OPERATION-large

Urology is a surgical specialty which deals with diseases of the male and
female urinary tract and the male reproductive organs. Although urology is
classified as a surgical specialty, a knowledge of internal medicine,
pediatrics, gynecology, and other specialties is required by the urologist
because of the wide variety of clinical problems encountered. In recognition of
the wide scope of urology, the American Urological Association has identified
seven subspecialty areas:

  1. Pediatric Urology
  2. Urologic Oncology (cancer)
  3. Renal Transplantation
  4. Male Infertility
  5. Calculi (urinary tract stones)
  6. Female Urology (urinary incontinence and pelvic outlet relaxation
    disorders)
  7. Neurourology (voiding disorders, urodynamic evaluation of patients and
    erectile dysfunction or impotence).

Historically, the subject which clearly established the specialty of
urology as being distinct from general surgery was the treatment of obstructive
uropathy. This treatment ranges from the correction of obstructing posterior
urethral valves or ureteropelvic junction obstruction in the infant to the
correction of bladder outlet obstruction from benign prostatic hyperplasia in
the older male. Through the decades, we have witnessed a tremendous increase in
our general understanding of the diverse functional disorders of urine
transport associated with various overt and covert forms of neuromuscular
dysfunction. The rapidly evolving discipline of urodynamics has established
itself as a major resource in the diagnosis and therapy of such disturbances.

Stone disease of the urinary tract has always provided a substantial
portion of general urologic practice. The recent introduction of rigid and
flexible ureteroscopy has greatly improved the capacity of the urologist to deal
with the problem while the management of stones in the kidney has been
revolutionized twice in the immediate past: first with the introduction of
percutaneous methods for stone disintegration and extraction, and secondly by
the application of extracorporeal shockwave lithotripsy. Collectively these
techniques have largely rendered open surgical procedures for dealing with
kidney and ureteral stones obsolete. These new technologies remain under
urological stewardship. In addition, advances in the diagnosis and metabolic
management of recurrent nephrolithiasis allow urologists to reduce the risk of
recurrent stone formation.

Another area of major urologic concern is that of congenital anomalies. The
urinary tract is affected by congenital anomalies more than any other organ
system. These congenital abnormalities run the gamut from the relatively common
problem of cryptorchidism to the complex area of intersexuality. Most
urologists do surgically repair many congenital anomalies in children, but the
more complex problems are often referred to urologists with specialized
training in pediatric urology.

Involvement of the urologist in the problems of renal insufficiency and
end-stage renal disease has been necessitated by an enormous increase in the
number of patients on dialysis and requiring transplantation. In a number of
centers, urologists are the prime surgical arm for renal transplantation and,
in others, serve as members of the surgical team. This practice has tended to
increase the experience of the urologist in vascular surgery which has been
beneficially incorporated into other areas such as renal vascular
reconstruction and in the new microvascular surgical procedures performed for
certain cases of impotence. The enhanced communication between nephrologist and
urologist often leads to involvement in the general area of hypertension and
adrenal disorders.

The treatment of malignant disease is a very large portion of urologic
practice. Some of the most encouraging results in the medical and surgical
management of solid tumors have involved genitourinary tumors, namely testis
tumors and Wilms’ tumors. The development of multimodal therapy, in which
chemotherapy, radiation therapy, and surgical treatment are used in
conjunction, will hopefully improve the results of the treatment of other
genitourinary malignancies. Newer diagnostic methods for the detection of
prostate cancer have recently emerged and currently the diagnosis and treatment
of prostate cancer occupies much of many urologists’ time.

Urinary tract infections affecting every age group in both sexes comprise a
significant fraction of urological practice. While urinary tract infection may
be the obvious and definitive clinical symptom at presentation, it may also
reflect other disorders of the urinary tract such as obstructive uropathy. Much
recent interest has been focused on the characterization of pathogenic bacteria
that are particularly prone to cause persistent urinary tract infections,
specifically pyelonephritis. Bacteriuria is such a common clinical problem that
there is inevitably a large cross-disciplinary approach to this problem.
Urologists often interact with internists, pediatricians and gynecologists in
the management of patients with bacteriuria.

The importance of urologic problems seen primarily in women (stress urinary
incontinence, interstitial cystitis, urethral diverticuli, etc.) is being
increasingly recognized. The diagnosis and therapy of urinary incontinence
constitute a significant portion of most urology practices. New therapies, both
surgical and non-surgical, are being constantly developed. The number of female
patients treated by urologists is substantial, and urologists need to
understand gender differences in the medical and surgical approaches to these
patients.

Male sexual dysfunction and infertility have become virtual subspecialties.
The management of impotence has been revolutionized first and foremost by the
introduction of prosthetic devices in urology. The area of prosthetics in
urology has gradually expanded to encompass not only the various forms of
penile prostheses, but also the use of the artificial urinary sphincter. The
management of infertility in the male has generally focused on the surgical
correction of various acquired and congenital obstructions within the genital
system, and increasingly sophisticated efforts to diagnose and treat the
problem of coexisting male subfertility and varicocele. Continued improvements
in the medical management of male infertility require a high level of expertise
in the area of reproductive physiology and endocrinology.

Trauma to the genitourinary system involves the urologist as one member of
the trauma team during the initial evaluation of the multiply-injured patient.
Recent improvement in imaging techniques for the evaluation of renal trauma and
standardization of approaches to the problem of lower urinary tract trauma have
significantly improved the care of such patients. There are a vast number of
operative approaches to the problem of the late correction of injuries to the
lower urinary tract which fall under the general heading of reconstructive
surgery.

The specialty of urology is constantly changing. Much of this change has
been the result of improved technology. Refinements in the area of ureteral and
renal endoscopic surgery have already revolutionized the therapy of urinary
tract stones and, working in conjunction with the new generation of
extracorporeal lithotriptors, many of the traditional surgical and even
endoscopic approaches to the problem of renal and ureteral calculi are now
largely obsolete. Other traditional urologic procedures, specifically
vasovasostomy and hypospadias repair have improved results in selected cases
with the use of the surgical microscope. Skill and experience using the
surgical microscope will undoubtedly be an important part of urologic practice
in the future. Lasers are in their infancy, but will influence the practice of
urology in the management of neoplasms and, in a somewhat different context,
the management of ureteral calculi. Much recent research effort has evolved in
the area of laparoscopic surgery. Many urologic operations which have been done
by open surgery in the past can now be performed through the laparoscope. The
development of new cancer chemotherapeutic agents has significantly altered
therapy for some urologic cancers. In summary, urology is a rapidly changing
and exciting area of medicine which requires practicing urologists to be
actively involved in continuing education.