The Evolution of the Urological Species
William A. See, MD, Professor of Urology, Chairman of Urology
The pace and breadth of change the field of urology has undergone in the last several decades is truly amazing. When I began my residency in 1982, ureterolithotomy was an accepted approach for managing stone disease. Over the six years of my training, this cornerstone of calculous management was rendered obsolete by advances in endoscopic instrumentation and the development of extracorporeal shock wave lithotripsy. Much like the dinosaurs, an approach that dominated the landscape became extinct as a consequence of environmental factors. The fossils of that era, instruments such as the Randall stone forceps, have been relegated to museums, private collections and forgotten storage closets. Similar examples of recent dramatic evolutionary change could be cited for other urological conditions including benign prostatic hyperplasia, erectile dysfunction, neurogenic bladder and incontinence.
Much as was the case for these diseases, other “foundation stones” of the specialty are currently being challenged. Chief among these today is the role of open surgical intervention. Minimally invasive approaches to diseases requiring reconstructive/extirpative management have rapidly morphed into related but distinct species. Hand assisted laparoscopy, robotic assisted laparoscopy, natural orifice translumenal endoscopic surgery, percutaneous cryosurgery, and high intensity focused ultrasound are recent derivations of conventional laparoscopy and ablative surgical techniques. All of these approaches offer the promise of decreased morbidity and equivalent efficacy. This inaugural issue of the Medical College of Wisconsin Department of Urology newsletter highlights some of the minimally invasive strategies being utilized at our institution in an effort to improve treatment outcomes.
While effective disease management in combination with improved patient care should be paramount, the Darwinian pressures culminating in the origin of these new surgical species are complex. It is important to recognize that a spectrum of additional environmental forces is playing a role in this evolutionary process. Direct to consumer marketing, industry growth strategies, legitimate scientific discovery, and personal/professional gain are contributing to the “selection” of the dominant approach. Whether or not we, as healthcare professionals, condone the role of these non-patient focused market forces, they none-the-less reflect the reality of our current healthcare environment.
While a powerful and omnipresent force, evolutionary pressure does not always culminate in durable change. The fossil record is replete with examples of short lived events. As academicians, we must neither fear nor embrace the new surgical species spawned by evolutionary change. Rather, it is our responsibility to promote technological advancement coupled with scientific evaluation, followed by data driven change. This sequence, in some ways analogous to the scientific method, is an ongoing evolutionary paradigm that must be embraced by the academic urology community.
As we continue to push the envelope of discovery, a cognizance of the environmental forces at work, coupled with a continued emphasis on data driven change, will ensure the outcome of “natural selection” truly serves the needs of our patients. Today, the data supports a value of minimally invasive surgical approaches in selected patients. As such, at The Medical College of Wisconsin we remain committed to the continued refinement of these approaches and ultimately, to the definition of their ecological niche.