What has stayed and what disappeared in benign urology

"Looking back at the past 50 years, I recounted the achievements and yet-to-be-conquered goals," writes Gopal H. Badlani, MD.

“Any knowledge that doesn’t lead to new questions quickly dies out: it fails to maintain the temperature required for sustaining life,” said poet and Nobel Laureate Wislawa Szymborska.

Looking back at the past 50 years, I recounted the achievements and yet-to-be-conquered goals. It is also prudent to think back to what ideas/concepts have withstood the test of time, in the quest for knowledge and the inherent desire to replace old with new.

What has disappeared?

Females are no longer subjected to urethral dilation, a practice that was popular in the past based on the concept that, what we recognize today as dysfunctional voiding/pelvic floor dysfunction, was caused by the urethra and that overstretching it would fix the problem. Of course, it temporarily helped, but they were back for more.

Credé voiding and use of Bethanechol is another nonphysiologic process that has slowly disappeared—with good reason, because it had no scientific merit in neurologically intact individuals. It has been replaced largely by intermittent catheterization in both neurogenic and nonneurogenic patients with incomplete emptying.

Another diagnosis or myth that should disappear is “prostatitis” and a “boggy prostate” to define it. Chronic pelvic pain syndrome in males is now well recognized, and I wish we could teach primary care and emergency department physicians to stop throwing antibiotics at these young or not-so-young individuals. Despite negative urinalysis, this diagnosis is often made and doing a prostate-specific antigen (PSA) test is one way I have found to convince the patient and a referring physician that the prostate is not inflamed as the PSA level is very low.

The male urethra has seen better days; visual or tactile cannulation of the stricture by a guide wire is much less traumatic than the filiforms, followers, or metal sounds passed by feel. Such devices may have worked in some experienced hands, but many patients paid the price before that experience was gained. We described this technique of trying to avoid trauma/bleeding from the urethra of a patient undergoing cardiac surgery in The Urologic Clinics of North America (I. Urologic Pearls) in the early 1990s.1

Similarly, rigid cystoscopy of the male urethra in the office is uncommon practice today, and patients do not have to come off the table during the procedure. I heard from so many of my teachers that it did not hurt the way they did it. I assure you, the patient did not say that.

Monopolar transurethral resection of the prostate is also on its way out. Although still used in many parts of the world due to lower cost, it has been replaced in North America by bipolar and other less invasive procedures.

What has sustained

Urodynamic testing has remained the mainstay of voiding assessment. There are many more components to the machine, and the electronics of the pressure transducers are much more accurate, but the basic concepts have not changed significantly. With International Continence Society terminology, we simply may have changed the terms and added some nomograms.

Since Jack Lapides, MD, made it the norm, intermittent catheterization has served many patients faithfully and improved quality of life. We have made it expensive by discarding the catheter after each use despite many studies showing no difference in the incidence of urinary tract infections with “clean” technique vs reusing the catheters.2

The use of lasers has evolved but is now inseparable from urology. We keep learning of new wavelengths and better ways to use lasers for stones, the prostate, and certain urothelial cancers. These uses remain confined to the Western world due to the high cost. This use has allowed smaller, flexible scopes to reach the stone or lesions. The evolution of flexible endoscopy has been a marvel over the past 50 years and made the upper tract so accessible to the urologist regardless of the size of the patient. I fondly recall Demetrius Bagley, MD, who led this path among many others in this field. Bagley said, “Ureter is never fat and if you see fat, you are in the wrong place.”

The innovator F. Brantley Scott, MD, along with his partners Gerald W. Timm, PhD, and William E. Bradley, MD, left us a legacy of the artificial urinary sphincter (AUS) and inflatable penile implants (IPPs). Although there have been improvements, it is amazing that no new device has thus far replaced the AUS and IPP. Surgically, after so many variations of urinary diversion, the suprapubic tube and the ileal conduit remain the leaders.

I have reflected on many of my failed attempts to innovate.3 It is the desire to question, to improve current practice, that keeps me testing the so-called “norm.”

References

1. Barry JM, Resnick MI. The Urologic Clinics of North America (I. Urologic Pearls).

2. Smith WR, Badlani GH. Are reusable catheters safe? Study provides an answer. Urology Times®. October 30, 2019. Accessed June 2, 2022. https://bit.ly/3t7LH0z

3. Badlani GH. Success is built on a string of failures. Urology Times®. March 6, 2019. Accessed June 2, 2022. https://bit.ly/3za4eNT