 |
       |
|
|
UROLOGY AT THE TURN OF THE MILLENNIUM
A G Phadke
Prof. and Head, Dept. of Urology, Bombay Hospital Institute of Medical Sciences, Mumbai 20.
Turn of the millennium is a big event for the human race. Every aspect connected with human life—philosophy, art and science saw mind-boggling progress during the second millennium. In reality, most of the progress of the human race in general and of science in particular took place during this period. Medical science and its various specialties like urology were no exception. When we review progress in urology, we have to scan various relevant developments that took place during the 20th century. In that sense, urology is relatively a young science. This becomes obvious when one notes that the American Urology Association, the first national organisation to recognise urology as a specialty staged its 94th Annual conference in Dallas in 1999. Urology was considered as a sub-specialty of general surgery for a very long time. United States was probably the first country to give it an independent status. Soon, the other countries followed the suit. Urological Society of India will celebrate its 33rd Annual Conference in the year 2000.
Progress of medical science during the last century has been astounding to say the least. Urology has benefited due to various inventions and discoveries in allied sciences and technologies. Specialisation as a result of focussed thought process and technological advances has become a password in modern medicine. Urology, which was considered as a sub-specialty of general surgery 50 years ago can boast of atleast 7 areas of super-specialisation like uro-oncology, urodynamics, paediatric urology, renal transplantation, endourology, andrology and female urology. All this is not just an exercise in semantics or splitting hair but it represents an in-depth appreciation of various urological problems and attempts to solve them. Today a discerning patient or a family physician would rather approach a young superspecialist than consult a senior general urologist. It must be appreciated that this is all for the benefit and welfare of the patient. This is a relatively recent but healthy trend observed in various branches of medicine.
When one takes a bird’s eye view of the various developments and inventions in the field of urology, one has to acknowledge with gratitude the contributions of many outstanding men of science.
In 1877, Max Nitze was the first surgeon to design an instrument that enabled a physician to take a peek into the mysterious and as yet unfathomed passage and a cavity of human body like urethra and urinary bladder. Successful use of a cysto-urethroscope heralded a new era of endoscopy in modern medicine. Wappler and Bovie in 1933 devised an electro-surgical cautery machine capable of under-water cutting. Induction of this machine in the urologist’s armamentarium went a long way in the development of operative endoscopic surgery. Endoscopic resections of benign enlargement of the prostate and superficial bladder tumours enhanced the effectiveness of endoscopic surgery.
Prof. Hopkins of the Reading University, UK is credited with incorporating wide angled rod lens system and fibreoptic technology in the telescopes used by the urologists. These innovations considerably improved the quality and the brilliance of the images viewed through the telescope. For these contributions he was deservingly felicitated and the British Association of Urological Surgeons conferred their highest honour on him for thesecontributions.
Dr. Charles Huggins of Chicago of USA achieved a major breakthrough in the understanding about the behaviour of cancer when in 1941 he demonstrated convincingly that cancer of the prostate was a hormone dependent tumour. He was awarded the Noble prize for medicine for this work. Till 25 years ago Wilm’s tumour in children and testicular tumours in young men were considered to have poor prognosis in general. Introduction of chemotherapy for these diseases has transformed the grave outlook of the future of these young patients. This fact was brought out with dramatic conviction when Adams of USA who had multiple metastasis due to a testicular tumour was treated so effectively and successfully with chemotherapy that he went on to win Tour de France in 1999. This bicycle race is considered as one of the toughest test of human endurance and stamina.
The most significant advance in the field of uro-oncology during the last decade has been recognition of PSA (prostate specific antigen) as a tumour marker for carcinoma of prostate. PSA is both sensitive and specific for diagnosis and prognosis of carcinoma of prostate. Increased public awareness that a simple blood test can help in early detection of cancer of the prostate, has induced many men to get their PSA estimation done as a part of routine health check ups. It has enabled the urologists to make diagnosis of early cancer of prostate. The concept of nerve sparing radicle prostatectomy introduced by Dr. Patrick Walsh at John Hopkins University has found wide acceptance in the urological community. Even more appealing and attractive treatment of organ confined carcinoma of prostate has been brachy therapy popularised by Dr. Blasko and his colleagues at Washington University, at Seattle USA.
Transplanting organs from other human beings or animals and making them work in the recepients body had been a fond dream of man since time immemorial. There are many examples of such successful transplantations in the mythological scriptures of every civilization in human history. To a rational mind, it always remained a myth or a flight of poetic imagination till, in 1954, John Merrill and Murray at Boston did a successful renal transplantation in identical twins. Dedicated clinicians like Sir Roy Calne, Thomas Starzl and David Hume backed up by immunological basis offered by Sir Peter Medawar went on to establish human renal transplantation as a successful treatment for end-stage renal disease.
With improvement in the fields of anaesthesia, surgical asepsis and antibiotics, surgery was made safe for the patients in the later half of the 20th century. Hundreds and thousands of lives were saved by modern surgery. In spite of this success, the patients often resented the invasiveness of these procedures. Appreciating these demands of the patients, Dr. Arthur Smith, Dr. Ralph Clayman from USA and Dr. John Wickham, UK, pioneered and established the concept of endo-urology in the early eighties.
Though endourology was started with the idea of dealing with urinary calculi by minimal invasive techniques, the scope of this sub-specialty has widened to encompass treatment of Pelviureteric junction. Obstruction, ureteral strictures and superficial epithelial tumours. The list continues to grow with passage of time. A cynical urologist once defined endourology as "end of urology" for the general urologists.
Search for minimal invasive treatment for urolithiasis reached its pinnacle when Dr. Christian Chaussey alongwith the technologists of Dornier Company in munich West Germany came out with the treatment of urolithiasis without surgery. This invention of extra-corporeal shock wave lithotripsy (ESWL) is one of the wonders of modern medicine. Now it has become possible to offer out-patient treatment without surgery to patients with urolithiasis.
Impotence and infertility had adverse impact onmarital bliss from time immemorial. The relentless search was on by physicians and quacks to find out satisfactory remedies. Nature defied these efforts for many centuries leading to frustration in the minds of medical men. Introduction of revolutionary concepts of intracytoplasmic sperm injection (ICSI) for treatment of infertility and oral therapy for erectile dysfunction in the form of sildenefil citrate (Viagra)has changed the scenario dramatically. These two inventions within the last 5 years can be considered as parting gifts by science to human race at the turn of the millennium.
If one realizes that scientific progress in medicine is increasing in geometrical proportions and that most of the significant discoveries took place in the last 50 years, it will be preposterous for anybody to predict what is in store for humanity in the next millennium. Even making a guess of what will be the shape of things to come in the next 10 years could be considered audacious. If what we are seeing today happening around us is used as a yardstick for peeping in the future, one can hazard few guesses.
It appears to be a writing on the wall that the scope of surgery will diminish considerably with the availability of more effective drug-therapies. Even in surgery, minimal invasive surgery will eclipse the standard surgical procedures. Precision in localisation in the disease process and its spread in the human body will be made possible with the ever-improving imaging techniques. This will enable the surgeon to zoom in on the pathology with precision and with minimal invasion. Majority of the infections and infectious diseases will be brought under control with effective chemotherapy, antibiotics and vaccines. With ever-increasing longevity of human life, degenerative diseases like atherosclerosis, osteoarthritis along with cancer in its various forms will dominate the scene of medicine. Genetic engineering is on the threshold of making a major breakthrough. It will enable the scientists to understand and to deal with many as yet unsolved riddles of human ill-health. At this stage all that one can say with confidence is that the coming generation will witness wonders of medical science as yet not dreamt of by the medical men of today.
 |