Endourology explained: The flag-bearer for camera-assisted procedures

Highly esteemed consultant urologist Mr Sudhanshu Chitale sheds light on the medical specialty of endourology and how the field of urology has developed in recent years. The leading expert also details the impact of innovative camera-assisted procedures in all areas of modern surgery.

What is endourology and how does it differ from urology?

Urology has been a subspecialty of general surgery for the last fifty years or so. Prior to that, general surgeons would perform all urological procedures along with any other type required, as they were trained to operate on anything from head to foot.

Since that time, urology has developed as a subspecialty within general surgery and therefore those that perform urological procedures are termed as urologists. This applies to those trained specifically to operate on the urological system: starting with kidney at the top end of the urinary tract, the ureter (the tube linking the kidney to the bladder), the bladder itself, the prostate and finally the urethra (which goes through the prostate and down the penis). Urologists also operate on the genital systems such as the penis, the foreskin on the penis, the testes and the vas deferens (which is involved in procedures such as vasectomy). Therefore, any pathological condition affecting these systems is now treated by a surgeon with a subspecialty in the genitourinary tract.

Many operations of this type have historically been performed with an open approach and continue to be done so today. Using an open approach refers to making an incision so that the surgeon can reach the target organ, such as the kidney, bladder or the testes in the scrotum, so that the appropriate procedure can be performed. Open urological surgery remains a sub-specialty within the wider field.

Subsequently, then there was the development of the camera, or endscope as we call it. The endoscope became available to urology specialists much earlier than other types of surgeons and naturally, the development of skills and technologies in the area later transferred to all other specialties meaning that it has many applications, as is the case today.

Endoscopy refers to using a camera to look at parts of the internal body, either through a natural orifice or an unnatural one. A cystoscopy procedure involves looking down the urethra into the bladder (cysto means bladder, scope means to see) and similarly, a urethroscopy refers to looking down the penis through the water pipe, the urethra.

Commonly, however, these procedures are combined when both areas need to be examined, which is known as a cystourethroscopy. In this way, anyone who was performing endoscopic surgery (using a camera inserted within the natural orifice, the urethra) was called an endourologist. This is how the endoscopy became a standard of care for all of the urological operations on the lower urinary tract, which deal with the urethra, the bladder and the prostrate.

How has this technology been applied to other areas of urology?

This form of examination using a camera through the natural orifice (the urethra) has since been extrapolated into procedures on the upper tracts (the kidney and ureter). This involves going down the urethra, into the bladder, then through the tube which connects to the kidney (the ureter) to finally reach the kidney. Surgeons performing this type of procedure are also known as endourologists, and a distinction is often made between those who specialise in upper and lower urinary tract endourological operations.

Endoscopic examinations which reach the upper tract with a camera going up the natural orifice do not pierce the body anywhere, as they use the water pipe to enter the body. However, kidney endoscopic operations can also be performed by puncturing the kidney from the back (where the kidney is located under the rib cage). This allows the surgeon to directly access the kidney and perform the examination using a camera. This type of surgery is known as a percutaneous (going through the skin) endourological procedure.

Over the last ten years, urologists have sub-specialised with far more detail in terms of the types of procedures they perform: be they upper tract endoscopic surgeons, endoluminal endourologists or percutaneous endourologists.

How has endoscopic technology been applied to other areas of surgery?

While endourologists have become very specialised in their practice, other surgeons have also picked up the endoscopic or camera examination techniques. Gynaecologists, for instance, started performing procedures such as hysteroscopy, in which the cervix is examined by looking inside the ureter and colposcopy, where an examination is made through the vagina, using the same types of cameras as we use in urology.

Colorectal surgeons also used to perform an exam known as sigmoidoscopy through the lower part of the rectum and anal canal. This has since been further advanced and now uses a long, winding instrument called colonoscope with which you can put the endoscopic equipment (the camera) all the way up the colon from the back passage into the junction of the large and small bowels.

Additionally, upper gastroenterology specialists, both surgeons and physicians, began inserting cameras down the oesophagus (an oesophagoscopy) and into the stomach (a gastroscopy).

Nowadays, there is an unending list of endoscopic surgical procedures which all started with the camera being used back in 1934 by urologists to perform a cystoscopy examination. This area of medicine continues to develop and doctors have now started looking into the groin and chest with an endoscope (thoracoscopy). Additionally, gynaecologists and general surgeons now routinely perform laparoscopy, which involves making a hole in the belly button and other areas in order to look into the abdomen. Endourology is a real flag-bearer for the advances in endoscopic surgery.

Mr Chitale is one of the UK’s leading consultant urologists, with a wealth of expertise in lower urinary tract surgery. To learn more about Mr Chitale or to schedule a consultation with him, visit his Top Doctors profile.