'Cutting for the stone': the ancient art of lithotomy

OBJECTIVE

Bladder stone was a common ailment plaguing mankind from antiquity to the 20th century. Largely forgotten today, lithotomy relieved the anguish of bladder stones and identified urology as a medical specialty nearly 2500 years ago.

METHODS

The historical literature pertaining to lithotomy was reviewed. Translated and original documents describing operative techniques and developments pertaining to the history of lithotomy were obtained through the internet and library sources.

RESULTS

The ancient art of lithotomy was first recorded by the Greeks and evolved through five phases: the Celsian method, or ‘lesser operation’; the Marian, or ‘greater operation’; the lateral operation; suprapubic cystotomy, or ‘high operation’, and proctocystotomy. The practice of open lithotomy ceased to exist owing to better minimally invasive alternative methods and most notably by the virtual disappearance of bladder stones in modern man.

CONCLUSIONS

The history of lithotomy is a fascinating story of how early surgeons forced by the culture and customs of the time dealt with common but devastating bladder stones. Out of their efforts, urology was born.     

The prohibition of lithotomy within the Hippocratic Oath: historical and ethical considerations on the history of surgery

A passage with one of the most contradictory interpretations of the so-called Hippocratic Oath, which was presumably created between 500 and 300 before Christ, is the prohibition of lithotomy. The oldest handwritten traditions of the Hippocratic Oath are dating back to the 11th-12th century. However the section of the prohibition of lithotomy is missing in the oldest preserved tradition (Codex Urbinas gr. 64), which led to some authors interpretation of being added later on. Beyond all doubt the analysis of the texture of the Hippocratic Oath leads to the conclusion that the prohibition of bladder stone lithotomy must have been an integrative part of the oath from the very first beginning. The author could have been inspired by the following reasons to have a non oath related doctor let done the medical operation: the removal of a bladder stone by an operation, which was outfitted with many complications, was one of the most difficult surgical interventions in the antique. Celsus (1st century A. D.) mentioned "severe fever, urine fistula and deadly inflammations" after lithotomy. Since the operation was done perineally, presumably a negative sexual potency was feared. No doctor engaged to help and not to harm his patients was allowed to make this kind of operation, which was often followed by many complications. Nevertheless sometimes patients were "tantalised to death by suffering dreadful pain" through those bladder stone diseases. Consequently "practising men" (the term "surgeon" was created at a later date), those who had been specialised in that operation and had not been linked to the oath, were allowed to make this kind of dangerous operation. Due to a greater experience of those specialists (named as "Lithotomos" by Celsus ih the 1st century A. D.) the danger of this kind of operation was reduced. The prohibition of lithotomy could be interpreted as a commitment to realize the limits of ones own medical actions.     

German urologists under national socialism

Objectives

The first full-time professorship for urology at a German university was established in 1937 and in 1942, a rare teaching qualification (Habilitation) for urology was granted, both at the prestigious Berlin University. At the same time, nearly a third of all physicians who worked in the field of urology were classified as “non-Aryan” according to Nazi race laws and were forced out of their profession and their homeland. Many of them committed suicide or, if they refused to flee, were murdered in concentration camps. German urologists also contributed to compulsory sterilization of men according to the “law for the prevention of hereditarily diseased offspring” between 1934 and 1945.

Methods

Historical sources on the history of urology in Nazi Germany were reviewed and analyzed. These include textbooks and medical journals from the 1930s and 1940s, as well as files from different state and university archives.

Results

For urologists, the changing political environment in Germany after 1933 offered possibilities to assert their personal and professional interests. Unfortunately, in many cases, moral principles were thrown overboard, and physicians advanced their own careers and the specialty of urology at the expense of their patients and their Jewish colleagues.

Conclusion

Under national socialism, German urologists backed Nazi health and race policies and in exchange gained further professionalization for their specialty, including university positions and increased independence from surgery. Only in recent years has this chapter of German urology’s past become a topic of debate among members of the professional society.     

Patients with microscopic and gross hematuria: practice and referral patterns among primary care physicians in a universal health care system

Background:

Hematuria is one of the most common findings on urinalysis in patients encountered by primary care physicians. In many instances it can also be the first presentation of a serious urological problem. As such, we sought to evaluate current practices adopted by primary care physicians in the workup and screening of hematuria.

Methods:

Questionnaires were mailed to all registered primary care physicians across Quebec. Questions covered each physician’s personal approach to men and postmenopausal women with painless gross hematuria or with asymptomatic microscopic hematuria, as well as screening techniques, general knowledge with regards to urine collection and sampling, and referral patterns.

Results:

Of the surveys mailed, 599 were returned. Annual routine screening urinalysis on all adult male and female patients was performed by 47% of respondents, regardless of age or risk factors. Of all the respondents, 95% stated microscopic hematuria was associated with bladder cancer. However, in an older male with painless gross hematuria, only 64% of respondents recommended further evaluation by urology. On the other hand, in a postmenopausal woman with 2 consecutive events of significant microscopic hematuria, only 48.6% recommended referral to urology. Findings were not associated with the gender of the respondent, experience or geographic location of practice (urban vs. rural).

Interpretation:

There seems to be reluctance amongst primary care physicians to refer patients with gross or significant microscopic hematuria to urology for further investigation. A higher level of suspicion and further education should be implemented to detect serious conditions and to offer earlier intervention when possible.     

A systematic review of mechanical thromboprophylaxis in the lithotomy position

Background

Venous thrombosis and compartment syndrome are potentially serious complications of prolonged, lithotomy position surgery. It is unclear whether mechanical thromboprophylaxis in this group of patients modifies the risk of compartment syndrome. This qualitative systematic review examines the evidence base to guide clinical practice.

The role of randomized controlled trials in evidence-based urology

Purpose

To review the current and future role of randomized controlled trials (RCTs) in urology.

Methods

A review of the urological literature was performed to assess the current role of RCTs in urology. These findings were put in context of current practice, and methodologic limitations of observational study design were discussed.

Results

Several RCTs have improved treatment of urology patients. However, overall, few studies in the urologic literature convey high-level evidence. RCTs represent the only study design that can assess causality, thus are the only means to significantly advance knowledge about therapy and improve patient care. Increased incidence and improved quality of RCTs may be achieved through education, community outreach, and better access to research infrastructure.

Conclusions

RCTs have significantly improved urologic practice. RCTs are superior to observational studies because of decreased risk of bias and confounding. To further advance clinical practice, clinical trials must play a predominant role and should be embraced by the urology community.     

Knowledge about urology in the general population: alarming results

Introduction:

For different reasons, urology appears to be one of the least known specialties in medicine. In this study, the main objective was to measure the knowledge about urology in the general population.

Methods:

A questionnaire was completed by 150 respondents. Seventy-five respondents were from Sherbrooke, QC (a French-speaking city) and 75 were from Burlington, VT (an English-speaking city).

Results:

Of the 150 respondents, 75% (113) said they knew little or nothing about urology and 63% (95) did not know that urology involves surgery. Also, when asked to name 3 diseases within the field of urology, 59% (89) of the respondents were unable to name at least 1 disease.

Conclusion:

This study demonstrates the lack of knowledge about urology in the general population. As urologists, we have to consider the need to conduct an informational campaign to increase the awareness of urology and the services urologists provide.     

A brief history of medicine's Hippocratic Oath, or how times have changed

Medicine has experienced many changes over the last three thousand years and surprisingly, the good and the bad of these changes can be found in the evolution of the wording of the Hippocratic Oath. This commentary reveals why the original Oath became a part of modern medicine's rite of passage and how society is now changing the very reason that the Hippocratic Oath was brought into the world of medical ethics. By examining the modern language of the Oath, it is possible to understand how these words have diluted its meaning and intent. The long-term consequences of these changes cannot be foreseen, but history has shown what can happen without a strong oath to guide the practitioner.     

Hippocratic Oath, 21st Century

Hippocratic Oath was first promulgated in 400 BC. Since then it became mandatory to take this oath for any medical profesional who practices medicine. The Oath envisaged all the important guidelines required to be possessed before the medicine is practiced. Recently there had been debates over the traditional oath and various revisionist versions were recommended. The enormous available literature compells us to think and revisit the status of orignal oath vis a vis the practice of medicine in 21st Century.     

Hippocratic Oath: professional or ethic code?

In order to study the historical relationship of early medical professional codex and contemporary demands and challenges, which are currently being placed before physicians, the first such text, known as Hippocratic Oath has been re-translated. According to the source, it is clear that this is a Code of professional conduct, primarily for the welfare of patients, and in order to maintain and preserve medical authority. All parts of the Oath have been discussed and presented, as well as the historical data from which one can see how the system in ancient Greece and Rome worked. The study includes historical data from that time on two controversial issues: the liability of medical awards, and addressing medical services. These are mistakenly considered to belong to the text of the Oath. Examples of the amount of medical awards are stated, as well as the examples of selflessness and dedication of the physicians in that time. A physician was obliged to help by law, only in the case of accidents and injuries. It is obvious that "medical doctrine" existed also in this time. Requirements set to a doctor were realistic, modest and appropriate to the call, with the main purpose of protecting the reputation and dignity of the profession. Despite the historical distance, classical text of the Oath is still up to date. In this context, ambiguities and errors result from not being familiar with the both, the basic text, and the circumstances prevailing at the time and society, in which the Oath was made.     

Reflections of the Hippocratic Oath in Modern Medicine

Hippocratic Oath indicates a prevailing ethos rather than a professional approach, and it is still regarded as the cornerstone and foundation of the medical profession. Medicine in Ancient Greece was strongly influenced by the values of classical philosophy as introduced by its main representatives: Plato and Aristotle. Hippocrates himself has been recognized not only as a pioneering physician, but also as an outstanding philosopher. In his writings, he claimed that “the physician must insert wisdom in medicine” and denounced the technocratic aspect of the medical profession. The Hippocratic Oath constitutes a synopsis of the moral code of Ancient Greek medicine and contributes to the stabilization of the tri-part relationship among the physician, the patient, and the illness, as described by Hippocrates. The harmony of this interactive triangle has been deranged by several factors, such as technological evolution, public media, and cost-effective modalities with multiple consequences. In these terms, the reevaluation of the Hippocratic Oath and its time-enduring messages seems essential to reinstate the relationship between the physician and the patient under a new philosophico-medical prism.     

Nachwuchs gewinnen – aber wie?

Background

There is an increasing lack of young doctors in German hospitals, including urology departments. The aim of this study was to evaluate the benefit of urology practice-oriented courses for German students in a skills laboratory with respect to acceptance, learning success and enthusiasm of the students for urology.

Methods

Transurethral catheterization, digital rectal examination and kidney/bladder sonography were trained in the urology course. Using a 12-point questionnaire, acceptance and quality of the training were evaluated. Learning success was checked using a urological OSCE-station (Objective Structured Clinical Examination). Additionally, participants were questioned on interest in urology and the consideration of future work in the field (medical elective or practical year).

Results

A total of 147 questionnaires from 190 participating students were suitable for analysis. Acceptance and quality of training were highly ranked accompanied by a very satisfying objective and subjective learning success. Interest for urology was stimulated in 98.4 % and future work in urology was imaginable for 60.4 % of the students.

Discussion

Practice-oriented urology student courses show high acceptance, high learning success and increase of attractiveness of urology. The training of urological skills represents a sufficient tool to entice students for urology and is helpful in enhancing the future of urology.     

Diagnosis and medical treatment of lower urinary tract symptoms in adult men: applying specialist guidelines in clinical practice

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Several sets of comprehensive treatment guidelines (national and international) exist for managing male lower urinary tract symptoms (LUTS), but these are not widely adopted in primary and secondary care, and are not consistently applied across Europe. This paper will improve the consistency of treatment approaches for adult males with LUTS by providing a clear, concise summary of existing treatment guidelines that can be easily adopted by urologists and primary care specialists.

OBJECTIVE

• ? To review current treatment guidelines (international and national) on managing male lower urinary tract symptoms (LUTS) and to summarize them for easy application in clinical practice.

METHODS

• ? A group of European urology specialists from primary and secondary care reviewed current treatment guidelines for male LUTS.

RESULTS

• ? The most appropriate recommendations for managing male LUTS were identified from existing international and national guidelines, and were summarized and simplified for use as a quick reference guide for healthcare professionals managing LUTS in adult males.

CONCLUSIONS

• ? Current guidelines for managing male LUTS were developed by urologists and are too complex for easy application in routine practice.
• ? This brief summary of current guidance should help to achieve consistent adoption of recommendations for best practice, improve working relationships between primary care specialists and urologists and clarify which patients' treatments should be managed entirely by urology specialists.

     

TELERADIOLOGY IN UROLOGY: COMPARISON OF DIGITAL IMAGE QUALITY WITH ORIGINAL RADIOGRAPHIC FILMS TO DETECT URINARY CALCULI

Purpose

Teleradiology systems are now being evaluated as a mechanism to provide rapid, accurate and cost-effective diagnostic radiographs to off-site physicians. Little data are available on the role and safety of teleradiology in urology. To address these issues a personal computer based system was developed to assess the diagnostic accuracy and ease of use of transmitted digital images when evaluating for urinary calculi.

Materials and Methods

A total of 100 plain abdominal scout films from excretory urograms performed during acute urological referrals was digitized on a laser scanner. The 10 megabyte files were transferred over public telephone lines and written to compact disks. The images were viewed on a 1280 × 1640 resolution monitor using "Imager-3D" software run on a 133 MHz. pentium personal computer with 32 megabytes of random access memory. Two faculty urologists and 2 urology fellows each looked at 50 original radiographs and 50 digital images. Diagnostic interpretations of the presence and location of calculi were recorded, and confidence in the diagnosis, assessment of image quality and diagnostic difficulty were scored using a numerical scale.

Results

The accuracy for all readers was 86.5% for plain radiographs and 81.5% for digital images (p >0.2). There was no statistical difference between faculty and fellows. Diagnostic accuracy did not differ between plain films and screen images when the results were assessed with respect to image quality, diagnostic difficulty or the reader confidence in the diagnosis (p >0.1). Compared to plain films, more screen images were classified as lower image quality (60 versus 40%) and the diagnostic confidence was lower (low and medium grade 50 versus 35%), although this did not interfere with diagnostic accuracy.

Conclusions

These data imply that a high quality affordable teleradiology system is effective and accurate compared to plain films for assessing urinary calculi.     

An assessment of urologists' training and knowledge of energy-based surgical devices

OBJECTIVE

To assess surgeons’ training and current understanding of existing energy‐based surgical instrumentation (ESI), we disseminated an online questionnaire to urology residents, fellows and attending urologists.

SUBJECTS AND METHODS

A two part 24‐question survey was disseminated to 1000 urology residents, fellows and attending physicians. The first part of the questionnaire assessed the respondents’ demographics and education about ESI; the second part evaluated the respondent’s knowledge of surgical energy methods and ESI, and was stratified into nine basic‐ and six advanced‐knowledge questions.

RESULTS

In all, 136 people (13.6%) viewed the survey and it was completed by 63 (6.3%). Respondents comprised 27 (43%) attending physicians, 14 (22%) minimally‐invasive urology fellows and 22 (35%) urology residents. Among participants, 41 (64%) had received no formal didactic training on ESI, and a further 14% of respondents’ didactic experience was limited to one lecture. Of the respondents, 70% said that monopolar energy was the mode most often used in surgery. Overall, the participants correctly answered 41% of the questions. Of the nine questions classified as ‘basic’ knowledge, respondents correctly answered 49%. Of the six questions classified as ‘advanced’ knowledge, 29% were answered correctly. The highest percentage score was obtained by the attending urologists, with a mean (range) score of 41 (29–86)%, followed by the fellows, with a mean score of 39.5 (29–57)%, and then the residents, at 34 (14–64)%.

CONCLUSION

Despite widespread and growing use of ESI, there is currently minimal formal training on energy modes and current energy devices being provided to urological surgeons. Both practising and training urologists have a limited understanding of surgical energy modes and of existing ESI.     

Evidence‐based medicine training in residency: a survey of urology programme directors

OBJECTIVE

To investigate whether and in what format urology residents receive formal training in evidence‐based clinical practice.

METHODS

In 2007 we conducted a survey of the Accreditation Council for Graduate Medical Education (ACGME)‐accredited urology residency programmes in the USA. The survey instrument was sent to all programmes, using postal mailing, e‐mail and a web–based interface. Programme director and coordinator names and basic demographic information such as programme size and length were retrieved from the institutions’ websites and the ACGME database.

RESULTS

Of 117 ACGME‐accredited urology programmes, 108 responded (92.3%). Most respondents either agreed or strongly agreed with statements that formal evidence‐based medicine (EBM) training was valuable to urology residents (97, 89.8%) and should be part of all residency programme curricula (91, 84.3%). Eighty‐four programmes (77.8%) indicated that their curricula included formal educational activities related to EBM. These programmes provided a median (interquartile range) of 10 (4.8–25.0) h of EBM teaching per academic year. Most programmes (65.9%) provided fewer hours of EBM training than programme directors perceived as ideal. Asked what would make it easier to integrate EBM into the programme, respondents identified urology‐specific educational materials (33.3%), a formal curriculum (24.4%) and faculty development (16.3%) as central needs.

CONCLUSION

In this survey we found that most programme directors recognize formal EBM teaching as an important aspect of urology residency training. However, most programmes devote less time to EBM training than they would like, and urology‐specific resources have been lacking. These findings support increased efforts to provide urology residents with opportunities to learn EBM‐related knowledge and skills in a variety of educational formats.     

Change in prostate cancer presentation coinciding with USPSTF screening recommendations at a community-based urology practice

Objective

The benefits of prostate-specific antigen (PSA)–based prostate cancer screening are controversial. We sought to determine the change in prostate cancer presentation coinciding with the release of the United States Preventative Services Task Force recommendations against screening in a high-volume community-based urology practice.

Surgery on the larynx and pharynx in Byzantium (AD 324-1453): early scientific descriptions of these operations.

We present the techniques of various operations on the larynx and pharynx (incision of abscesses of the tonsils, tonsillectomy, tracheotomy, uvulectomy, and removal of foreign bodies) found in the Greek texts of Byzantine physicians. The techniques of these operations were the first to be so meticulously described and were compiled from the texts, now lost, of the ancient Greek physicians. These medical texts, which followed and enriched the Hippocratic, Hellenistic, Roman, and Galenic medical traditions, later influenced medieval European surgery, either directly through Latin translations or indirectly through works of Arab physicians.