new rays are produced by the impact of cathode rays on a material object. As their nature was then unknown, he gave them the name X-rays. Later, Max von Laue and his pupils showed that they are of the same electromagnetic nature as light but differ from it only in the higher frequency of their vibration.
Numerous honors were showered upon him. In several cities, streets were named after him and a complete list of prizes, medals, honorary doctorates, honorary and corresponding memberships of learned societies in Germany, as well as abroad. Röntgen married Anna Bertha Ludwig of Zürich whom he had met in the café run by her father. She was a niece of the poet Otto Ludwig. They married in 1872 in Apeldoorn, The Netherlands. They had no children, but in 1887 adopted Josephine Bertha Ludwig, then aged 6, daughter of Mrs. Röntgen's only brother. Four years after his wife, Röntgen died at Munich on February 10, 1923 from carcinoma of the intestine.
Ronald Virag, MD (1938)
Ronald Virag, MD (Fig. 1.60), a vascular surgeon, is known for his work with phentolamine and papaverine for ED during the 1980s. He was born in Metz, France in 1938. Dr Virag graduated from Paris University in 1962. After training in general and cardiovascular surgery at Paris hospitals, Dr Virag in 1977, created a multidisciplinary group for studying erectile dysfunction, on which he had focused since 1978. In 1981, he founded a private institute in France devoted to the clinical study and research on impotence and developed early programs using intracavernous drugs to treat the condition.
During his career, Dr Virag has belonged to the French college for vascular pathology, the International College of Angiology (FICA), the International Union of Angiology, the French Society of Microcirculation and the AUA. He has also published numerous books and articles. Dr Virag received the Gold Medal of the Merit “Rene Fontaine” from the Brazilian Society for Angiology and Vascular Society. He presented at the AUA's John Lattimer Lecture in 1986.
Donald F Gleason, MD, PhD (1920)
Donald F Gleason (Fig. 1.61), MD, PhD was born in Spencer, Iowa on November 20, 1920. Dr Gleason earned his medical degree in 1944 in the Army Specialized Training Program at the University of Minnesota. Dr Gleason passed his anatomic and clinical pathology boards in 1952. He served as chief of laboratory in the Veterans Administration (VA) Hospital between 1954 and 1975 and then obtained his PhD from the University of Minnesota in 1966.
As chief of laboratory, Dr Gleason joined the VA Cooperative Urological Research Group study of prostate cancer. With them, he devised a grading system based on the increasing disorganization of the histologic structure of the prostate cancers. The histologic grades were illustrated with photomicrographs and Dr Gleason's drawings, which were easily recognized by other pathologists. The histologic grades correlated with the varying degrees of clinical malignancy of the cancers. As the Gleason grading system was easily learned from the drawings, it has been accepted and applied to the diagnosis and treatment of prostate cancer around the world. Dr Gleason retired from the VA in 1976 and spent 10 years as staff pathologist in the Fairview Hospital system, Minneapolis, before his final retirement in 1986. In 2002, he received the honorary Presidential citation from the AUA.
Patrick Craig Walsh, MD (1938)
Patrick C Walsh (Fig. 1.62), MD born on February 13, 1938 and raised in Akron, Ohio is the chair of urology at the Johns Hopkins University. Dr Walsh received his medical degree from Case Western Reserve University in 1964, spent 3 years at Peter Bent Brigham Hospital and Boston's Children's Hospital as a resident in surgery and pediatric surgery and did his urology training at the University of California, Los Angeles from 1967–1971. Dr Walsh published the first description of 5-alpha reductase enzyme deficiency in 1974, providing the basic framework that led to the development of the 5-alpha reductase inhibitor for the treatment of benign prostatic hyperplasia. He wrote several papers on androgen receptors and the prostate.
In 1979, he published his technique for the management of the dorsal vein complex during radical retropubic prostatectomy. Dr Walsh's technique illustrated that patients who underwent radical retropubic prostatectomy did not always become impotent or incontinent.
Later that year at a meeting of the genitourinary surgeons, Dr Walsh met Pieter Doncker, MD, the outgoing chair of urology in Leiden, Netherlands. They maintained contact and in 1981 Dr Walsh attended a conference in Leiden and worked with Dr Doncker to dissect the pelvic nerves of an infant. They spent 3 hours tracing the nerves to the corpora cavernosa and observed that they were located outside the capsule and fascia of the prostate, and showed that the nerves traveled in a cluster of arteries and veins of the prostate.
On April 26, 1982, Walsh performed the first purposeful nerve-sparing radical prostatectomy on a 52-year-old patient who reported 7 months later that he was potent. In 1980, only 7% of men with localized prostate cancer underwent radical prostatectomy for fear of incontinence and loss of potency; 18 radical prostatectomies had been performed that year at the Brady Institute. In the year 2000, thousand radical prostatectomies were performed at Hopkins. Walsh, in a letter to his staff, went on to say “I share all of this with you not to take any major credit. Rather, I share these thoughts so that you can understand how important discoveries can be made—a simple act of kindness to a lonely old man (Dr Doncker), followed 4 years later by trying to understand what he was doing now that he was retired. Never underestimate what you can learn from others.” His major accomplishment is that through his meticulous dissection, he has dramatically decreased the fear of impotence, but much more so the fear of incontinence in men facing radical pelvic surgery. His work has stimulated many others to evaluate new approaches to prostate cancer. In 1978, he received the AUA's Gold Cystoscope Award and in 2004, Dr Walsh received the AUA's Hugh Hampton Young Award. His charisma, his fame and his skills have enabled him to create more than six endowed professorships in his department. Additionally, he actively supports his community, sharing his leadership skills and resources.
Thomas A Stamey, MD (1928)
Thomas A Stamey (Fig. 1.63), MD was born April 26, 1928 in Rutherfordton, North Carolina. He attended the Johns Hopkins University School of Medicine, receiving his medical degree in 1952. After his internship at Hopkins, he entered the urology residency program under William W Scott, MD and in 1958, joined as full-time faculty. Dr Stamey left Hopkins in 1961 to become the chairman of the division of urology at the Stanford University School of Medicine in Stanford, California. After 26 years as chairman, he is now Professor Emeritus.29
Dr Stamey has garnered multiple awards from American urology groups including the Hugh Hampton Young Award and the Ramon Guiteras Award from the AUA and the Valentine Award from the New York Academy of Medicine.
Dr Stamey was president of the Clinical Society of Genitourinary Surgeons from 1988 to 1989. Dr Stamey's early interest was in the field of renal vascular hypertension and renal physiology. In the early 1960s, he became one of the leading researchers in the pathogenesis of urinary tract infections and subsequently immunologic characterization of prostatic infections. Since 1982, he has concentrated his research on various aspects of prostatic cancer with special interest in the field of the prostate-specific antigen and prognostic indicators of prostate cancer.
BIBLIOGRAPHY
- Abdel-Halim RE, Altwaijiri AS, Elfaqih SR. Extraction of urinary bladder stone as described by Abul-Qasim Khalaf Ibn Abbas Alzahrawi (Albucasis) (325-404 H, 930-1013 AD). A translation of original text and a commentary. Saudi Med J. 2003;24(12):1283–91.
- Androutsos G. [Pierre Franco (1505-1578): famous surgeon and lithotomist of the 16th century]. Prog Urol. 2004;14(2):255–9.
- Campbell D. Arabian Medicine. London, Regan, Paul Trench, Trubner; 1926.
- Charaka Samhita. Chandra Kaviratna. Translated into English. Calcutta; 1912.
- Chaussy C, Brendel W, Schmiedt E. Extracorporeally induced destruction of kidney stones by shock waves. Lancet. 1980;2:1265–8.
- Elis H. A History of bladder stones. Oxford, Blackwell Scientific; 1969.
- Encyclopedia Britannica. Available from www.britannica.com/eb/topic-92902/The-Canon-of-Medicine. [Retrieved November 2008].
- “Encyclopedia Iranica”. Available from www.iranica.com/articles/avicenna-x. [Retrieved July 9, 2010].
- Foley FEB A self-retaining bag catheter. J Urol. 1937;38:140–3.
- Freyer PJ. Clinical lectures on disease of the prostate, 5th edition. London: Bailliere, Tindall and Cox; 1920.
- Girish Dwivedi, Shridhar Dwivedi (2007). History of Medicine: Sushruta - the Clinician - Teacher par Excellence. National Informatics Centre (Government of India).
- Hilton-Simpson MW. Arab Medicine and Surgery. London: Oxford University Press; 1922.
- History of Urology at Massachusetts General Hospital.
- Hoernle ARF. Studies in the Medicine of Ancient India, Part I. Oxford, Clarendon Press; 1902.
- Kutumbian P. Ancient Indian Medicine. Orient Longman; 2005.p.233.
- Leake, Chauncey D. The old Egyptian medicine papyri. Lawrence, Kansas: University of Kansas Press; 1952.
- Lock, Stephen, et al. The Oxford Illustrated Companion to Medicine. USA: Oxford University Press; 2001. ISBN 0192629506.
- Max Neuburger, Dr Med Et Phil, Vienna. Translated by David Riesman, M.D., Sc.D., Philadelphia. The early history of urology. “Aus der Vergangenheit der Urologie,” Wiener Klinische Wochenschrift; 1936.
- Millin T. Retropubic prostatectomy; a new extravesical technique. Lancet. 1945;2:693–6.
- Morris H. The origin and progress of renal surgery. London: Cassell; 1898.
- Murphy Leonard JT. History of Urology Charles C Thomas. Publisher Springfield, Illinois, USA; 1972.
- Osler W. The Evolution of Modern Medicine. New Haven: Yale University Press; 1921.
- Pare A. The works of that famous chirugion Abrose parey. Translated by Thomas Johnson. London; 1634.
- Shoja MM, Tubbs RS, Loukas M, et al. Vasovagal syncope in the Canon of Avicenna: the first mention of carotid artery hypersensitivity. Int J Cardiol (Elsevier). 2009;134(3):297–301.
- Susruta-Samhita: Trans KL. Bhishagratna. 3 volumes. Calcutta, Wilbur Press. pp.1907–16.
- Sutchin R Patel. History of Urethral Catheterization. Medicine and Health, Rhode Island. 2004;87(8):240–2.
- Weiss RM, George NJR, Reilly POH. Comprehensive Urology. Mosbey London, Edinburgh N York; 2001.pp.1–14.
- William P Didusch. Didusch Center for Urologic History of the American Urological Association (AUA).