Back to Blog Homepage
July 1st in the world of medicine is the equivalent of New Year’s Day, a hallowed transition date when medical students become interns, interns become residents, residents become fellows, and fellows become attending physicians. It’s not the best of times to be in the hospital because of the changing of the guard and transitional mass confusion!
As another year in practice has come to an end and a new one begins, it gives me pause to reflect on what has been and what is. Since the beginning of my career that officially started on July 1st, 1988, there has been extraordinary evolution in urology and today’s entry reviews some of these changes, most for the better, but some arguably worse.
1988 –> 2022
In times past, checking the amount of urine remaining in the bladder after urinating (post-void residual) required placement of an uncomfortable urethral catheter, but ultrasound technology created the bladder scan that provided the same information non-invasively.
The cystoscope to the urologist is the equivalent of the stethoscope to the cardiologist. It allows us to visualize every nook and cranny of the lower urinary tract. The rigid metal cystoscope has gone by the wayside, replaced by the flexible cystoscope. No more agonizing screams that could be heard all the way in the waiting room, scaring already apprehensive patients.
Cameras have replaced the need for directly looking into the cystoscope. This provides magnification, the ability to show the patient the details of the cystoscopy, and spares urologists from cervical spine issues that were rampant prior to this technology because of the need for constant bending of the neck. Furthermore, no more mouthfuls of prostate chips during the prostate “roto rooter” procedure (TURP-transurethral resection prostate)!
Although the TURP is still performed, it has largely been replaced by laser procedures (Greenlight photo-vaporization) and other minimally-invasive techniques that have the advantage of being done on an outpatient basis, incurring less bleeding, and less time needed for a catheter.
Back in the day, our go-to imaging study was the IVP (intravenous pyelogram) that was done in the office. It is history, supplanted by ultrasonography and more accurate contrast imaging studies, including CT urography and MR urography.
In the past, if you had a kidney or ureteral stone that failed to pass, you needed an open operation (pyelolithotomy or ureterolithotomy) and at least several days in the hospital and a long recovery period to heal from a painful incision. These procedures have been virtually completely replaced by shock wave lithotripsy or laser procedures performed through rigid or flexible ureteroscopes, both done on an outpatient basis with a rapid recovery and convalescence.
The PSA (prostate specific antigen) blood test to screen for prostate cancer was not available when I first went into practice. Screening was a digital rectal exam and evaluation was a prostate biopsy if an abnormality was detected. Biopsy back then was 2 cores obtained, guided by a finger in the rectum on the prostate abnormality. Advanced prostate cancer was much more common without the screening means of today (annual PSA and digital exam). Nowadays, prostate biopsies are ultrasound and MRI-guided and a minimum of a dozen cores are obtained.
Treatment for prostate cancer was not nuanced as it is now. Almost everybody diagnosed with prostate cancer – regardless of their pathology – underwent a radical prostatectomy, and many incurred significant side effects. Nowadays, we have the means to determine who needs active treatment and who can be carefully monitored. Active surveillance for low-risk prostate cancer is more popular than ever before and robotic prostatectomy and radiation therapy – that have become increasingly sophisticated – are reserved for intermediate and high-risk prostate cancer.
In the late 1980s, almost all urological operations were open surgical procedures. Open procedures are now few and far between, with the lion’s share of surgical procedures now performed using a robotic-assisted laparoscopic approach.
In the old days, hormone therapy for advanced prostate cancer was surgically removing the testicles. This radical treatment has been replaced with androgen deprivation therapy medication that provides the same benefit, without the need for surgery.
In antiquity, there were few options for treating advanced prostate cancer. In the last decade, there have been unparalleled changes with numerous new-generation treatments (advanced hormonal therapy, bone-targeted therapy, immunotherapy, and cytotoxic therapy), capable of improving the quality of life and survival for those with advanced prostate cancer.
In days gone by, we had few effective medications to manage voiding dysfunction. Now we have at our disposal a host of effective medications: finasteride, dutasteride, tamsulosin, silodosin, alfuzosin, vibegron, mirabegron, etc.
In former times, we had minimal treatment for erectile dysfunction, often prescribing yohimbine, originating from the bark of an African tree. Now we have a host of effective oral, intra-urethral, and intra-cavernosal medications available as well as refined prosthetic surgery.
Female urology in prehistoric times was largely about urethral dilation. Female patients would come to the office on a regular basis to get their urethras stretched. That ancient practice has been supplanted by the sophisticated subspecialty of female urology and pelvic reconstruction that deals with overactive bladder, stress urinary incontinence, voiding dysfunction, pelvic organ prolapse, recurrent urinary infections, etc.
Many patients in olden times thought to have chronic prostatitis or interstitial cystitis/pelvic pain syndrome are now recognized as having pelvic floor muscle tension myalgia as the primary underlying cause of their problems. Pelvic floor physiotherapy has emerged as an extremely helpful management modality.
In bygone days, many urologists were jack of all trades. This has evolved into sub-specialization: urological oncology, laparoscopic and robotic urology, prosthetics and genitourinary reconstruction, female pelvic medicine and reconstructive surgery, endourology and stone disease, and pediatric urology.
Way back when, the only treatment for bladder cancer was surgery. In 1990, BCG immunotherapy was approved. It is often used with large tumors, when many tumors are present, with high-grade tumors, or with tumors that have recurred. It is particularly useful for carcinoma-in-situ (CIS), a variant of bladder cancer that is superficial and flat, yet high-grade. It’s use, along with other new cytotoxic agents that are instilled in the bladder, has dramatically reduced bladder cancer progression and recurrence.
At an earlier time, medical documentation was done with paper medical charts. Although imperfect, paper worked rather well, with charts neatly organized into multiple sections. This allowed complete and immediate access within seconds to all of a patient’s pertinent clinical information for the attending physician and any colleagues who might be covering for the attending. With the transition to electronic medical records (EMR), the objective remained the same but also expanded into documenting patient visits to satisfy billing and insurance criteria and to fulfilling government regulatory demands. Although there are numerous advantages to EMR, it is expensive, cumbersome, time-consumptive, and seems to have been designed more for bureaucrats than physicians. The biggest obstacle that remains is that there are many EMR systems, many of which are not integrated with each other.
The good old days of the quaint “mom and pop” urology practices are over. Nowadays, to survive in medicine, physicians either become employed by a hospital or join a large group practice. I have chosen the latter. Our practice has been corporatized into a business, an industrial complex with all the inherent advantages and disadvantages that accrue as such.
To sustain a living, we need to see a much higher volume of patients as compared to back in the day because of decreasing insurance reimbursements and increasing practice expenses. To help manage the augmented volume, many practices are now using advanced practice providers – nurse practitioners and physician assistants. Furthermore, many practices now use medical scribes, documentation assistants who transcribe information during clinical visits into the EMR in real time under physician supervision, allowing us to have face-to-face contact with patients and not stare into a computer screen.
