Abstract
Throughout history, many innovations have contributed to the development of modern urological surgery, improving patient outcomes and expanding the range of treatment options available to patients. This article explores five key historical innovations that have shaped modern urological surgery: External shockwave lithotripsy, transurethral resection of prostate, cystoscope, perioperative prostate-specific antigen and robotic surgery. The selection of innovations for inclusion in this article was meticulously determined through expert consensus and an extensive literature review. We will review the development, impact and significance of each innovation, highlighting their contributions to the field of urological surgery and their ongoing relevance in contemporary and perioperative practice.
Introduction
Urological surgery has come a long way since its inception, with numerous innovations revolutionising the field and leading to improved patient outcomes. The development of these innovations has expanded the range of treatment options available to patients, enabling urologists to address complex conditions with greater precision and efficacy. In this article, we delve into the historical advancements that have played a pivotal role in shaping modern urological surgery, focusing on five key innovations: external shockwave lithotripsy, transurethral resection of prostate (TURP), cystoscope, perioperative prostate-specific antigen (PSA) and robotic surgery.
The field of urological surgery owes much of its progress to these innovations, which have not only transformed surgical techniques, but have also enhanced diagnostic capabilities and patient care. By examining the development, impact and significance of each of these innovations, we aim to shed light on their contributions to the field and highlight their continued relevance in contemporary urological practice. External shockwave lithotripsy stands as a remarkable breakthrough in the treatment of urinary calculi. This non-invasive technique revolutionised the management of kidney stones, offering patients a safe and effective alternative to traditional surgical interventions. We will explore the evolution of shockwave lithotripsy, its mechanisms of action and its impact on patient outcomes, highlighting its ongoing relevance in the modern era. TURP emerged as a transformative procedure for benign prostatic hyperplasia (BPH). Its minimally invasive nature and high success rates have made it the gold standard for the surgical management of BPH. We will discuss the historical progression of TURP, its impact on patients’ quality of life and its role in the current urological armamentarium.
The development of the cystoscope opened new frontiers in the diagnosis and treatment of urinary tract disorders. This invaluable tool has enabled urologists to visualise the urinary tract, diagnose conditions accurately and perform various therapeutic interventions. We will delve into the evolution of the cystoscope, its instrumental role in urological examinations and its continuing significance in contemporary practice. Furthermore, we will explore the introduction of perioperative PSA measurement, which revolutionised the diagnosis and management of prostate cancer. PSA monitoring has played a crucial role in early detection, risk stratification and treatment monitoring, profoundly impacting patient outcomes. We will examine the historical context of PSA measurement, its influence on urological practice and its ongoing relevance in perioperative decision-making.
By comprehensively reviewing these historical innovations, their impact and significance, this article aims to provide a deeper understanding of the advancements that have shaped modern urological surgery. Recognising the enduring relevance of these innovations will contribute to the continued evolution of urological practice and enhance patient care in the years to come.
The innovations as described in the article were selected by the following process. A scoping review of the literature was performed, which consisted of a PubMed search identifying systematic reviews, randomised controlled trials and meta-analysis. The terms searched included ‘innovations’, ‘Urological Surgery’, ‘history’, and ‘advancements’. Authors of this article individually reviewed abstracts using the COVIDENCE-literature review management software. Finally, articles from the literature search were analysed by a panel of expert urology consultants, who gave their consensus on the final five innovations selected in this article.
External shockwave lithotripsy
Kidney stone disease has been known to be referenced in Egyptian texts of thousands of years BC. Historically, management involved surgery or transurethral lithotripsy, which was first done by the French surgeon Jean Civiale in the early half of the 19th century (Tailly 2013). On 7 February 1980, Christian Chaussy, Bernd Forssmann and Dieter Jocham, using the Dornier HM1 lithotripter, become the first team to perform extracorporal shockwave lithotripsy (ESWL) (Chaussy et al 1980). The technique proved so popular that in a matter of years, the upgraded Dornier HM3 was being used in specialist hospitals worldwide. However, early lithotripters, where bulky, so machines progressively became smaller and more efficient, allowing small centres to treat stones, diluting the patient load from specialist centres, with a procedure that is performed by most urology departments in the UK (Tailly 2013).
Focused shock wave therapy (FSWT) is used in lithotripsy. Commonly three types of mechanisms can be used to form focused shockwaves for FSWT: electrohydraulic, electromagnetic and piezoelectric. Electrohydraulic generators are produced by an expanding and immediately collapsing vaporisation bubble to form a shockwave that is focused using a reflector. Magnetic fields cause membrane repulsion to cause a shockwave by electromagnetic generators. Again, the wave is focused by reflectors or acoustic lenses. Finally piezoelectric shockwaves are generated by passing a current through crystals, causing them to vibrate, which in turn causes shockwaves. The stones are targeted using adjunct technologies, such as ultrasound and fluoroscopy, and coupling agents are used to maximise the focused delivery of shockwaves (Ng et al 2004, Pishchalnikov et al 2006, Rassweiler et al 2011). FWST specifically targets tissues at specific depths. These shockwaves created rising positive pressures of 5–120 MPa in 5 nanoseconds to ‒20 MPa. This causes the positive pressure to be absorbed into the stones and the negative pressure to then subsequently cause cavitation air bubbles that then collapse to cause a second shockwave of micro fluid (Manzoor & Saikali 2021, Simplicio et al 2020).
It has been shown that ESWL can achieve stone-free rates of around 75% (Assimos et al 2016). Given its non-invasive nature, it can be an attractive option for many. However, more invasive procedures such as ureteroscopy and percutaneous nephrolithotomy have been shown to achieve a higher rate of Stone-free-Rate (SFR), especially for larger stones (Reynolds et al 2018). So, it is important to pick the correct population for ESWL. The most important factor in patient selection is stone location and stone burden. Stones < 2 cm in size are best selected for ESWL. Those with high stone burden may also have unfavourable outcomes, including treatment failure, steinstrasse, post-SWL colic obstruction and need for multiple trials of ESWL. Stones in the lower calyceal region generally have poorer outcomes as the region is more dependent, and hence clearance is generally poorer. Hence, stones > 10 mm generally have lower SFR rates (Reynolds et al 2018, Türk et al 2016, Wiesenthal et al 2011). Calcium oxolate, cystine and calcium phosphate stones are more resistant to ESWL. In addition, higher obesity leads to increased skin-to-stone distance, decreasing the effectiveness of ESWL, especially over 10–11 cm (Ringden & Tiselius 2007). Finally, patients with a stone density of >970 Hounsfield units have shown to have a poorer prognosis (98% versus 38% SFR) (Ouzaid et al 2012).
The largest contributing factor over the last 40 years for improved ESWL outcomes has been improved patient selection rather than radically different technology. Fine-tuning techniques, such as coupling and adjunct imaging - for example ultrasound and fluoroscopy, are being actively researched to increase efficacy and safety. In addition, advancements such as burst shock wave lithotripsy have started offering new options and perspective to treatments. Burst wave lithotripsy has been shown to deliver more energy, more quickly, by delivering at a higher pulse repetition frequency (PFR). It offers more therapeutic advantages such as the fact it may be performed in an ambulatory setting with a handheld device and requires less sedation (Maxwell et al 2019, Raskolnikov et al 2022). As described earlier, stone position is a major factor in patient selection. Ultrasound propulsion of the stone, as first described by Shah et al (2010), has shown to use transcutaneous ultrasound waves that produce a radiation force allowing repositioning for stones making them more amenable to ESWL (Raskolnikov et al 2022). Dual shockwave lithotripters are also being developed to try and minimise cavitation experiences in current lithotripsy by introducing two rapidly successive shock waves (Raskolnikov et al 2022).
In conclusion, since its conception in 1980, ESWL has revolutionised the method in which small stone disease can be managed, allowing smaller units to treat patients locally in a non-invasive manner in the day case setting. However, patient selection remains extremely important for this technique, and future advancements will be needed to be able to bring this technology to a wider patient population in a safe manner.
Transurethral resection of prostate
Evolution of the resectoscope
BPH is one of the most common urological diseases affecting older men with an age-specific prevalence of 50% in the sixth decade of life (Berry et al 1984). The distinguished 18th century surgeon John Hunter (1835) was the first to publish a series of experiments outlining the effects of prostatic enlargement on decreasing the flow of urine. At that time, the mainstay of treatment remained catheterisation, a modality still used in certain cases to this present day. It was not until 1909 when Hugh Hampton Young (1913) created a tubed outer sheath with a sharpened inner sheath to perform a transurethral prostatic ‘punch’ as depicted in Figure 1 above. Then, the later addition of electrical current aided in haemostasis.
The prostate ‘punch’ devised by Hugh Hampton Young (circa 1909)
Maximilian Stern is credited with inventing the modern resectoscope in 1926, when he added an electrified tungsten loop to scoop prostatic fragments (Blandy et al 2004). Joseph McCarthy added a wider lens and a Bakelite sheath that insulated the loop and allowed for an extending gear system in 1931 – thus creating the popular Stern-McCarthy resectoscope as depicted in Figure 2 (Blandy et al 2004). Then, the addition of ‘the two-foot switch’ pedal, for alternating between cutting and coagulating diathermy, by Theodore Davis in 1931, led to the eventual operative description of the modern TURP technique by Reed Nesbit in 1943 (Agrawal & Mishra 2022). From the 1970s onwards, technological growth led to fibre optic lighting, lens quality improvement and closed-circuit video, to complete the development of the modern resectoscope (Mebust 1990).
Stern-McCarthy resectoscope (circa 1932) with a rack-and-pinion working mechanism
Use of bipolar
Then in 1999, the next major innovation in TURP came when the Gyrus PlasmaKinetic Endourologic system received Food and Drug Administration (FDA) approval and became the first bipolar electrocautery device (B-TURP). Importantly in B-TURP, energy is confined between electrodes at the site of the resectoscope, allowing the use of a more physiological isotonic electrolyte medium for irrigation, namely normal saline 0.9%. Conventionally, TURP has been performed using monopolar diathermy (M-TURP) (Cabelin et al 2000). This requires a hypo-osmolar solution, typically glycine 4%, for bladder irrigation to act as a conduit for the energy dispersed from the monopolar electrode to reach a skin pad. However, the excessive absorption of this fluid can result in symptomatic dilutional hyponatraemia, known as transurethral resection (TUR) syndrome (Yang et al 2004).
B-TURP is favoured by some urologists over M-TURP because of an improved peri-safety profile, with no risk of TUR syndrome and decreased risk of intraoperative and postoperative bleeding (Yang et al 2016). The largest meta-analysis published to date concluded that B-TURP reduced TUR syndrome and blood transfusion events by 20 and 28 fewer events per 1000 participants, respectively (Alexander et al 2019). The study also concluded that B-TURP may carry a similar risk of urinary incontinence (UI) and may result in similar rates of re-TURP in the short-term (four fewer events and one more re-TURP per 1000 participants, respectively), compared to M-TURP (Alexander et al 2019). The latest American Urological Association (AUA) guidance considers a urologist’s individual operative experience and states that either M-TURP or B-TURP may be used as long as it facilitates optimum resection speed – TURPs lasting over 90 minutes carry a significantly increased risk of complications (Riedinger et al 2019).
The ‘gold standard’
Approximately 40,000 TURPs are performed annually in the United Kingdom alone (O’Donnell & Foo 2009). The European Association of Urology (EAU) cites that for ‘more than nine decades’, TURP has formed the ‘gold standard’ of male non-neurogenic lower-urinary-tract symptoms (LUTS) treatment (Oelke et al 2011). As per the latest AUA and EAU guideline panels, TURP should be offered as a first-line surgical treatment option for patients with LUTS or BPH where pharmacological treatment has failed or is contraindicated (Enikeev et al 2022). The caveat of prostate size was introduced by EAU in 2013 and recommended that TURP should not be used for a prostate volume > 80 cm3 – instead, open surgery or transurethral holmium laser enucleation is better suited (Enikeev et al 2022). Several novel minimally invasive procedures have been introduced in the last decade for a smaller prostate volume. However, the current guidelines reflect that in the hands of a skilled endourologist, TURP remains the cornerstone of surgical management for BPH as it did in the middle of the 20th century (Figure 3).
Fundamentals of the operative steps for a TURP
Enhancing perioperative team proficiency and collaboration through TURP
The benefits offered by TURP extend to both the perioperative team and the patient. TURP has shown notable enhancements in LUTS, a positive impact on quality of life and increased patient satisfaction, which have been consistently maintained over a 12-year long-term follow-up period (Mishriki et al 2008).
Progress in the management of BPH has led to skill enhancement among health care professionals. Surgeons and nurses engaged in TURP procedures now have the opportunity to hone their expertise in utilising endoscopic and minimally invasive techniques. Notably, advancements in TURP, particularly through minimally invasive approaches, have presented numerous skill-improvement prospects for surgeons. Training programmes for TURP simulation also encompass elements of communication and team building (Viswaroop et al 2015).
Cystoscope
Historical background of the cystoscope
The innovation, development and use of the cystoscope in the late 19th century marks the start of modern urology as a separate surgical specialty (Samplaski & Jones 2009). Prior to the cystoscope, much of our understanding of urological disease was limited to pathological findings from autopsies. The lack of x-ray and fluoroscopy at the time prompted the need for better diagnostic and therapeutic approaches. The first functional cystoscope was developed by Maximilian Nitze, regarded as the ‘father of the cystoscope’, in 1887. This spurred widespread adoption and development of the cystoscope in both Europe and America (Herr 2006) (Figure 4). It permitted visualisation of the urinary tract for the first time and revolutionised our understanding, diagnosis and treatment of urological diseases. Bransford Lewis (1907), the fourth president of the American Urological Association, described the cystoscope to have ‘transferred the study of urinary diseases from an inexact, intangible, shifting basis to one of definite and established proportion’.
Maximillian Carl-Freidrich Nitze, regarded as the ‘father of the cystoscopy’ (Herr 2006)
Historical development of the cystoscope
Phillip Bozzini, the first endoscopist ideologist, invented the ‘Lichtlieter’, or the light conductor, in 1805, in an attempt to visualise inside the bladder and other body openings (Rathert et al 1974) (Figure 5). In 1853, Antoine Desormeaux was the first to introduce his cystoscope into a patient and used a reflected kerosene lamp as an external source of light; he also pioneered endoscopic intervention by carrying out an excision of a urethral papilloma. However, the first generation of cystoscopes had several drawbacks due to the use of extracorporeal reflected light and small, distant visual fields (Samplaski & Jones 2009).
Prototype of the Nitze cystoscope introduced in 1877 (Herr 2006)
The second generation of cystoscopes ushered in the use of intracorporeal light sources and better visual fields. Recognising the limitations of early attempts at cystoscopy, Nitze in 1876, with the help of two opticians Wilhem Deicke and Louis Beneche, developed a miniature telescope with lenses to magnify the view inside the bladder and also used a water-cooled platinum filament lamp to illuminate inside the bladder (Herr 2006). Subsequent iterations, developed in conjunction with Joseph Leiter in Vienna, did not receive much acclaim, with questions raised around the possible applications of the cystoscope and difficulty in using a complex cooling system for the platinum filament light source (Herr 2006).
The third generation of cystoscopes came into practice in 1887, when Nitze deployed a small light bulb on top of one of his cystoscope, which was regarded as the first truly functional cystoscope (Samplaski & Jones 2009) (Figure 6). Nitze photographed images through his cystoscope in 1893 and published the first atlas of Bladder Pathology in 1893 (Patel et al 2018). In America, Howard Kelly & Burnam (1914) manufactured the first American air distension cystoscope in 1893. He also subsequently published his textbook Diseases of the Kidneys, Ureters and Bladder in 1914, wherein he describes detection of ureteric stones by the presence of scratches on the surface of ureteric catheters coated with wax. William Otis’ Wappler Lens system, in 1905, produced an image four times larger than previous generations, enabling inspection of the entire bladder. Following on from this, in 1908, the Brown-Berger combination cystoscope was introduced by Leo Buerger, where an extra prism converted inverted images to upright, and this became the standard cystoscope in America for over 60 years. Leo Buerger also published his findings from cystoscopy and was able to correlate cystoscopic findings with histological appearances (Patel et al 2018).
Nitze’s cystoscope showing probe channel, urethral probe, and bulb illumination (Ringleb 2013)
In 1951, Harold Hopkins, a physicist, applied fibre optics to the cystoscope, and this marked the beginning of the era of flexible optics (Gow 1998); his patent was purchased by Karl Storz (Cockett & Cockett 1998). In 1962, John McGovern and Myron Wolzak documented the first fibreoptic endoscopy (Marshall 1964).
In the late 20th century, the introduction of digital chip sensor technology, integration of the cystoscope with video-endoscopy systems and external monitors, not only greatly enhanced image quality further, but also enabled the modern urologist to multitask and carry out complex endoscopic interventions (Quayle et al 2005).
Modern-day use
The cystoscope is used mainly as a diagnostic tool for the evaluation of haematuria, suspected bladder cancers, LUTS, trauma and fistulas. It also has some therapeutic applications such as removal of foreign bodies, injection of botox, small biopsies, insertion/removal of ureteric stents and diathermy/laser of small bladder lesions. It can be performed either with a flexible cystoscope under local anaesthesia in the outpatient setting or as a rigid cystoscope, under general anaesthesia in theatre.
White light cystoscopy (WLC) is the gold standard for initial evaluation of bladder cancer. The sensitivity and specificity of WLC for detection of papillary bladder tumour range from 62% to 84% and 43% to 98%, respectively (Jocham et al 2008) (Figure 7). Narrow band imaging (NBI) is an optic enhancement technique that enables light to be strongly absorbed by haemoglobin, and only penetrates tissues superficially, enhancing the appearance of bladder tumours as brown or green. In photodynamic diagnosis (PDD), or blue light cystoscopy, photoactive porphyrin analogs, such as a 5-aminolevulinic acid (5-ALA) and hexaminolevulinate, are instilled in the bladder, and blue intermediate porphyrins accumulate preferentially in neoplastic cells, leading to the demarcation of bladder cancer tissue as bright red lesions against a blue background (Loidl et al 2005). This has been reported to further improve detection rates of papillary tumours and Urothelial carcinoma in situ (CIS), altering management in upto 14% of cases (Daneshmand et al 2018).
White light (a) and blue light fluorescence (b) endoscopic images of a flat tumour in situ (Tis). 5-Aminolevulinic acid (5-ALA) solution was instilled intravesically before cystoscopy
Despite the development of other modern imaging modalities, such as virtual cystoscopy, parametric magnetic resonance imaging (MRI), positron emission tomography-computed tomography (PET-CT), among others (Abouelkheir et al 2021), the cystoscope’s ability to enable direct visualisation along the urinary tract will likely lend itself to remain an invaluable and reliable diagnostic tool, in the modern urologist’s arsenal, for years to come.
Revolutionising cystoscopy: Enhancing patient care and perioperative team efficiency through innovative advancements
Innovations in cystoscopy have brought about various advancements, including improvements in stent application techniques and the design of stent removal devices. A notable example of such progress is the development of single-use flexible cystoscopes, which excel in terms of portability and simplifying the process of ureteral stent removal. These devices guarantee sterility upon manufacture and are not intended for reuse, contributing to reduced rates of bacteriuria and urinary tract infections (Adam et al 2021). In addition, their accessibility has been associated with shorter stent indwelling times, alleviating the workload on hospital staff (Lütfrenk et al 2023).
Over the past few decades in the UK, nurse-led flexible cystoscopy has emerged as a response to the rising prevalence of bladder cancer, growing demands on health care delivery and the increasing workload faced by urologists (Sapre et al 2012). Nurse-led cystoscopy clinics benefit significantly from enhanced continuity of care and follow-up (Gidlow et al 2000).
Given the global scarcity of specialised access for patients, tele-cystoscopy emerges as a viable solution. Tele-endoscopy has demonstrated cost-saving benefits and expedited care in other medical fields, suggesting that similar advantages may be attainable through tele-cystoscopy (Hougen et al 2016).
Perioperative PSA
Prostate cancer is the second most diagnosed cancer and accounts for a large proportion of cancer-related deaths among men worldwide (Culp et al 2020, Siegel et al 2022). The global burden of prostate cancer is projected to increase to almost 2.3 million new cases by 2040, highlighting the critical need for early diagnosis and treatment for improved prognostic outcomes (Culp et al 2020, Siegel et al 2022). In addition to digital rectal examinations and imaging techniques, the measurement of PSA serum concentration is one of the main diagnostic tools for detecting prostate cancer (Descotes 2019, Smith et al 2007).
Structural evolution of PSA
PSA is an androgen-regulated serine protease primarily produced by prostate epithelial cells. It belongs to the tissue kallikrein family and acts on seminal plasma, causing the liquefaction of seminal fluid (Balk et al 2003, Diamandis 1998). PSA production occurs in secretory epithelial cells of the prostate glands. Disruption of the cell layers and basement membrane, characteristic of early prostate cancer, allows PSA to enter the peripheral circulation, leading to increased serum levels (Balk et al 2003, Diamandis 1998). While elevated PSA levels can indicate the presence of prostate cancer, they can also be caused by other benign prostate diseases such as benign prostate hypertrophy (BPH) (Lilja et al 2008).
Discovery and history of PSA
The discovery of PSA dates back to the late 1900s when antigenic properties were identified in prostate tissue (Flocks et al 1960). The search for male-specific antigens in semen for forensic purposes led to the discovery of ‘prostate-specific antigens’ (Ablin et al 1970). In 1980, PSA was identified in the serum of prostate cancer patients, and an enzyme-linked immunosorbent assay (ELISA) for measuring PSA levels became available shortly after (Chu 1997, Tokudome et al 2016). The FDA approved the PSA test in combination with digital rectal examination for the early detection of prostate cancer, and it has since become the premier tumour marker for diagnosis and monitoring (Loeb & Catalona 2007).
Clinical use of PSA
The widespread use of PSA testing has had a profound impact on the epidemiological features of prostate cancer. The European Randomised Study of Screening for Prostate Cancer (ERSPC) demonstrated a 20% reduction in prostate cancer mortality among men undergoing PSA screening (Schröder et al 2014). However, controversies surrounding PSA screening persist, leading to varied recommendations worldwide (Martin et al 2018, Wilt & Ahmed 2013). Currently, a serum total PSA level greater than 4 ng/mL is widely used as a threshold for a positive screening result, although it may exclude some patients with clinically significant prostate cancer (Loeb & Catalona 2007, Stephenson et al 2009).
Biosensors for PSA detection
To improve the specificity of PSA measurement as a tumour marker, PSA analysis methods have been substantially updated and enhanced, particularly through the development of biosensor technology (Akbari Jonous et al 2019, Damborska et al 2017). Antibody-based biosensors offer a sensitive and specific means of measuring PSA levels, enabling the detection of low concentrations in the blood and facilitating early detection of prostate cancer (Akbari Jonous et al 2019, Damborska et al 2017).
PSA-targeted drugs
In addition to diagnosis and screening, the proteolytic properties and activity profile of PSA in the tumour microenvironment have motivated the exploration of PSA-targeted drugs for the treatment of prostate cancer (Chandran et al 2007, Sawpari et al 2023). Doxorubicin, an anticancer anthracycline, has shown promise; however, drug resistance and cardiotoxicity limit its clinical use (Chandran et al 2007, Sawpari et al 2023). To address these limitations, doxorubicin prodrugs specifically metabolised by PSA have been designed to improve the therapeutic index by leveraging the relative specificity of PSA to prostate tissues (Pereira et al 2019, Sawpari et al 2023).
PSA plays a vital role in the diagnosis and management of prostate cancer. Despite the limitations of PSA screening, it remains an important tool for early detection and improving patient outcomes. Biosensor technology has revolutionised the detection of PSA and holds the potential to enhance the accuracy of prostate cancer diagnosis. Ongoing research aims to exploit the enzyme activity and specificity of PSA to advance targeted therapies in prostate cancer (Akbari Jonous et al 2019, Pereira et al 2019).
Robotic surgery
For the last decade, urology has pioneered progression in the field of robotic-assisted surgery (RAS). RAS systems such as the da Vinci Surgical System (Intuitive Surgical, Inc, USA) build on the advantageous principles of minimally invasive surgery by adding three-dimensional (3D) magnified vision, EndoWrist (Intuitive Surgical, Inc, USA) technology, depth perception and dexterity (Figure 8). This technology is suited for surgical access in the anatomically restricted pelvis, as highlighted by robotic-assisted radical prostatectomy becoming one of the most common robotic procedures. Furthermore, a landmark meta-analysis showed comparable oncologic and perioperative outcomes to laparoscopic and open techniques (Tewari et al 2012). These positive outcomes have also been reported with robotic partial nephrectomy in a prospective multicentre cohort study when utilised for anatomically low-risk renal tumours (Bravi et al 2021).
The da Vinci surgical robot approved for use in 2000 (Tewari et al 2012)
Anticipated developments in robotic urological procedures are poised to revolutionise future practice. Striving for comprehensive tumour removal while minimising incisions and dispersion, innovative approaches may involve implementing a robotic en-bloc resection for non-muscle invasive transitional cell carcinoma (Bach et al 2015). Likewise, a perineal approach to robotic radical prostatectomy is on the horizon (Akca et al 2015). Furthermore, advances such as the Telelap ALF-X (TransEntrix, Inc, USA) enhance the existing da Vinci surgical environment by utilising 3D glasses to heighten situational awareness and incorporating haptic force feedback. The outlook for robotic urological surgery is promising. However, this progression comes with complexities in terms of logistical requirements, staff training and cost. It is essential to note that while robotic surgery holds great potential, it has yet to demonstrate superiority over laparoscopic surgery in various procedures, such as radical nephrectomy. This underscores the imperative for ongoing improvements, especially within global health care systems grappling with limited resources.
Conclusion
In conclusion, the history of urological surgery is rich with innovations that have had a significant impact on patient outcomes and treatment options. From the advent of TURP, to the development of perioperative PSA, the five key historical innovations explored in this article have played a crucial role in shaping modern urological surgery. The advancements in external shockwave lithotripsy, TURP and the cystoscope have provided effective solutions to long-standing challenges in urological surgery, while perioperative PSA has revolutionised diagnostic and treatment capabilities. Furthermore, new robotic procedures are also likely to be implemented in the future. As urological surgery continues to evolve, these innovations remain relevant and continue to inform contemporary practice.
