Editor's note: All but one of the instruments depicted in this brief survey of the development of the cystoscope are in the collection of the William P. Didusch Center for Urologic History, the official museum of the American Urological Association. Dr. Rainer Engel, who curates the collection, selected the photographs and wrote the accompanying text.
Since the earliest 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. A mirror on the inside reflected light from the candle through attachments (shown in Figure 1) 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.
Whatever its impracticality, the Lichtleiter was a catalyst for further experimentation and invention. By the mid-1800s, several new instruments had been created. One, a variation on the instrument by Bozzini, was designed by Antoine Desormeaux (1815-1882) in Paris (Figure 2). The instrument was a long metal channel through which a mirror reflected light from a petroleum-fueled lamp. This instrument had one of the same drawbacks as Bozzini's Lichtleiter -- it became quite hot in use. The very acute beak at the tip is interesting, but its purpose is unclear.
At about the same time, new instrument models were being developed in the United States. The best was an instrument designed in 1860 by Phillip Skinner Wales while he was doing postgraduate study at the University of Pennsylvania. His creation, shown in Figure 3, was produced by Horatio Kern, a well-known instrument maker in Philadelphia. Wales' instrument contains a metal shaft, again with a very acute beak, but it uses an ophthalmologic mirror to reflect light down the channel. One peers through the center hole to look into the bladder. It was elegant, light, and relatively easy to use.
In 1878, true endoscopy was born. In that year, Maximilian Carl-Friedrich Nitze (1848-1906), a German urologist, presented the first working cystoscope, which he had created in collaboration with the Viennese instrument maker Joseph Leiter (a prototype model had been presented in October of the previous year). The Nitze/Leiter cystoscope was a landmark discovery, but it was by no means perfect. The instrument's biggest drawback was the tungsten wire used for lighting, which got very hot and required a complicated water-cooling system. Figure 4 shows 2 big horns coming out near the eyepiece -- these are the in- and out-flow funnels for the coolant water. The 2 thinner pegs are electrical contacts to illuminate the bulb.
The next improvement came about when ElectroSurgical Instruments in Rochester, New York, under the direction of Dr. Henry Koch and Charles Preston, the head electrician, created what has become known as the mignon bulb, a low-amperage light bulb that was small enough to fit into the tip of a cystoscope. These bulbs enabled the development of cheaper and easier-to-use instruments. The only problem was that light bulbs burn out, often at the most inopportune moments, like in the middle of a procedure.
Some physicians, however, were still using simple instruments not subject to such failures. Howard Kelly, the chair of OB/GYN at Hopkins, for instance, used a small speculum-like tube that was used with the patient in the knee-chest position. Initially, it had neither a light nor a lens system attached to it.
In 1890, Reinhold Wappler (1870-1933), a young instrument maker, immigrated to New York from Germany. Soon after arriving, he set up his own company to produce an American cystoscope. One of the first instruments developed at the new workshop was the Tilden-Brown composite cystoscope (Figure 7), an elegant set of instruments with a lens to look straight forward, one at a slight angle, and another at a right angle. Obturators that were used to insert the instrument blindly were exchanged for the lens system.
Meanwhile, in Europe, inventors and clinicians continued to make refinements and improvements in Leiter and Nitze's instruments. One such innovator was the German doctor Leopold Casper, whose catheterizing cystoscope is shown in Figure 8. This instrument was not easy to use -- it employed a complex mirror system between the eyepiece and the shaft, but it had one big advantage: It allowed ureteral catheterization. However, the instrument did not have a deflector to guide the catheter tip into the urethral orifice; that would come later.
Alexander Brenner (1859-1936) in Vienna, Austria, was one of the first, along with Karl Pawlik in Prague, to catheterize the female ureter. Brenner taught his procedure to James Brown, who returned to Hopkins and managed to catheterize a male ureter. Such an instrument from 1890 is shown in Figure 9. The channel for catheter insertion can be seen clearly. The catheter would come straight out of the shaft, but a mechanism to change the course of the catheter was still lacking.
By 1900, instruments had been developed to catheterize ureters and irrigate the urethra and the bladder. Figure 10 shows an instrument created by Friedrich Nitze for catheterization. This is actually a modification of an instrument designed by the Cuban-born French urologist Joaquín Albarrán (1860-1912). One can see a turnscrew on the side of the cystoscope; this allowed the Albarrán deflector to be moved and thus deflect the urethral catheter. Note also the electric cord, which is covered in tightly woven cotton. It was obviously impossible to sterilize the electric cord.
Figure 11 shows a Brown-Buerger cystoscope from 1910. This instrument was created by Leo Buerger (1879-1943), a young urologist in New York, who based his design on one by Tilden Brown. The instrument was then produced by the Wappler Electric Company (later ACMI, today Gyrus/ACMI). The Brown-Buerger cystoscope remained the workhorse of the American urologist for nearly 6 decades. It was easy to use, enabled catheterization of the ureters, and provided an excellent image. Virtually every urologist owned 1 or 2 of these instruments.
The power to illuminate the bulb was produced by a transformer like the one shown in Figure 12. The transformer was either a larger wood-encased apparatus or a small metal-encased device that the urologist wore around his waist. A power cord led to the outlet in the wall. One wonders about the risk for electrical shock.
Into the 1960s, we used various battery boxes to light our instruments. One was actually a small transformer device that was hung close to the examination table. More formidable was a wood-encased battery box with 3 rechargeable batteries. However, these heavy boxes worked very well with the instruments used in those days (Figure 12).
Then came the next revolutionary change: fiberoptics. The ability of light to follow a curved glass rod had been known for many years, but it took several decades for physicists and physicians to discover how to harness this ability for clinical use. Early patents in fiberoptics were issued to researchers in Britain and the United States in the mid-1920s. The first attempt to create a fiberoptic endoscopy system was made in Germany in 1930, but it was technically unsatisfactory. Twenty years later, researchers were more successful in the United States, and the gradual emergence of this system as a practical technology began. In 1954, Brian O'Brien obtained a US patent for an endoscope. Six years later, Victor F. Marshall described the first fiber ureteroscope produced by ACMI. Figure 13 shows a glass fiber bundle. These bundles, which incorporated several thousand individual fibers, were initially used simply to transmit light, but researchers later learned how to make them convey images.
The next big step forward occurred when a urologic surgeon in Liverpool who was unhappy with the results of his endophotography consulted professor Harold H. Hopkins in London, who developed what became the Hopkins lens system. His rod lens was patented in 1959. Initially, industry showed no interest in this new technology; however, a young man just starting a company, Karl Storz, saw promise in the new system and bought the patent. With the Hopkins system, Storz created endoscopic instruments with a tremendously brilliant image and superb illumination. It was not long before every cystoscope maker began to create similar lens systems.
Great strides were simultaneously being made in fiberoptics. The biggest problem had been the need to line up the glass fibers in a coaxial fashion, meaning that every fiber had the same position at the eyepiece as it had at the other end in the patient. Today we have flexible cystoscopes and flexible ureteroscopes, allowing us to look all the way up into the ureter.
Figure 14 shows a flexible cystoscope from 2007, which can be used for a whole range of procedures from urine collection to small-tissue sampling. We still lack the technology to perform formal resection through a fiberoptic instrument, but seeing how instruments have developed and changed over the past centuries leads us to expect great things for the future.
Max Nitze's vision of his cystoscope is encapsulated in his words from 1888:
"...this writing presents only a framework, the complete construction of which will be accomplished over the course of years through the joint work of numerous researchers. We are dealing here with a large new field of work which assuredly harbors untold treasures of knowledge..."
Berlin, December 1888
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Cite this: Development of the Modern Cystoscope: An Illustrated History - Medscape - Oct 24, 2007.