RADIOLOGY CORNER: The Evolution of the Field of Urology: Where It Has Been and Where It Is Going
By: Tavya G. R. Benjamin, MD; Ardeshir R. Rastinehad, DO | Posted on: 01 Nov 2022
A critical inspection of every field of medicine, particularly interventional subspecialties, shows an intricate transformation of breadth and skill throughout its history. For example, cardiology, which once only encompassed the medical aspect of cardiovascular disease, now provides a multitude of interventional procedures, from cardiac catheterizations to balloon angioplasties and coronary stent placements. The field of interventional cardiology owes its existence to interventional vascular radiologists such as Dr Charles Dotter, who pioneered the now widely accepted method for angiography and transluminal angioplasty.1 Likewise, interventional neurology was born from neurosurgeons applying techniques developed by radiologists to their areas of expertise. Dr Charles Strothers, a dual-trained neurologist and interventional neuroradiologist, pioneered the field and paved the way for neurologists to provide interventional care for their patients.2 If it were not for such physicians’ open-mindedness, the field of medicine would look vastly different than it does today. Similarly, the field of urology has evolved to its current state through the progressive prodding of its leaders and the influence of technological advancements adapted from other surgical specialties. For this reason, we make the case that the future of urology depends on our adaptation and acceptance of modern and potentially unfamiliar treatment methodologies.
Patient Case Presentation
Urology (the patient) is a centuries-old surgical subspecialty with a rich past medical history of innovation and ingenuity. What began as blindly sounding the urethra and bladder to evaluate for stones in 1878 metamorphosized into the primitive version of a cystoscope, allowing for real-time visualization.3 A few years later, Dr John Macintyre published his experience using x-rays to confirm the presence of renal stones prior to operating, becoming one of the first surgeons to use radiologic technology to aid in diagnosing and treating a urological disease.4 Within the next 100 years, the first semirigid ureteroscope was developed using a 9Fr fiber-optic scope introduced into the ureter via a 26Fr endoscope sheath.5 These once-revolutionary ideas have formed the basis of endourology, with intraoperative fluoroscopy allowing the direct assessment of the stone’s location.
Urology’s family history is notable for its close association with general surgery. The early 1980s saw the application of laparoscopy to abdominal interventions by general surgeons, with laparoscopic cholecystectomies gaining popularity within the general surgery community.6 Soon a group of urologists in St Louis, Missouri, brought this technology to their surgical domain and performed the first laparoscopic nephrectomy, paving the way for laparoscopy and robotic interventions to be applied to all facets of the field.7
Today, Urology presents for evaluation of innovative stagnation. It states that there has been a lack of ingenious growth within the field for the past few years, and it is looking to find the next significant advancement in the field. Upon review of its clinical history, you see that at its core, Urology has always been a collaborative specialty, leaning on technology from radiologists and utilizing techniques and instruments developed by general surgeons to better care for patients. In the past, collaboration has led to some of the most significant advancements in the field’s history. As such, collaboration is the avenue upon which Urology’s future must traverse.
Considering this, you recommend that Urology evaluate and embrace new, potentially field-transforming treatment modalities. These include advances in genomics, imaging, surgical navigation, and interventional radiology, all of which improve the quality of life for our urological patients and pave the way for our next evolution in patient care. Utilizing intraoperative cone-beam CT with 3D navigation to identify and navigate towards residual stone fragments prior to completing a ureteroscopy will improve our post-treatment stone-free rates. The incorporation of magnetic resonance/ultrasound fusion–guided prostate biopsies, focal therapy for prostate cancer, and interventional procedures for novel drug delivery and the treatment of outlet obstruction, such as prostate artery embolizations, have the potential to revolutionize and improve the care we offer our patients.
These treatment methods perfectly illustrate the collaborative experience that urologists have demonstrated for over a century. Focal therapy uses the lessons learned from magnetic resonance/ultrasound fusion–guided prostate biopsies, now taking the next logical step for precise localization and treatment of the diseased area. Building upon this, focal therapy encompasses multiple ablative energy modalities, including cryoablation, nanoparticle thermal ablation, and high-intensity focused ultrasound. On the other hand, you have prostate artery embolization, which applies techniques perfected by interventional radiologists to allow particles, coils, or liquid embolics to diminish blood flow to the gland, thus causing ischemic necrosis and shrinkage. These care pathways provide ways for field growth, continued collaboration, and the application of emerging imaging modalities.
As one can see, the field of urology has a rich history of innovation and passion for groundbreaking research. As a progressive and advanced specialty, Urology has also pushed the limit in science and research, breaking down silos, and calling for a more collaborative approach to care. As a field, we are only as good as our professional partnerships allow. Without close relationships with our colleagues in radiology, general surgery, internal medicine, etc, we will never achieve our full potential. As a field, we should embrace these new techniques and approaches with an open and analytical mind. We must inspire future generations to push past the status quo and the current standard of care for the benefit of our patients. Socrates once said, “the secret of change is to focus all of your energy, not on fighting the old, but building on the new.” We must lean into the evolutionary cycle of our specialty, for if we do not, we will cease to attract revolutionary minds and extraordinary talent to this discipline. Without a deliberate commitment to innovation from the leaders of our field, Urology will be doomed to be the surgical specialty left behind.
- Lakhan SE, Kaplan A, Laird C, Leiter Y. The interventionalism of medicine: interventional radiology, cardiology, and neuroradiology. Int Arch Med. 2009;2(1):27.
- Edgell RC, Alshekhlee A, Yavagal DR, Vora N, Cruz-Flores S. Interventional neurology: a reborn subspecialty. J Neuroimaging. 2012;22(4):319-323.
- Engelsgjerd JS, Deibert CM. Cystoscopy. In: StatPearls [Internet]. StatPearls Publishing; 2022. https://www.ncbi.nlm.nih.gov/books/NBK493180/.
- MacIntyre J. Roentgen rays. Photography of the renal calculus; description of an adjustable modification in the focus tube. Lancet. 1896;148(3802):P118.
- Marshall VF. Fiber Optics in Urology. J Urol. 1964;91:110-114.
- Vecchio R, MacFayden BV, Palazzo F. History of laparoscopic surgery. Panminerva Med. 2000;42(1):87-90.
- Kerbl K, Clayman RV, McDougall EM, Kavoussi LR. Laparoscopic nephrectomy. BMJ. 1993;307(6917):1488-1489.