The Wales Endoscope: The First American Cystoscope.

INTRODUCTION: Philipp Bozzini, a German army surgeon, in 1807 invented the Lichtleiter, the predecessor of the modern cystoscope. By the mid-1800s, several new instruments were created including one, a variation on Bozzini's instrument by Antoine Desormeaux in Paris. The William P. Didusch Museum of Urologic History acquired the Wales endoscope, a rare and unique cystoscope that was invented around the same time in the United States. METHODS: We researched the life of Philip Wales and the description of his cystoscope as well as Horatio Kern, the instrument maker that produced Wales' instrument. We examined the Wales cystoscope acquired by the William P. Didusch Museum. RESULTS: Philip Skinner Wales (1837-1906) was a surgeon who entered the United States Navy in 1856 and served throughout the Civil War. He organized and held charge of the Naval Hospital at New Orleans during the operations of Admiral Farragut's fleet in the Mississippi River. He was one of the first surgeons to attend President Garfield when he was shot. He was Surgeon General of the Navy (1879-1884) and founded the Museum of Naval Hygiene in Washington D.C. which later, combined with the naval laboratory and Department of Instruction, became the prototype of the Naval Medical School. In 1868 he published a series of papers in the Philadelphia Medical and Surgical Reporter on "Instrumental Diagnosis," with a paper entitled "Description of a New Endoscope." The instrument contained a metal shaft with an acute beak and used an ophthalmologic mirror to reflect light down the channel. The surgeon peered through the center hole to look into the bladder. Wales used his instrument multiple times in his private practice. Wales writes that the advantages of his cystoscope were that it was simple to produce and cheap compared to Desormeaux's endoscope. Furthermore it was light, weighing approximately 2 pounds. The main drawbacks of Wales' cystoscope were the inadequate illumination, as the light source was external and projected from the outside through a narrow channel into the bladder, and that without an optical system the image appeared relatively small. Horatio Kern, a well-known instrument maker in Philadelphia, that also supplied surgical sets and instruments for the U.S. Army during the Civil War, produced Wales' cystoscope. While he was Chief of the Bureau of Medicine, a subordinate embezzled Navy funds and Dr, Wales was court-martialed. Though he was eventually exonerated, he lived the rest of his life in disgrace in France. CONCLUSION: The Wales endoscope is unique in that it had an American inventor, was simple in design and cheap to produce. It is an important historical artifact and is one of the earliest and rarest cystoscopes developed.

Marketing and medicine: a questionable mix.

Historically, medicine has been an evolving art and science. It never remains the same. Only in the past few decades has it been acceptable for doctors to market and promote their practices. This article will review the history of medical marketing and provide ethical examples of marketing that might be available to any physician, in any practice, and in any geographic location.

Sir William Osler's speech at Troy: a Trojan horse?

Troy, New York, is a city of 55,000 people in upstate New York located along the Hudson River. A city of surprisingly rich cultural heritage, it was the home of New York state's first hospital outside New York City. The 50th anniversary celebration of Troy's hospital brought William Osler to the city as the keynote speaker. This speech, delivered on November 28, 1900, is one of Sir William's less well known addresses. Osler began his comments with Sir Thomas More's Utopia and talked at length about the hospital, its obligations, the influences it has upon the community, and the role of physicians and surgeons. He broached one of his old saws, the salary of attending physicians and their needed role in hospital management. His words were published in the diamond jubilee's records, but the hospital did not outlive its prominent guest professor, and it closed its doors in 1914. Just like the great historical city of Troy, New York's own Troy was on the brink of decline, and its hospital would be the first fatality. Therefore, it is almost prescient that the words of Osler, taken into historical context juxtaposed against the socioeconomic forces at work, are akin to the Greek's offering of a wooden edifice to end the Trojan War.

Robotic instrumentation: Evolution and microsurgical applications.

This article presents a review of the history and evolution of robotic instrumentation and its applications in urology. A timeline for the evolution of robotic instrumentation is presented to better facilitate an understanding of our current-day applications. Some new directions including robotic microsurgical applications (robotic assisted denervation of the spermatic cord for chronic orchialgia and robotic assisted vasectomy reversal) are presented. There is a paucity of prospective comparative effectiveness studies for a number of robotic applications. However, right or wrong, human nature has always led to our infatuation with the concept of using tools to meet our needs. This chapter is a brief tribute to where we have come from and where we may be potentially heading in the field of robotic assisted urologic surgery.

The light bulb, cystoscopy, and Thomas Alva Edison.

BACKGROUND AND PURPOSE: Thomas Alva Edison was an icon of American achievement who literally invented the 20th century. Although best known as the inventor of the electric light bulb, the phonograph, and motion pictures, he also left a lasting legacy via peripheral developmental applications, such as endoscopes. METHODS: A review of published urologic writings about incandescent cystoscopes was cross-referenced to writings about or from Edison. Important events that allowed transference of technology from the Edison laboratory to clinical practice were emphasized. RESULTS: Edison was born in 1847 while Lincoln was serving in Congress; he died in 1931 when Hoover struggled with the Great Depression. Edison's life spanned the formative period of America that Henry Adams called the "coming of age." Edison received a Sprengel vacuum device in late 1879, and as usual, he was able to tweak the machine to better performance. For 5 days in October, 16 to 21, he improved the vacuum from 1/100,000 to 1/1,000,000 atm, and his first incandescent bulb burned softly. On December 21, 1879, he leaked the story to N.Y. Herald journalist Marshall Fox, and the world was notified of the light bulb. Special Christmas light visits started in Menlo Park just 4 days later. Edison patented the screw cap for easy changes, and the first bulbs sold for 40 cents (cost $1.40). 100,000 bulbs sold in 1882, 4 million by 1892, and 45 million in 1903. Immediately, competitors and specialty manufacturers entered the market. Dr. Henry Koch and Charles Preston in Rochester, N.Y., developed a smaller, low amperage bulb that could be fitted to medical devices. CONCLUSIONS: No discussion of electricity and modern applications would be complete without some discussion of Thomas Alva Edison and his sentinel contributions. The first church, post office, and ship were illuminated in 1892. The first hotel, theater, and electric sign were in 1893. The rapidity of dispersal and secondary applications of Edison's inventions is typified by the rise of cystoscopes. Nitze used a modified Edison bulb in his second and third generation scopes by 1887-1888 within 8 years of discovery.

Enlightenment via simulation: "crone-ology's" first woman.

A little known 18th century midwife, Angélique Marguerite Le Boursier (1715-1794) may well be the true founder of modern surgical simulation. This fiercely independent medical practitioner stood equally amongst the many enlightened minds of this period and fought with every modern method to reduce infant/maternal mortality during childbirth. Her original textbook Abrégé utilized some of the first color anatomical illustrations, her method of teaching complex birthing techniques to peasant woman throughout France, and most notably her birthing simulator complete with fluids (wet ware) were all available for close scrutiny. The color illustrations in Abrégé remain profoundly effective but the only existent models of her simulator are even more remarkable. Le Boursier du Coudray sought to bring education to the woman and physicians in villages and towns throughout France in response to the population crisis and the high birth morbidity and mortality. Her teaching methods affected untold thousands of medical practitioners, from midwives to surgeons. Voltaire wrote about her and she became an icon of progressive France, but remained ostracized by much of the conventional medical practitioners. She continued to train midwives for 23 years before retiring at the age of nearly 70. Madame du Coudray began to write, illustrate and simulate in the mid 18th century and obtained unprecedented success in bringing to the public the humane practices of modern childbirth with relevant understanding of anatomy and physiology. She is the matron not only of modern simulation methods in healthcare but was the epitome of professional healthcare commitment, educating approximately 10,000 students regardless of social status for free.

Missed diagnoses by urologists resulting in malpractice payment.

PURPOSE: Missed diagnoses are a patient safety concern and they can result in malpractice allegation. The specialist physician may be liable for missed or delayed diagnoses even if an abnormality in the physician area of expertise is ruled out. We approached this largely unstudied area of medical malpractice in an effort to increase physician awareness and identify opportunities for prevention. MATERIALS AND METHODS: Working with the Medical Liability Mutual Insurance Company of New York State, we evaluated malpractice claims in urology that were closed with indemnity payment between 1985 and 2004. We identified all such claims resulting from alleged missed or delayed diagnoses by urologists. Claims were divided into 2 main categories based on whether the missed diagnosis was primarily urological, ie testis torsion, or not urological, ie appendicitis. RESULTS: A total of 75 missed diagnosis claims were identified, representing 15% of claims overall. The total indemnity payment for missed diagnosis claims was $32,591,013, which represented 27% of all indemnity payments for the study period. They were divided into 58 missed urological diagnoses and 17 missed nonurological diagnoses. Cancer represented 71% of missed urological diagnoses and 41% of missed nonurological diagnoses. Urological cancer missed diagnosis claims were associated with the highest average indemnity payment of $526,460. The average indemnity payment for missed diagnosis claims was 92% greater than the average indemnity payment for all other claims ($434,546 vs $226,133). An increase in the frequency of missed diagnosis claims closed with indemnity payment and in the amount of payment for missed diagnosis claims were observed during the 20-year study period. CONCLUSIONS: Indemnity payments resulting from missed diagnosis claims represent a disproportionately high percent of total indemnity payments (27%) due to a high average payment for such claims. Liability for the urologist resulted from missed diagnoses not only of urological conditions, but also of nonurological conditions.

Bidirectional-barbed sutured knotless running anastomosis v classic Van Velthoven suturing in a model system.

BACKGROUND AND PURPOSE: Robotic prostatectomy is exploding into popular utilization throughout much of the United States. It is expected that the rise in the number of these cases into 2006 will continue exponentially. A significant amount of research has begun to focus on the anastomosis, because the robot allows unprecedented illumination and dexterous control to make the quality of this repair equal to that of a microscopic approach. Here, we report our results with a circular anastomosis technique using an innovative bidirectional-barbed suture material for knotless, tension-free repair and compare it with a standard polyglecaprone single-knot technique. MATERIALS AND METHODS: Using a previously described in-vitro model of microfiber synthetic material, a running anastomosis was performed using the da Vinci Surgical System by one surgeon. Two pre-tied 3-0 polyglecaprone sutures on a tapered Rb-1 needle were compared with a bidirectional-barbed suture (3-0 PDO) designed specifically for our use (Quill Sutures, Research Triangle Park, NC). The times needed to perform the anastomosis, the accuracy in idealized phantoms, and the surgeon's security in the quality of his work (linear scale) were all recorded for 10 consecutive anastomoses. RESULTS: The PDO suture was faster to deploy (17.3 minutes v 19.2 minutes), and the security score by the surgeon was greater. The accuracy was equivalent for both types of running closure comparing the classic van Velthoven with the PDO-sutured anastomosis. CONCLUSIONS: It appears from our preliminary work that a bidirectional-barbed suture might improve the vesicourethral anastomosis during a robotic radical prostatectomy. Further investigations should be done to measure the disruptive force necessary to distract these sutures, whether the applied forces of the barbs are adequate for maintaining a watertight seal, and the reproducibility of our results by other surgeons. All of these investigations are in progress in our laboratory.

Does laparoscopy beget underuse of partial nephrectomy for T(1) renal masses? Competing treatment decision pathways may influence utilization.

BACKGROUND AND PURPOSE: It has been suggested that renal laparoscopy has resulted in an underuse of partial nephrectomy (PN) for small renal masses in the U.S. In the absence of evidence-based medicine (EBM) guide-lines, multiple-perspective reasoning is required where complete v partial nephrectomy and the laparoscopic v the open surgical approach must be considered. We report on the PN rate in a contemporary laparoscopicera series of patients with T(1) renal masses and examine the potential influence of the management decision tree on the PN rate. PATIENTS AND METHODS: An actively managed database of referred patients with T(1) renal masses was utilized retrospectively. All patients were evaluated by a single fellowship-trained urologic oncologist with formal laparoscopic training. Patients were presented with a management decision tree in which PN v total nephrectomy (TN) was the first decision node, laparoscopy v open surgery was the second decision node, and the actual PN rate was reported. We then constructed a hypothetical decision tree in which the first and second decision nodes were reversed and the criteria for performing laparoscopic nephrectomy remained constant. RESULTS: Seventy consecutive patients were entered during a 36-month period (July 2002-June 2005). The actual PN rate was 60%: 91% for lesions <2.0 cm, 68% for lesions 2.1 to 4.0 cm, and 33% for lesions 4.1 to 7.0 cm; and 62% of patients were treated laparoscopically. When the first and second decision nodes were reversed and this hypothetical model was applied to the study cohort, the projected PN rate was 23%, and 96% of the patients were treated laparoscopically. In the hypothetical model, the PN rate fell when patients who chose laparoscopy at the first decision node were excluded from PN at the second decision node if the criteria for laparoscopic PN were not met. CONCLUSION: Laparoscopy did not appear to result in underuse of PN. We explain this by suggesting that the PN rate may be influenced by variation in the decision tree itself. Such variation is inherent in complex clinical decision making where EBM guidelines are lacking.

Jacques de Vaucanson: the father of simulation.

BACKGROUND: Jacques de Vaucanson's accomplishments are remarkable from almost every standpoint. His appreciation of human anatomy allowed him to formalize and discuss at the Royal Academie of Churgeons the first surgery/anatomy trainer. METHODS: Works on the history of automata are replete with descriptions of de Vaucanson's creations. I sought to better understand this intriguing individual and his mechanical accomplishments in light of current interest in surgical simulators and skill enhancement. RESULTS: de Vaucanson is known to have built at least three highly sophisticated automated robotic devices. His first robot was constructed in 1735: a life-sized flutist that could play 12 melodies. The fingers moved by levers, and a bellow-like device piped air into the robot's mouth. His second robot, another musician, could play 20 melodies. His third automaton became the most famous, a mechanical duck. The duck consisted of a gold-plated copper exterior with more than a thousand moving parts, including a gastrointestinal system. Voltaire would quip that France now had as its glorious mascot a golden creature that was famous for its excrement. Lastly, de Vaucanson created another musical automaton that could play 20 melodies. CONCLUSIONS: de Vaucanson worked with famed surgeon La Cat and in 1741 gave a talk to the Academy of Art on "Constructing an automaton figure which will imitate in its movements animal functions, the circulation of blood, respiration, digestion, the combination of muscles, tendons, nerves, etc." The Academy's minutes recorded "this ingenious machine, which will represent a human anatomy lesson." Add to de Vaucanson's list of accomplishments as devising, albeit not producing, the first anatomic simulator.

Rossum's universal robots: not the machines.

PURPOSE: One assumes in the era of rapidly expanding technology that robot implies mechanical beings. This is not how the word was used initially and represents one of those metamorphoses to another conceptualization. This is an investigation into Capek's original play, Rossum's Universal Robots, for an understanding of his intended meaning. METHODS: Karel Capek was Czechoslovakian. His play was written in 1920, first performed in 1921, and presented in New York in 1922. It has come to symbolize Western society's feelings about robots. Capek's writing and the original play might clarify the definition of robot for the record, in light of some controversy as to whether the da Vinci Surgical System is a robot or not. THE PLAY: Rossum was a great physiologist who chemically synthesized living protoplasm and was capable of constructing artificial life forms: first, a dog; then, a man. His son was an engineer who quickly was able to manufacture large numbers of humanoids at lower costs " ... producing a robot has been brought down within 15 years from $10,000 to $150." This is the first foreshadowing of Moore's Law. But critically, these are not machines, even though his robots outperform humans. The story turns sinister as the robots eventually revolt and kill their creators. CONCLUSIONS: Like many things in our vocabulary, the term robot was initially used for a biologic organism that was created for servitude. Defined by the Robotic Institute of America (1979), a robot is ... "a reprogrammable, multifunctional manipulator designed to move materials, parts, tools, or specialized devices through various programmed motions for the performance of a variety of tasks." This is far from the in tended use envisioned by Capek, but applies to the da Vinci Surgical System. As Alquist in R.U.R. concludes: "... if there are no more human beings left, at least let there be Robots!"

Evolution of robotic arms.

The foundation of surgical robotics is in the development of the robotic arm. This is a thorough review of the literature on the nature and development of this device with emphasis on surgical applications. We have reviewed the published literature and classified robotic arms by their application: show, industrial application, medical application, etc. There is a definite trend in the manufacture of robotic arms toward more dextrous devices, more degrees-of-freedom, and capabilities beyond the human arm. da Vinci designed the first sophisticated robotic arm in 1495 with four degrees-of-freedom and an analog on-board controller supplying power and programmability. von Kemplen's chess-playing automaton left arm was quite sophisticated. Unimate introduced the first industrial robotic arm in 1961, it has subsequently evolved into the PUMA arm. In 1963 the Rancho arm was designed; Minsky's Tentacle arm appeared in 1968, Scheinman's Stanford arm in 1969, and MIT's Silver arm in 1974. Aird became the first cyborg human with a robotic arm in 1993. In 2000 Miguel Nicolalis redefined possible man-machine capacity in his work on cerebral implantation in owl-monkeys directly interfacing with robotic arms both locally and at a distance. The robotic arm is the end-effector of robotic systems and currently is the hallmark feature of the da Vinci Surgical System making its entrance into surgical application. But, despite the potential advantages of this computer-controlled master-slave system, robotic arms have definite limitations. Ongoing work in robotics has many potential solutions to the drawbacks of current robotic surgical systems.

Medical malpractice in urology, 1985 to 2004: 469 consecutive cases closed with indemnity payment.

PURPOSE: Malpractice premiums have increased by up to 57% for urologists in the last 3 years, for which the reasons are not clearly reported. We sought to better understand factors contributing to the current medical malpractice crisis in urology. MATERIALS AND METHODS: Working with the Medical Liability Mutual Insurance Company of New York State we evaluated malpractice claims in urology that were closed with indemnity payment between 1985 and 2004. Individual claims were assessed for the purported negligent act, the procedure when applicable and the expense incurred. We also evaluated the impact of new technologies, eg laparoscopic nephrectomy, on reported claims. RESULTS: A total of 469 urology malpractice claims were closed with indemnity payment during the period evaluated for a total loss indemnity of Dollars 99,335,431. The number of files closed with indemnity payment yearly remained relatively constant at an average of 22 claims. The average indemnity payment increased each year and after correcting for inflation a 191% increase was observed for the period evaluated. The greatest number of claims was related to postoperative events (total of 101), followed by intraoperative events (96), failure to diagnose a given condition (60), medication administration error (21) and a foreign body left following surgery (20). In the area of new technologies laparoscopic surgery accounted for 4 claims and transurethral needle ablation accounted for 1. Vasectomy accounted for 8 claims. CONCLUSIONS: In the current study surgical procedures were the greatest generator of claims with the most common being oncological. Emerging and new technologies, eg laparoscopy and robotics, did not account for the increase in indemnity payments observed to date. Only further investigation will determine whether this is secondary to a lag time in the closure of suits related to these emerging technologies or to a lack of such suits. The actual number of claims closed with indemnity payment yearly remained relatively constant. However, the indemnity payment per claim far outpaced that expected for inflation. The observed increase in indemnity payment per claim would appear to be a significant contributing factor to the current malpractice crisis in urology.

Pheochromocytoma multisystem crisis.

Pheochromocytomas can present with profound, life-threatening conditions, such as hypertension, fever, and rarely with a host of clinical conditions producing a multisystem crisis. We report a case of this syndrome and comment on clinical management.

External validation of outcome prediction model for ureteral/renal calculi.

PURPOSE: We externally validated a previously designed neural network model to predict outcome and duration of passage for ureteral/renal calculi. The model was also evaluated using a 6 mm largest stone dimension cutoff in predicting stone outcome. MATERIALS AND METHODS: The model was previously designed on 301 patients at Albany Medical Center (free shareware from www.uroengineering.com). The model had a prediction accuracy of 86% for passage outcome and 87% for passage duration. In this study we tested the model on a separate 384 patients from 6 different external institutions to assess the prediction accuracy. All patients had a single renal/ureteral calculus by evaluation in an emergency room setting or by primary physicians and were then referred for further treatment. Model accuracy was also compared to using a 6 mm largest stone dimension cutoff in predicting the need for intervention. RESULTS: Testing on the 384 patients from all 6 external institutions revealed an outcome prediction accuracy of 88%. The area under the ROC curve was 0.9. Using a 6 mm stone size cutoff provided 79% (ROC 0.8) accuracy. The model duration of passage prediction accuracy was 80% (133 patients passed the stone, area under ROC of 0.8). CONCLUSIONS: The model provided high stone outcome prediction accuracy (ROC of 0.9 and 0.8) at the 6 external institutions, comparable to that of the design institution. The model provided higher accuracy than using only the largest stone dimension as a cutoff. Increasing experience will further assess the model's accuracy.

The da Vinci robot.

BACKGROUND: One might assume from the title of this paper that the nuances of a complex mechanical robot will be discussed, and this would be correct. On the other hand, the date of the design and possible construction of this robot was 1495, a little more than five centuries ago. The key point in the title is the lack of a trademarked name, as Leonardo was the designer of this sophisticated system. His notes from the Codex Altanticus represent the foundation of this report. METHODS: English translations of da Vinci's notebooks are currently available. Beginning in the 1950s, investigators at the University of California began to ponder the significance of some of da Vinci's markings on what appeared to be technical drawings. Such markings also occur in his Codex Atlanticus (the largest single collection of da Vinci's sheets, consisting of 1119 separate pages and 481 folios) along with a large number of other mechanical devices. Continuing research at the Instituto e Museo di Storia della Scienza in Florence has yielded a great deal of information about Leonardo's intentions with regard to his mechanical knight. RESULTS: It is now known that da Vinci's robot would have had the outer appearance of a Germanic knight. It had a complex core of mechanical devices that probably was human powered. The robot had two independent operating systems. The first had three degree-of-freedom legs, ankles, knees, and hips. The second had four degrees of freedom in the arms with articulated shoulders, elbows, wrists, and hands. A mechanical analog-programmable controller within the chest provided the power and control for the arms. The legs were powered by an external crank arrangement driving the cable, which connected to key locations near each lower extremity's joints. Da Vinci also is known to have devised a programmable front-wheel-drive automobile with rack-and-pinion suspension mechanisms at age 26. He would recall this device again, when, at age 40, he is thought to have built a programmable automated lion, but by then, he had produced his own metal springs as well as drum-containing springs called tambours. He positioned his fusee to a stationary rotating power output shaft that would be used to power his programmable automaton. CONCLUSIONS: Part of the obscurity of da Vinci's robot comes from the difficulties interpreting Leonardo's markings. His designs precede any formal method of blueprint designing. The technical aspects had to be deciphered before anyone could even attempt to reproduce his intended device. This robotic device fits together with other pieces of evidence that link 15(th) Century automatons to da Vinci's design, namely the automated Tea Servers from Spain. As with many things from da Vinci, looking backward at this master leaves one with a pronounced sense of awe at his prescient view of the world.

Sir William Osler's perceptions of urolithiasis and the case of the indigo calculus.

BACKGROUND: Sir William Osler published his textbook, The Principles and Practice of Medicine, in 1892. It became the definitive treatise on a wide variety of diseases. The section on nephrolithiasis clearly presents the etiology, pathology, symptoms, diagnosis, and treatments. What remains a mystery is the mention, under rare forms of human stones, of a type called "indigo." MATERIALS AND METHODS: A search of Index Medicus starting from 1909 backward to its inception in 1879 was performed for key words "indigo," "calculus," "renal" or "bladder stones" and "indicanuria." Twelve textbooks of urology published before 1940 were scrutinized for references to indigo calculi. RESULTS: Only two references to indigo were found, both related to its use for treating constipation (1887 and 1891). Of the 12 textbooks, only 4 make passing reference to "indigo stones." They all mention that such calculi are very rare, but direct references to cases are lacking. One textbook references a study of blue stones from Egyptian mummies. CONCLUSION: It is unlikely that Osler's reference to an indigo calculus was taken lightly during his writing of The Principles and Practice of Medicine. The case of the indigo calculus is fascinating and perhaps enlightening if only for the source of Osler's intrigue.