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Urological Surgery
Developments in the Fields of Endourology and Minimally Invasive Surgery
a report by
Christian Bolenz and Maurice Stephan Michel
Department of Urology, University Hospital Mannheim
Almost 30 years ago, Arthur D Smith first coined the term ‘endourology’, conclusive results have been reported on this topic to date, and peri-
which he defined as “closed controlled manipulation within the operative outcome and complications should be further validated in
genitourinary tract”.
1
Since then, endourology has become a field of comparative clinical trials.
consistent technical innovation. Minimally invasive techniques actually
account for up to 80% of all interventions in the field of operative urology, Also, a new high-frequency generator for TUR-P has been introduced into
compared with about 10% of the surgeries performed in the 1960s.
2
clinical practice.
10
It should provide an optimised incision and better
Endoscopic and minimally invasive techniques have revolutionised the field haemostasis, and can be used for both conventional unipolar and bipolar
of endourology, as well as the many other surgical specialties. resectoscopes. They allow for ‘coagulating intermittent cutting’, that is,
combining tissue resection and haemostasis synchronically to achieve a
In the late 1950s, progress in endoscopic procedures was initiated by the ‘dry cut’. Whether this technique provides better haemostasis and an
development of the rod-lens optical system by Hopkins and the fibre improved clinical course after both unipolar and bipolar procedures will
optic cold-light source by Storz.
3
The work of Berci greatly contributed to be clarified within the next few years.
the early stages in designing endoscopic equipment and promoted
clinical applications of novel techniques.
4
Further technical progress in the Bipolar resectoscopes are also available for transurethral resection of
field of fibre optics, radiographic imaging and various forms of lithotripsy bladder tumours (TUR-BT). TUR-BT is still the gold standard in the initial
gave rise to modern techniques such as ureteroscopy. Currently, management of transitional cell carcinoma (TCC) for both diagnostic and
minimally invasive treatments of ureteral stones and tumours within the therapeutic purposes in the non-muscle-invasive stages of the disease.
11,12
genito-urinary tract are provided by high-tech endoscopic devices, and However, the diagnosis of urothelial flat lesions and carcinoma in situ
lead to great benefits for patients. (CIS) remains a problem in clinical practice, since in these cases no
papillary or solid tumour masses are obvious. In order to optimise the
This article aims to review recent progress in shockwave lithotripsy, detection rate of these lesions, fluorescence-guided cystoscopy has been
endoluminal and endoscopic surgery, as well as promising tools and evaluated in clinical trials.
13
Aminolevulinic acid (ALA) is introduced into
applications for the future. We focus on a few of the most important the bladder via catheterisation prior to TUR-BT. The ALA solution
developments to give the reader an update on the status of the various selectively accumulates in pre-malignant transformed cells, which then
endourological and minimally invasive procedures. appear fluorescent during cystoscopy performed using back-scattered
blue light.
14
Two large, randomised trials were reported at the
Transurethral Resection 2007 annual meeting of the European and American Urological
Various endoscopic procedures for the treatment of benign prostatic Associations.
15,16
These trials demonstrate that fluorescence-guided
enlargement (BPE) are available; however, devices such as electro-vapour
resection, radiofrequency needle ablation, holmium (Ho) laser
enucleation and potassium-titanyl-phosphate (KTP) laser ablation have
Christian Bolenz is a third-year resident in the Department of
Urology at the University Hospital Mannheim in Germany.
not yet replaced transurethral electro-resection of the prostate (TURP) as
He is also a Fellow in a urological basic research group
the best alternative available.
5
primarily dealing with transitional cell carcinoma.
Bipolar Resectoscopes
A recent development in TURP worth mentioning are bipolar
resectoscopes.
6,7
These are equipped with an active and a neutral
Maurice Stephan Michel is Professor of Urology and Vice
electrode, which feed back the resection current. Both electrodes are fully
Director of the Department of Urology at the University
insulated from the sheath and all other metal components, thus reducing Hospital Mannheim. He is Head of the Department of
the current flow path to a narrow defined space. In this way, obturator
Research and Head of the Uro-oncology Section in
Mannheim. His main clinical and scientific interests are
reflexes are avoided, and there is no need to switch off pacemakers in
conservative and operative urological oncology,
patients suffering from heart disease. Another advantage of this resection
endourological techniques, management of clinical trials,
basic research in tumour therapy and benign prostatic
device is that saline-based solutions can be used in bipolar resection, thus
hyperplasia, as well as urolithiasis. He is Section Editor of
avoiding the so-called TUR-syndrome.
8
However, concerns have been the Journal of Endourology and is a past winner of the Arthur Smith Award of the
raised about the higher rate of urethral strictures caused by bipolar
Endourological Society, which is the highest scientific international award in the field of
endourology. He has also obtained two patents.
devices.
9
There is an ongoing debate on the question of whether bipolar
resection may induce less severe bleeding during and after TUR-P. No
© TOUCH BRIEFINGS 2007 51
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