The History of Urologic Surgery

Irmina Nahon, PhD(c); Gordon Waddington, PhD; Grace Dorey, PhD, FCSP; Roger Adams, PhD

Disclosures

Urol Nurs. 2011;31(3):173-180. 

Abstract and Introduction

Abstract

Bladder function has interested man since prehistoric times. Evidence of health and well being was often measured from observation of urine. When urologic function was impaired, the extent of the ensuing pain often called for dramatic measures to obtain relief. The practice of urology has advanced substantially since the days when reeds were used to alleviate obstruction of the bladder. This article presents a brief historical overview of urology and the strides made in prostate surgery with modern technology.

Introduction

From ancient times, man considered urine to be permeated with, "soul substances," and for some early African societies, rain was considered the urine of a deity (Roheim, 1930). While the idea of urine being rubbed on the body to protect against evil spirits (Wershub, 1970) seems strange, some superstitious beliefs and remedies may actually have some basis in terms of therapeutic effects.

The use of urine for cosmetic or hygienic purposes can be found throughout history to cure, soften, and whiten animal skins (Auel, 1985). The ammonia in urine, when used as a mouthwash, works prophylactically against dental cavities. Pierr Rauchard, known as the father of dentistry, recommended ,"rectified urine" for use as a dentifrice and toothache remedy (Wershub, 1970, p. 11). Urine was also utilized as a skin softener in the 17th century, with French ladies taking urine baths to beautify their skin. It was also promoted as a cure for corns and warts, and as a substance that could cure baldness by promoting new hair growth.

Urine was one of the main 'humors," or bodily fluids, used by medicine men, doctors, and charlatans alike to assess the well being of their patients. Collecting urine for functional purposes may have led incidentally to the observation that urine qualities change with differing states of health. For example, Hippocrates observed that a change in water consumed could change the state of urine (Hippocrates, 400 BCE-a).

The significance of changes in the appearance of urine was discussed by Galen (129-216 ACE). By the middle ages, there were several treatises written on the art of uroscopy, which consisted of analyzing urine for color, smell, density, and clarity. A uroscopy wheel used in describing urine is seen in Figure 1. Figures 2 and 3 illustrate doctors using a glass (see Figure 4) flask to analyze the urine. Hippocrates devoted much time to the study of urine as did Aretaeus of Cappadocia (1st Century ACE), describing how its features changed with different disease states. Examination of the characteristics of urine is still seen as an important indicator of a person's state of heath. As alchemy developed into the science of chemistry, the true value of urinalysis became apparent, since diseases and conditions can be inferred by analysis of what the kidneys excrete.

Figure 1.

The Fasciculus Medicinae, Johannes De Ketham, 1491
Source: Reprinted with permission from Trustees of the British Museum.

Figure 2.

Physick Painting by Ostade
Source: Reprinted with permission from Trustees of the British Museum.

Figure 3.

'De Bleekzuchtige Dame' by Samuel van Hoogstraten (1627–1678)
Note: Note the doctor in the background with a flask of urine.
Source: Reprinted with permission from Rijksmuseum Amsterdam.

Figure 4.

Free-Blown Glass, Pontiled with a Woven Basket
Source: Reprinted with permission from Trustees of the British Museum.

The anatomy of the urinary tract was well known by the time Galen (129-216 ACE) wrote On the Natural Faculties in the second century. He was the first to detail the anatomy of both humans and animals, and left descriptions that were not improved upon until Andreas Vesalius in 1543 (O'Malley, 1964). Galen (129-216 ACE) described the way urine was made by the kidneys and "how the ureters are prevented from receiving back the urine from the bladder." Rufus of Ephesus was the first to describe the prostate, calling it the parastates glanduleux (Bitschai & Brodny, 1956). The problem of "the stone in the bladder" is also a subject of much discussion in these papers both on its origin and its removal. Unfortunately, anatomists of the middle ages were often not allowed to dissect humans, and this may have contributed to a neglect of the prostate. For example, Leonardo da Vinci's sketches and drawings do not show the prostate. Wershub (1970) proposed this was perhaps due to the use of oxen as alternative subjects for dissection. These animals have a small atrophic prostate, as they are castrates.

Surgery to the external genitalia has been performed since ancient times. Cutting away the hood of the penis, or circumcision, can be traced to the ancient Egyptians (see Figure 5) and was common among all the primitive peoples of the Orient, Africa, and Polynesia. The ancient Chinese practiced castration to prepare young men as eunuchs to function as guards or servants in a harem or court (see Figure 6). The treatment of hydrocoele, by cutting through skin and muscle to release the fluid, was also probably practiced by primitive man. Problems with obstruction of the bladder have been documented by the ancient Egyptians (Shackley, 1999) and Chinese (Murphy, 1972). Roman and Egyptian physicians have been recorded as using reeds as catheters to overcome blockages (Schultheiss, Hofner, Oelke, Grunewald,&Jonas, 2000). The use of catheters to relieve retention has also been described in India and China (Murphy, 1972).

Figure 5.

Egyptian Papyrus
Source: Reprinted with permission from Trustees of the British Museum.

Figure 6.

Egyptian Ritual Circumcision of the Penis of Priests and Nobility
Note: Perhaps the most ancient surgery is the Egyptian practice of ritual circumcision of the penis of priests and nobility. This relief of the 6th Egyptian Dynasty, in the Saqqara Necropolis outside of Cairo, is from the Tomb of Ankhmahor (2345 BCE), referred to as the "Tomb of the Physician." The mural shows the two young men, one with arms restrained, undergoing circumcision.

The concept of surgical interventions for the prostate did not become widespread until the anatomists of the Middle Ages; Andreas Versaluis correctly described the internal organs. Limited anatomical knowledge, however, did not allow for substantial development of surgical techniques. However, the Hippocratic school discussed in great detail diseases of the urinary tract and perineal lithotomy. While Hippocrates never mentions the prostate, there might have been reference to it in his work Aphorisms, where he notes, "Diseases about the kidneys and bladder are cured with difficulty in old men" (Hippocrates, 400 BCE-b, VI.6).

From the days of Hippocrates, operations for the removal of stones have been noted. Aretaeus of Cappadocia (1st Century ACE) recommended a surgical incision to manually remove the stone (see Figure 7). The Roman Aulus Cornelius Celsus (25 BC-50 AD) described the need for a "wide incision to remove stones without uncontrolled rupture of tissue, potentially causing urinary fistula" (Murphy, 1972, p. 25). By the 16th century, these techniques usually involved opening the urethra, there by causing significant post-operative complications, such as abscesses and incontinence. As anesthetic had not yet been invented, the procedure itself would have been quite harrowing (see Figure 8).

Figure 7.

Aretaeus of Cappadocia, Translated from the Original Greek
Source: John Moffat, MD, 1785. Reprinted with permission from The British Library Board.

Figure 8.

Earliest operation for the stone. The patient is lying on a platform and the physician is performing an operation before a large crowd which includes King Louis XI of France
.Source: Antoine Rivoulon, 1810–1864, ©1851.

Toward the end of the 16th century, suprapubic approaches were being used to remove stones from the bladder. The experience gained from doing caesarean operations would have been invaluable according to Wershub (1970). The first suprapubic cystotomy for the removal of bladder stones is credited to Franco, a surgeon of Lausanne, in 1559 (Cumston, 1912). As noted by Cumston (1912), Franco performed this operation against his personal judgement, since both patient and parents were insistent that death would be a better option than life with the pain. While the child survived, Franco did not advocate this approach because he felt the danger of infection after surgery was too great. Not all agreed with this view, and two centuries later, Heister (1755) described surgery that successfully opened the bladder, where the patient survived without problems. The perineal approach, however, was preferred by most surgeons of the time (Cumston, 1912). A treatise of lithotomy was authored by François Tolet in 1683 (see Figures 9 and 10). He studied the technique throughout Europe and Egypt, as well as in Arabic countries. Tolet's descriptions of the lithotomy (which was done without anesthetic) were very detailed and included instructions on how to care for the patient and manage urinary retention after surgery. A passage in the treatise on "spilling of urine" or incontinence describes the use of a clamp-like device that compressed the urethra (Tolet, 1683, p. 168).

Figure 9.

Preparation for Lithotomy
Source: Tolet, 1683. Reprinted with permission from St. John College Library, Oxford.

Figure 10.

Removal of the Stone
Source: Tolet, 1683. Reprinted with permission from St. John College Library, Oxford.

It has only been in the last 500 years that the prostate was identified as a cause of obstruction of urine flow. After Vesalius' Tabula Anatomicae Sex first depicted the as yet unlabeled prostate in 1538, Casper Bartholin named the gland in 1611. Over the next two centuries, the association between prostatic hypertrophy and urethral obstruction was discussed (Gross, 1851). Most of the knowledge of the time was published in a monograph, Treatment of the Diseases of the Prostate Gland, by Sir Everard Home. While this monograph is not obtainable, a later book by Gross (1851) explores possible treatments for the management of an enlarged prostate. It is here that the first excision of the prostate is mentioned (Gross, 1851).

It was not until the end of the 18th century that there was any treatment for obstructive symptoms other than catheterization, prevention with a bland diet, or medication (Murphy, 1972). For more than 2000 years, obstructions were relieved using catheters made of hollow leaves, metal, glass, and more recently, rubber and gum elastic compounds (see Figure 11). With further advances in surgery and anesthetics in the 19th century, urologic surgery made more significant advances.

Figure 11.

Catheters – Bronze, Roman Work, 1st Century AD
Source: Reprinted with permission from Trustees of the British Museum.

According to Litchfield (1826), removal of a stone from the bladder (see Figure 12) was considered "one of the most formidable and serious operations that the surgeon has to perform" (p. 1). Interestingly, the suprapubic approach was generally avoided due to the possibility of urine leakage into the "cellular membrane about the pubes" causing abscess, mortification, and death (Litchfield, 1826, p. 13). It would not be until the 21st century that controlling the loss of blood into the peritoneal cavity and the draining of the bladder by a catheter would allow for this approach to be used more successfully. By the last decade of the 19th century, the development of aseptic techniques and refinement of general anesthesia, as well as the invention of the direct light endoscope, allowed urologists to see the effect prostatic hypertrophy had on the flow of urine (Shackley, 1999). While urologists explored ways to remove stones, variations to lithotomy procedures were also discovered to allow for the removal of the prostate.

Figure 12.

Crushing of the Stone
Source: Coulson, 1857.

Prostate cancer was not considered to be a common affliction during the 19th century (Thompson, 1868). By 1881, a few cases of prostate cancer occurring in older men had been described (Coulson, 1857). Coulson (1857) cites a Mr. Haynes Walton's description of a 59-year-old man with "malignant disease of the prostate" where the enlargement of the prostate was not apparent until well after initial symptoms of pain and difficult micturition. Autopsy revealed "a morbid growth, which proved to be the prostate gland converted into a malignant tumor" (Coulson, 1857, p. 375). By the 20th century, the study of the histology of the removed enlarged prostates convinced doctors that carcinoma of the prostate was more common than at first thought (Murphy, 1972). For most of the 19th century, treatment of malignant disease of the prostate was "of course, merely palliative" (Coulson, 1857, p. 376). Removal of the prostate was usually done by a peritoneal approach (see Figure 13).

Figure 13.

Removal of the Prostate
Source: Coulson, 1857.

The late 19th and early 20th centuries saw the development of different approaches for the removal of the obstructive prostate (Murphy, 1972). Several surgeons are credited with having performed the first prostatectomy. Harrison removed some prostatic tissue in 1881 to better access the bladder stone he was removing via lithotomy. Both Goodfellow and Gouley are recorded as having taught others how to enucleate the prostate in the 1880s-1890s (Murphy, 1972).A complete perineal prostatectomy was performed by Goodfellow in 1891, and in 1902, Peter Freyer developed the first procedure for the removal of the prostate gland via a suprapubic approach (Murphy, 1972).

The development of different techniques to relieve the obstruction led to the first reported removal of the prostate for cancer, performed by Hugh Hampton Young in 1904 (Scott, 1997). Prostate cancer had first been described by J. Adams in 1853 after an histological examination (Denmeade & Isaacs, 2002). Young performed the first radical perineal prostatectomy, removing the entire prostate with its capsule and adjacent seminal vesicles (Young, 2002 [1905]). This surgical approach became the standard treatment for early prostate cancer with survival rates being close to the rate for age-matched controls without prostate cancer. Perineal prostatectomy was the favored surgical approach in the United States until the 1930s. In 1932 the suprapubic approach was pioneered in the United Kingdom by J. Swift Joly at St. Peter's Hospital for Stone (Wilde, 2004). The modified approach to the suprapubic prostatectomy developed by Harry Harris in Sydney in 1928 was preferred by surgeons in Australia and New Zealand. The retropubic approach was popularized in the northern hemisphere from 1945 by Millin and Macalister (Gil-Vernet, 1996). Between 1950 and 1980, prostate surgery was almost abandoned in parts of Europe as being too difficult and having too many complications. This disfavor occurred despite prostate surgery being performed in other parts of the world (Gil-Vernet, 1996). The sequelae of incontinence and impotence were the main reasons many men were not offered surgery. Transurethral prostatectomy took place in some centers, but the use of the endoscope by "feel" often caused perforations of the bladder and bowel (Wilde, 2004) and required a lengthy learning curve for surgeons. Advances in endocrinology made the medical management of prostate cancer possible, with hormone therapy being the treatment of choice for many men (Shackley, 1999).

Patrick C. Walsh pioneered nerve-sparing surgery in 1983, and for the first time, men were able to hope that they would continue to have erections after prostate surgery. This technique was initially developed to manage blood loss associated with radical retropubic procedures (Scott, 1997). According to Walsh, Lepor, and Eggleston (1983), rates of continence after retropubic surgery have been reported as being superior than perineal surgery. With careful study and dissection of the prostate, Walsh was able to preserve sexual function as well.

During this same time period, prostatic-specific antigen (PSA) screening was beginning to diagnose prostate cancer at a much earlier stage. Since radiation therapy was thought to be less effective than surgery in younger men, a resurgence toward suprapubic radical prostatectomy started. With younger men being screened, diagnosed, and treated with prostate surgery, the demand for procedures that did not have the devastating consequences of impotence and incontinence escalated.

In recent years, urologists have proposed methods to reduce the incidence of problems associated with prostate surgery. Some have modified surgical procedures to maintain erectile functioning post-surgery (Barré, 2007; Kessler, Burkhard, & Studer, 2007; Walsh, 2000), while other researchers have focussed on reducing post-surgical rates of urinary incontinence (Poore, McCullough, & Jarow, 1998; Sacco et al., 2006; van der Poel, de Blok, Joshi, & van Muilekom, 2009). Although this focus has led to some improvement, the results are still not optimal. These outcome data are apparent in many quality-of-life and function studies. Stanford et al. (2000) found that at 18 months post-radical prostatectomy, 8.4% of men were incontinent, and 59.9% were impotent. These were self-reported incidences, which is a reporting method thought to be more reflective of reality than doctor-reported (Litwin, Lubeck, Henning, & Carroll, 1998). Within the area of erectile functioning, Briganti et al. (2009) reported that if careful selection criteria are followed, the expected rate of recovery is high, with rates of 55% to 97%. Careful selection of patients is necessary, and it is not a new idea. Sir Astley Cooper was quoted in 1826 as saying "that the success of one surgeon being greater than that of another chiefly depends upon his judgement in the selection of favourable cases" (Litchfield, 1826, p. 24).

Urologic nursing has also evolved over the centuries. In a review published in 1997, Moore and Paul described the development of scientfically based nursing interventions for the management of continence. Between the late-19th century and the mid-20th century, the emphasis was on keeping patients clean and preventing skin problems secondary to incontinence. Catheterization of males was restricted to being done by doctors to prevent "distortion of the nursing service," but nurses could insert catheters into female patients (Moore & Paul, 1997, p. 111). Not until the 1950s were conservative stratagies other than containment offered. Dr Kegel's exercises offered a non-surgical option to continence management, now known as pelvic floor exercises (Kegel, 1948). In the 1970s, major advances in continence nursing followed the invention of artificial sphincter, closed urinary drainage, and disposable products (Moore & Paul, 1997).

The first suggestion that prostatectomy could be done with the assistance of a robot came from Davies, Hibberd, Coptcoat, and Wickham (1989). These researchers demonstrated with the aid of a model involving a potato held in a box made of hard clear plastic that a robot could remove the prostate in much less time than a surgeon. Laparoscopic surgery to the prostate was introduced by Heaton in 1994. He used the laparoscope to light up and film the procedure for better visual acquisition and as a teaching tool. This was soon followed with percutaneous procedures (Schuessler, Schulam, Clayman, & Kavoussi, 1997). Over the next few years, both laparoscopic and robotic-assisted surgery was gradually introduced across the world (see Figure 14) (Bentas et al., 2003; Pasticier et al., 2001; Rassweiler, Frede, Seemann, Stock, & Sentker, 2001; Schuessler et al., 1997). Rates of robotic assisted surgery rapidly increased in the United States between 2006, from 10% of all radical prostatectomies to 65% in 2008-2009 (Dasgupta & Kirby, 2009).

Figure 14.

Laparoscopic Operating Theatre
Source:Intuitive Surgical, Inc., 2010. Reprinted with permission.

Urology and prostate surgery have advanced substantially since the days reeds were used to relieve obstruction of the bladder. With the exploration of human anatomy came the understanding of how organs functioned, followed by the search for treatment and prevention of problems. Discoveries in the field of medicine, such as anesthetics and penicillin, improved surgical outcomes, and the quest for fewer side effects led to nerve-sparing surgery and robotics. The challenge has now moved to the prevention of con ditions (such as prostate cancer) from developing and to the minimization of effects urologic surgery has on the patient's quality of life. Nursing also needs to stay in the forefront of continence and erectile dysfunction patient care through clinical expertise, education, and ongoing research.

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