Year : 2013 | Volume
: 29 | Issue : 3 | Page : 193--194
Controversies in endourology
Madhu S Agrawal
Department of Urology, SN Medical College, Agra, Uttar Pradesh, India
Madhu S Agrawal
Department of Urology, SN Medical College, Agra, Uttar Pradesh
|How to cite this article:|
Agrawal MS. Controversies in endourology.Indian J Urol 2013;29:193-194
|How to cite this URL:|
Agrawal MS. Controversies in endourology. Indian J Urol [serial online] 2013 [cited 2020 Mar 29 ];29:193-194
Available from: http://www.indianjurol.com/text.asp?2013/29/3/193/117289
The history of endourology is as old as the specialty of urology itself. However, modern day endourology came into its own during the late 1970s with several path-breaking discoveries. These included percutaneous and ureteroscopic approaches to the upper tract, which following the arrival of extra-corporeal shock-wave lithotripsy (SWL) in early 1980s, completely revolutionized the management of urinary stone disease, rendering open stone surgery nearly obsolete.
The subsequent years have seen steady refinements and improvement in the armamentarium and technique of endourological procedures to make them more efficient, safe and cost-effective. The addition of flexible instrumentation and lasers has improved the reach and versatility of endourological approach. There has been widespread adoption and spread of this new technology to every corner of the world. To our satisfaction, India has been right in the forefront of this revolution. There are many centers in the country performing extensive endourological work both in qualitative and quantitative terms, with increasing international recognition.
Many of us current generation of Urologists have had the privilege to be closely associated with the evolution of endourology over these last three decades, from the time when it all started, to the present time when it has blossomed into a garden full of multiple and attractive options. Never before in the history of the specialty were so many minimally-invasive choices available for management of any given urological condition. On the other hand, availability of multiple options has brought in added dilemma in decision making. In this symposium, the articles address these contentious issues.
Management of small renal stones of 1-2 cm size is one of the most important contemporary issues where selection from among the available choices (SWL, retrograde intrarenal surgery, percutaneous nephrolithotripsy [PCNL] and its minimally invasive variants) can be a real challenge today. Srivastava and Chipde detail the available evidence from the literature on the subject to help the reader make an intelligent choice.
Shock-wave lithotripsy (SWL), hailed as a "miracle cure for all stones" when it arrived, has seen its ups and downs. Dr. Greet Tailly has reviewed the history and evolution of SWL, along with advances in shock-wave technology and has made out a convincing case for application of the right approach for restoring its rightful place in the urologists' armamentarium.
PCNL has been the flagstone of endourology in many parts of the world. Though the basic technique of PCNL is more or less standardized since its inception, each of the steps involved, starting from the method of puncture up to the placement of the nephrostomy tube has been a subject of debate due to differences in approach used by different authorities. As we all understand, a successful puncture is indeed the single most important step in the procedure of PCNL. Prof. Bannakij Lojanapiwat has highlighted the different methods to guide the puncture needle and the respective merits of fluoroscopically-guided, ultrasound-guided, computed tomography-guided and endoscopically-guided puncture.
The group at MPUH, Nadiad, led by Dr. Mahesh Desai has popularized the "micro-perc," a novel approach to minimally invasive PCNL. Sabnis et al. have highlighted the technique and its merits and have compared it to the other minimally invasive alternatives available for kidney stones. "Exit strategy" in PCNL is another subject of intense debate these days, with opinion divided between proponents of "tube" and "tubeless" procedures. Our article reviews the published literature, compares the available options and current evidence and highlights the emerging trends on this important subject.
Surgical management of benign prostatic hyperplasia is also set to undergo a significant change with the advent of the newer technologies. The "gold standard" monopolar transurethral resection of the prostate, after a reign of many decades, is being increasingly challenged by the bipolar technology on one hand and the all-attractive LASER on the other hand. However, again the choice is not easy due to the availability of different laser machines with differing capabilities and the hype surrounding each new entrant. Two review articles, by Gupta et al. and Maheshwari respectively, discuss this issue, one comparing bipolar technology with lasers and another comparing the various laser options. I presume that with the technology still in a state of flux, the last word on this subject has not been said yet.
Finally, Rizkala and Monga discuss flexible ureteroscopy, the last frontier representing natural orifice transluminal endoscopic surgery in endourology, which is the most technology dependent procedure of them all. Prof. Monga, who is one of the leading international experts in the field, has reviewed the subject, specially relating to the controversies in the use of wires, baskets and ureteral access sheaths in flexible ureteroscopy.
I take this opportunity to express my thanks and gratitude to all my fellow authors, all experts in their respective fields, who have compiled and presented a summary of the available literature on their subjects, in the true spirit of evidence-based medicine. Though the topics included in this symposium cover only a small portion of the vast field of endourology, I hope readers will be benefitted from this compilation, which will assist them in their decision-making on a day-to-day basis.