The early days of surgery for stones in the bladder.
Abstract: Man has suffered from bladder stones since the earliest times. The oldest specimen of a bladder stone so far discovered was obtained at the excavation of a grave of a boy of about 16 in an ancient Egyptian burial ground and was dated at around 4800 BC. Of the triad of 'elective" operations first performed by our surgical forefathers - circumcision, trephination of the skull and cutting for the stone - only the last was for a purely surgical indication and not for religious or ritual reasons; it may safely be pronounced as the most ancient operation performed for a specific surgical pathology.

KEYWORDS Bladder surgery / Bladder stones / Minimal access surgery / Ultrasound dissolution
Subject: Calculi, Urinary (Care and treatment)
Calculi, Urinary (Diagnosis)
Urinary organs (Surgery)
Urinary organs (History)
Author: Ellis, Harold
Pub Date: 05/01/2011
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2011 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: May, 2011 Source Volume: 21 Source Issue: 5
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 272168015
Full Text: There are three surgical approaches to the bladder; via the perineum, through the lower abdomen and by a crushing instrument passed along the urethra. Each has its long, and, before anaesthetics, extremely painful history. Only because the pain of bladder stone is so excruciating means that the sufferers, over the centuries, would submit themselves to these operations. Today, of course, the great majority of urinary calculi can be disintegrated by means of ultrasound.

Opening the bladder by an incision in the perineum was the oldest of these operations. It was practised by the ancient Hindu surgeons, by the Greeks, Romans and Arabs; it is even mentioned in the Hippocratic Oath, which states that this procedure should be left to the experts!

Over the centuries, the operation was a simple affair. The patient was held by the assistants with his legs up in the air and his buttocks brought over the edge of the table - which we still call the 'lithotomy position'. Two fingers inserted in the rectum pressed the stone against the perineum, an incision was made between the scrotum and anal verge, and the stone extracted, either with a finger or a hook. This procedure, with its small amount of equipment, became known as the 'apparatus minor'. About 1520 a new operation was introduced in Italy by Franciscus de Romanis of Cremona. A grooved staff was passed along the urethra and an incision made along the groove along the urethra and into the bladder. A series of instruments were used to tear through the prostate and bladder neck. Stone holding forceps were then inserted to remove the calculus, or, if the stone was too large to remove, crushing instruments were employed to disintegrate the stone. Not surprisingly, this operation was called 'the apparatus major'. Only the protracted agonies of the pain of bladder stone account for the fact that patients would submit to such torture, followed, of course, by the risks of haemorrhage, sepsis and perineal fistula, in order to obtain relief from their stone. The operation continued to be performed right up to the early years of the 20th century, now, of course, with the benefits of anaesthesia and asepsis.

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The first suprapubic removal of a bladder stone was reported by Pierre Franco, of Orange, France, in 1561, the year of his own death. The patient was a little boy of three, suffering from a hen's egg sized calculus. Franco attempted a perineal operation, but the large stone could not be pushed down into the bladder neck. He explained the situation to the parents, who begged him to try anything to end their child's sufferings. Franco pushed the stone upwards against the lower abdominal wall by means of his fingers in the rectum, got his assistant to it there and cut down on the bulge through the abdominal wall. The stone was removed and the little patient recovered, but Franco warned others not to attempt such a foolhardy procedure. Most surgeons seem to have taken his advice until John Douglas, in London, showed that, if the bladder was fully distended with water it could be opened extraperitoneally by a suprapubic incision and published a book on this subject in 1720. Three of the first four patients he operated upon by this method recovered safely. The 'high operation', as it became known, was taken up by William Cheselden, one of the leading surgeons of the day, on the staffs of the Westminster and St. Thomas' Hospitals, who invented an ingenious syringe attached to a metal catheter by means of a length of ox's ureter with which to distend the bladder. In 1723 he reported nine patients between the ages of 4 to 19 years treated by the 'high operation', with a single fatality. However, he then suddenly abandoned the operation and returned to the 'apparatus major'. No doubt this was as the result of some disaster or disaster in his own or other hands - perhaps laceration or prolapse of the bowel from inadvertent opening of the bladder or rupture of the bladder from over distension. It was only till the late 19th century, with the blooming of abdominal surgery, that removal of the stone by the abdominal approach became common.

Many surgeons attempted ingenious methods of removing stones by instruments passed through the urethra. Sir Astley Cooper, of Guy's Hospital, described removing a total of 84 small stones from the bladder of an elderly clergyman by means of specially designed fine curved forceps. However, it remained for Jean Civiale, of Paris, to perform the first successful lithotrity, the crushing of a stone, performed in 1824. His instrument comprised a straight metal tube, which was passed into the bladder. Through this was inserted a three-pronged hollow tube which seized the stone, which was then broken up by a gimlet, passed along the inner tube. Amazingly, with no anaesthetic, X-ray or other help, he succeeded! He must surely be called the father of modern minimal access surgery. Civiale went on to devise the lithotrite, virtually a metal catheter with crushing blades, which, now combined with a fibre-optic telescope, is still used today in those cases where lithotripsy by means of shock-wave ultrasound dissolution is not successful.

No competing interests declared

Provenance and Peer review: Commissioned by the Editor; Peer reviewed; Accepted for publication August 2010.

Correspondence address: Department of Anatomy, University of London, Guy's Campus, London, SE11UL.

by Professor Harold Ellis

About the author

Professor Harold Ellis

CBE, FRCS

Emeritus Professor of Surgery, University of London, Department of Anatomy, Guy's Hospital, London
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