Includes Index

Recognition of urology as a specialty within surgery occurred fairly recently.
However, for hundreds, if not thousands of years, uroscopy, from which urology
derives, was the basis of medical practice. The ancient Greeks, Babylonians, and
Egyptians, to name just a few, used the inspection and taste of urine to determine the
general state of health of the entire body [ 1 ]. The progress and course of any malady
could be followed by water-casting, a technique well described by Hippocrates
(460–370 BC). Urine was collected in graduated glasses, and by inspection of the
color and sediment, one could determine, or at least opine on, the condition of the
blood as a whole and diseases in other parts of the body. The twin saints Cosmas and
Damian have been depicted holding a urine glass. In The Merry Wives of Windsor,
Shakespeare refers to “the monarch of the urine” as an equal to the physician.
Uroscopy dominated medicine well into the eighteenth century and was only gradually replaced by microscopic examination and chemical analysis.
Urologic surgery has also been practiced for centuries. Circumcision has been
described for over 4,000 years. Depicted in Egyptian hieroglyphics, anesthesia
would seem to have been confined to physical restraint by an assistant. The
Hippocratic oath, taken by all newly graduated physicians today, notes:
“I will not cut for stone, even for patients in whom the disease is manifest; I will
leave this operation to be performed by practitioners, specialists in this art.”
In other words, Hippocrates acknowledged there were practitioners skilled in
stone removal, just not physicians. Catheters could be used to push back the stones
and relieve the obstruction. Nevertheless, incisions through the perineum and the
suprapubic areas have been described from earliest times, as was crushing of large
stones. Many different instruments were available, but it was not until Nitze fabricated the cystoscope in 1877 to be paired a few years later with the incandescent
lamp, invented by Edison, that urology became recognized as a specialty.
But what of anesthesia during these millennia? Little mention is made of attempts
at pain control apart from reference to herbs and opium in Arabic literature [ 2 ]. One
of the first reports of anesthesia in urology recognized the experiences at the Los
Angeles General Hospital from around 1905 to 1925 [ 3 ]. Approximately 5,500
patients received spinal anesthesia with cocaine, stovain, and finally tropacocaine
with about a 4% failure rate. Given that spinal anesthesia was first described by Bier in 1904, it would appear that this technique was quickly accepted in urologic procedures. Commenting on Negley’s good results, Miley and Wesson noted “We have all
been trained with the idea that little skill is required to give an anesthetic so such
duties fall to the junior intern or the nurse [ 3 ].” Similar to spinal anesthesia, sacral
or caudal anesthesia, described by Stoeckel in 1909, was also incorporated as a
preferred technique for urology in 1922 [ 4 ].
The thought that better results might come with more skilled operators was only
slowly realized. Prior to 1905, physicians assumed roles as the need arose –
surgeon, anesthetist, or assistant. In 1905, the Long Island Society of Anesthetists
was formed by a handful of physicians and would later become the American
Society of Anesthesiologists. By 1934, anesthesia had gained a firmer hold “with
the wide selection of anaesthetic agents and techniques which we now have at our
command [ 5 ].” Ether, chloroform, ethylene-oxygen, nitrous oxide, spinal analgesia
now with percaine, as well as avertin and some new barbiturates for basal anesthesia all had specific indications for use in different urologic procedures.
In this text, we have tried to present a review of anesthetic requirements and
contributions to urology today. Clinicians and researchers from many parts of the
United States and Europe have shared their expertise, and we are most grateful for
their help. Starting with a review of renal physiology as a background, the book
considers anesthetic choices and applications in all age groups and in both the operating room and outpatient settings. Special consideration is given to the pregnant
patient and to renal transplantation. Robotic surgery lends itself to prostatic surgery
and is becoming widely accepted. Not without its complications, the anesthesiologist must make several critical adjustments to ensure a good outcome in these
patients. Many urologic patients are older, presenting special problems related to
comorbidities and the risk of drug interactions. As training and recertification in
anesthesiology become ever more complicated, the adaption of the simulation lab as
a teaching tool is appealing. Although many options for pain control postoperatively are available, results remain imperfect in many instances. We present appropriate formulae for both inpatient and outpatient care. Finally, our world today must
be mindful of medicolegal considerations, and some of the analyses from the closed
claims study are considered. We hope that readers enjoy this text as much as we
have enjoyed writing it.
As ever, we are most grateful to Shelley Reinhardt, Daniel Dominguez, and the
staff from Springer for all the support that they have given us.