Chapter 15 - Society of Laparoscopic & Robotic Surgeons

Chapter 15

Heyday 1920s-1930s

Cystoscopy “was probably the most dangerous field in the whole of medicine because there is – in contrast to all the other fields – a great potential for mistakes leading to injury with serious consequences.”
-1937, E. Pflaumer

Long before gynecologists or any other specialty was involved with operative endoscopy, endo-urologists in Europe and the United States were by far making the most significant advances, beginning as far back as the late 19th century work of such impresarios, Grunfeld, Nitze, Ringleb, Goldschmidt, Kelly, Brenner, and Casper. Even as early as the 1850s urologists had been experimenting with chemicals or galvanized wires in order to cauterize the prostate or bladder tumors endoscopically (though without visualization).

Albarran’s 1908 innovations improved the practicality and safely considerably, while Beer in 1910 made what was described as the most groundbreaking discoveries for the field, whose influence reached well into the 1930s. By 1908, the endoscopic removal of bladder tumors had graduated to essentially a routine procedure for urologists.

However, just because it was a common practice doesn’t’ mean it was without trouble (note the same was true of the common practice of exploratory laparotomies). One of the best quotes to provide insight into this matter came from E. Pflaumer of Germany, who in 1937 stated emphatically that cystoscopy “was probably the most dangerous field in the whole of medicine because there is – in contrast to all the other fields – a great potential for mistakes leading to injury with serious consequences.” Complications included some very serious ones, such as perforated bladder, hemorrhaging to death, while others though not as life threatening, were just as devastating in terms of quality of life, such as incontinence. Bearing in mind this paradoxical era of both impending peril and dynamic development, we review the developments of this field, starting with the continuation of trailblazing innovations by the original master, Nitze.

Nitze – The Master Wouldn’t Quit!
The old 19th century nemesis of a small field of view continued to stifle further progress toward operative modalities. For such immensely confounding and complex sorts of problems, we can only take refuge under the tutelage of the great masters! The 19th century principles that Nitze and others founded continued to guide many pioneers toward the path of further discovery. Many of these companies were still holding Nitze as their point of reference and were still competing with him, attempting to perfect his original cystoscope. However, the master wouldn’t quit! Up until his last moments on earth, Nitze was still designing new and improved instruments; Nitze cystoscopes were on the market until the 1930s. Granted, this may have been more to do with economics than with the fact that it was superior. Still, Nitze was one of the first to design operating cystoscopes equipped with cautery knifes and loops for treating bladder tumors and so it made sense to use his examples to guide later pioneers into this slowly developing field.

New Contribution from Nitze – The Retrograde View Cystoscope
In 1903, Nitze became one of the first to come up with the idea of examining the anterior wall of the bladder and the bladder neck in 1903, a feat accomplished using his invention of the new retrograde view cystoscopes. This technological breakthrough allowed one to view the bladder from any direction. Achieving this required rather sophisticated optical engineering on Nitze’s part, not to mention creative design techniques in order to fit all the necessary equipment into an instrument small enough to pass through the ureter. Limited to the optics available in this era, Nitze nevertheless was able to transform what was available– such as Trouve’s prism- into a tiny, 3-in-1 telescope.

Naturally the whole system was bulkier, taking up the whole shaft of the scope, which reduced the field of view. All the same, the idea was a resounding hit and variations of the same retrograde theme streamed into the market. Most other endoscopists-engineers followed Nitze’ design principles to create their own modified masterpieces, with newly minted names such as the universal cystoscope and the pancystoscope.

Though issues of primacy are not clear (Lewis and Baer are just two who have been cited as being the first to introduce the idea) we do know for certain that this innovation was crucial in making diagnostic cystoscopy that much safer and accurate, a win by any measure for the lives of patients. Also, ureter catheterization was made considerably easier for the endoscopists– and for the patient too.

Conclusion Nitze
Nitze’s last invention was in 1905: a ureteral occlusion balloon catheter with accompanying occlusive ureterocystoscope. Nitze’s inventions of this last era of his life are significant as well because the represent the first phases of electro- endoscopy really taking off. His death in 1906 of a stroke marked the end of Nitze’s material life, but the legacy of his contributions remains with us today.

Device Heaven – Ringleb’s Brilliant Technical Contributions

If good instruments do go to heaven, Ringleb’s newly improved scope, introduced in 1908, surely is resting peacefully. The outstanding amount of improvements and problems that this singular instrument solved is simply stunning. That he was able to tackle each issue one by one into a synthesized singular scope is truly the work of unrepentant genius. Before we get to all the happy details, we start with the general principle and feature which usually attracts the most attention. Most histories focus on the fact that his new device was spectacular for its having solved what is often referred to as “Nitze’s error,” which relates to having set the ? to infinity, thus not correcting for the inverted image crisis that rocked the endoscopic world for some time. To boil the problem down to its essentials, it basically goes like this: All telescopes will have an inverted image unless an additional set of optics is placed correctly into the system to revert it; Nitze tried but initially failed to solve this; though (apparently) Ringleb wasn’t the first to solve it, he did much more with his 1908 invention.

So although Ringleb was not the first to invert the image, he created an entirely new system in 1908. Another one of Ringleb’s fantastic upgrades was his improvements of the resolution of the endoscope’s image. He increased the angle of view by making it larger and gave it more light by increasing the diameter of the pupil. Ultimately, his innovations led to the first time that the image, intensity of light, luminosity of light, and increased magnification were significantly improved. True, increased magnification could only come at the expense of brightness, which would decrease as a consequence. He therefore limited the field of view. Ringleb’s brilliantly designed cystoscopes were still on the market until the 1960s. Also, his optical systems were free of focus errors, such as astigmatisms and coma. In addition, the curvature of the field of view was not as noticeable due to the natural curvature of the bladder wall.

Ringleb also improved the view of cystoscope considerably with his “orienting cystoscope,” a breakthrough in 1908. He attached five different lenses, each with a different range of depth perception which helped inside the body. This allowed for optimum light and resolution to at various different depths and allowed the cystoscope to stay thin in shape while maintaining the wide angle and intensive luminous light. In fact, Ringleb cystoscopes were still on the market until the 1960s.

Related to this 1908 New System – The Infinity Issue
Sources state that in 1908, Ringleb corrected Nitze’s original mistake of setting the telescope lens to infinity, thusly solving the problem of an inverted image. However, there appears to be some historical dispute regarding Nitze’s work in relation to Ringleb. Apparently, Nitze allegedly designed an eyepiece that corrected the then inverted image of the cystoscope. However, for some yet to be disclosed reason, this design was rejected by either himself or his peers. This certainly could be possible, as many of the optical innovations and so- called discoveries of the 20th century were based on theories from the 19th century. Accromatic inverting lenses were invented before Ringleb (Nitze for example). The difference appears to be that Ringleb designed them the better way. At approximately the same time as Ringleb’s innovation, other probing minds were tackling the problem of inverted image, including H. Kollmorgen in 1907, ERW Frank in 1907, and CG Heynemann in 1907 and Jacoby, who in the same year also managed to set the image upright by building the first stereoscopic cystoscope. Later in 1910, Loewenstein did the same.

Amazingly and thankfully, the improvements did not stop there. In 1909, Ringleb’s introduced the clarification cystoscope, which increased the magnification of the orienting cystoscope. Later in 1912, he synthesized all these great new technological improvements, even managing to reduce the size of the instrument to a small diameter of only 7 mm. He also improved the lamps (that were later employed) by using different materials such as tungsten and osmium. Unlike other materials, these two usefully did not become hot. He also made improvements to the actual light bulb, increasing the light field.

Ringleb’s work seems to have certainly been beneficial to patients. Suprapubic prostatectomy used to have a mortality rate of 50% prior to the introduction of Ringleb’s new method, after which the rate went down to 10%. Invigorated with confidence by his success, he wrote a textbook on cystoscopy in 1910.

Multi-Tasking Renaissance Man
Ringleb was also a great medical historian, publishing texts on the work of Bozzini, Desi, Grunfield, Nitze, Stoeckel and Von Rohr. Medical historians frequently connect his name with to the “advance and rise of urology in the first half of the century.”

Ringleb was also substantially involved in endoscopic photography, referred to back then as stereocystoscopy. He invented new ways to improve the resolution of the pictures and kept trying to perfect the lighting in order to make better pictures!

Conclusion Ringleb
Alas, like many great men, the latter half of Ringleb’s life was quite tragic. Ringleb’s practice, apartment, and library were bombed out in 1944. American occupation forces then revoked his teaching license. He was also for a time interned at the American work camp for Nazi criminals of the medical faculty in Wannsee for ten weeks due to a false accusation against him. After all of this trauma he was found a crying and broken man after having been forced into hard labor. Shortly thereafter, he died in November of 1946.

Hans Goldschmidt
In 1907, Hans Goldschmidt introduced optical urethroscopes with air and water irrigation, complete with the Nitze-camera built in. Derived from the principle of blowing air into the urethra tube introduced in 1887, for the first time the urethra was stretched by using a water column and a telescope was employed for urethroscopy. Indeed, Goldschmidt revolutionized urethroscopy. His irrigation endoscope allowed the verumontanum and posterior urethra to be seen without difficulties for the first time ever. In fact, he used endophotodocumentation in order to prove this technique. He was also the first to perform simultaneous diagnosis of the bladder and the urethra. Moreover, his inventiveness in operative procedures includes the development of a prostate incisor.

At this juncture, he became interested in Nitze and the cysteomscope, going so far as to publicly advocate Nitze’s work. As a result, Goldsmidt’s work seems to have catalyzed operative endoscopy quite a lot; his version of the device is the one that is used today!

Leopold Casper (1859-1959) and the Start of Functional Renal Diagnosis
A urologist from Berlin, Leopold Casper was Nitze’s self proclaimed chief adversary, designing and constructing his own modified cystoscopes and lithotriptors. Along with F. Richter, Casper founded functional kidney diagnosis with the introduction of the phloridzin test as early as July 16, 1900. He incited much public controversy with Nitze, not only openly fighting with him, but suing Nitze as well. However, all bets were off when the Third Reich reared its horrific head; Casper was dismissed in 1933 and had to emigrate to New York at age 82.

Kidney surgery experienced an immense growth during the first decade of the new center, partly due to cystoscopy and ureter catheterization. Cystoscopy by itself was insufficient for the diagnosis of kidney disease. However, it was sufficient for evaluating kidney function and whether urine was containing blood. The separation of urine from the individual ureter was not yet possible. The diagnosis of kidney disease was very difficult and problematic before the era of ureter catheterization.

Even as early as 1900 Leopold Casper and PF Richter founded “functional renal diagnosis by lowering the freeing point using A von Koranyi’s procedure,” i.e., evaluation of kidney function using a cystoscope, also called chromocystoscopy and using dying agents such as methylene blue, to see the vessels and processes more clearly.

Casper competed with Nitze, designing and constructing his own modified cystoscopes and lithotriptors. He had some controversies with Nitze– some fights– and then when the third reich came to town, he was dismissed and had to emigrate to New York.

Edwin Beer of New York
Edwin Beer was a Columbia graduate practicing urology at Mt. Sinai in New York and leader in the promotion of the adoption of the ureterocystoscope as the preferred operating cystoscope for bladder tumors. For the history of endo- urology, Beer’s innovation is considered one of the most crucial of the 20th century. He employed a method that Oudin, a Parisian urologist, had already introduced for skin warts. With his improved device and Oudin’s method of high frequency (monopolar high frequency current), he was the first to coagulate bladder tumors in 1910. Apparently, this new method for treating bladder tumors was in spite of “strong opposition” from surgeons. Beer also published extensively.

Hugh H. Young of Baltimore
Claiming to have told off and even to have almost gotten into a “ knock down, drag-out fight” with Nitze over his newly designed cystoscope, Hugh H. Young innovated the punch resectoscope in 1909, going so far as to produce a new retrograde square prism system to improve the optics. He was also the first to conduct ureteroscopy with rigid endoscopes in 1912, doing so on a two-month- old child. Young also produced a new retrograde square prism system to improve the optics. By Young’s own autobiography, he claims to have almost gotten into a “knock down, drag-out fight” with Nitze, in response to his showing his newly designed cystoscope to Nitze. He says “in very bad German, I told him what I thought of him….”

Leo Buerger
Around 1911, Leo Buerger of New York constructed his own cystoscope telescope due to the inspiration of Ringleb. Buerger also constructed a successful universal urethroscope in 1917, which remained one of the most popular ever. Many other instruments were made by Bueger, in conjunction with Brown. The Brown-Buerger scope was quite sophisticated; it had two optical systems, and had either direct or indirect viewing, for catheterizing and operating respectively. It was versatile, capable of being both a cystoscope and urethroscope. The operating components were detachable (the catheterizing didn’t need telescope, but the operating unit did use the telescope).

Other Important Works in Endo-Urology
In 1918, AJ Cromwell reported successful treatment of ureter stones on several hundred patients with a new method of his with a 98% success rate. Cromwell’s method was still blind, though he did use infant cystoscopes.

Fenwick of London was a pioneer also who endoscopically treated ureteroceles, sometimes by cutting them open, other times by injecting them intermittently with chemical fillers. Sources also cite Fenwick was also the first to cauterize the orifice and was also was doing trocar cystoscopy as early as 1889. Heineberg in 1914 developed a system to rinse off blood from the lens.

George Luys

Today’s standard procedure of filling the parts to be examined with air was popularized in France in around 1905 by Parisian G Luys who apparently imitated the Valentine urethroscope and equipped it with an aspirating tube. Luys, among others, founded electrocoagulation in 1913-1914, a couple of years after Beer. From this year on, he employed the “forage de la prostate,” placing many coagulation necrosis in the prostate via a coil-shaped electrode; an air pump unfolded the bladder and posterior urethra. He used a ureteral cystoscope which had a bulb-tipped electrode (this part being the cautery part) on the end. It was applied to adenomyosis of the middle lobe and bladder neck. He reportedly achieved satisfactory results in more than 90% of his patients. His method was used mainly in France and Germany.

By 1926, he reported on over 100 electro-surgical operations of the prostatic hypertrophy. Luys is also considered one of the earliest to achieve urine separation for the catheterizing process.

Luys also created various modified designs of equipment, subsequently enjoying fairly wide success that was produced by the Gentile Company of his native land. Among the most important models included adjustable forceps and scopes with improved aspiration channels. He also made the practice of urine separation a popular methodology. He also modified the Valentine model with men and women, going so far as to doing some modest operative procedures, such as cauterizing bladder tumors and the prostate; he removed foreign bodies with small forceps. Even still, he improved upon and extended the cystoscope, creating further therapeutic uses such as new methods for treating prostate conditions. Overall, Luys was important for further expanding urethroscopy and cystoscopy in France.

Luys took Young’s method in 1914 and applied it to prostate obstruction operations, also under direct visualization. Luys seems to have modified it somewhat by changing the exact method of placement of the cystoscope. Luys recognized it as a great minimally invasive procedure, speaking of how it was superior to the “gravity” of a transvesical (AKA open) procedure for what amounted to a minor problem of discomfort.

Strangely, despite Luys success, it appears that open prostatectomies remained (as Gutierrez was writing in 1931) the procedure of choice in France.

Georges Marion
Georges Marion of Paris was one of the most important endoscopists and surgeons at the hospital Lariboisiere, where he was able to applied an indwelling catheter dilate and drained the ureter with the help of a permanent catheter in 1910. He introduced diathermy one year after Beer did in 1911. He also constructed his own resectoscope, modified after the Stern-McCarthy.

Heitz-Boyer achieved a breakthrough for endo-urology at the time by becoming one of the first to use high frequency treatment of prostate adenoma in 1911.

He designed his own high frequency (haute frequency) and by 1921 his instruments had three different optical systems and also three different electrodes. The French company Drapier later made another modified device using diathermy in 1927.

Heitz-Boyer had visited the American pioneer Young in Baltimore, who had demonstrated his punch operation. It was apparently Heitz-Boyer who advised Young to use high-frequency current and was apparently surprised that he was not using it.

American Endo-Urologists Make Significant Contributions

Ironically, even though European urologists pioneered and founded much of endo-urology in the 19th century, by this 1930s period Americans had embraced endoscopic surgical methods much more and were beginning to dominate the field in terms of significant breakthroughs. All of these developments in endo- urology were truly significant for decreasing mortality for open procedures. We often focus more on laparotomies for upper abdominal diseases, but laparotomies were also a method of choice for treating prostate disease up until fairly recently. The mortality rate for open procedures was astonishingly high. A German report from the 1930s indicated that the mortality for open prostatectomies was as high as 25%-30% in many cases, prompting one urologist of that era, Schlagintweit of Germany, to comment about the open method that he would “rather wear a catheter for the rest of my life than die in one day.”

The 1930s certainly was a heyday for American endo-urology in particular. One of the most fascinating statistics uncovered is the rapidity with which the endoscopic of TURP-styled procedures supplanted open prostatectomies. Hugh Cabot from the Mayo Clinic in Rochester tracked the statistics at the Mayo Clinic carefully. He found that in 1928, 93.3% of the patients were being surgically treated, but by 1933, only 2% were. Further, he did an excellent comparative report, comparing the two methods side by side. Using data from 600 TURPs and 600 suprapubic prostatectomies, performed over the course of fives years, the results on mortality was astonishing. The open method had a mortality rate of 9.5%, while the transurethral resection had a mortality rate of 1.3%.

Concerning the 1930s urology era, this Gutierrez guy says “[all of these improvements make] this a surgical era of safety, accuracy, and great accomplishment, reaching its maximum of efficiency in the operation of prostatectomy with its permanent good results, its total relief of symptoms, and its very low operative mortality – the rate being approximately 2 percent in the hands of an average competent urologist.”

Caulk and His Report on 8073 Cases of Prostate Resection (TURP) by 196 Surgeons!
A prominent endo-urologist from the 1933, Gutierrez, made reference to the greater use of TURP in America versus Germany, noting that ”the comparison of the statistics of caulk and Alexander von Lichtenberg shows the serious difference in number, experience indication and quality of turp in the USA vs Germany.” This review was in reference to one of the largest studies ever, compiled by the American urologist Caulk who reported on 8073 prostate resections (not punch, but closer to TURP methods) by 196 surgeons, with an overall mortality rate of 3.74% One German source (Wohlleben) noted this great difference in approach too, stating in 1938 that in America “almost in every case of prostate disease was (sic) treated electrically with the removal of considerable quantities of tissue (30-35 grams).” During the same time period, the largest German study of the kind was by Lichie, who reported on 158 resections on 70 patients with mortality rate of 4.3%. Gutierrez and others found that the literature of Germany on TURP methods, between 1933-1934, showed a total of 1000 patients from several different surgeons.

1925 – Max Stern – A Crucial Turning Point for Endo-Urology
In 1925 Maximilian Stern, who later developed the first resectoscope, presented instruments for the application of diathermy to the prostate. Clearly urologists were looking for multiple different ways to treat prostatic enlargement, and diathermy, or heat application, was just one of them. He presented an instrument consisting of an insulated shank that had two rotatable blades at the end. These rounded blades, when closed, could be inserted into the rectum and were then opened, hugging prostate and seminal vesicles. These were insulated and were connected to current for about 30 minutes. The indifferent electrode consisted of a tinfoil about 4” by 8” placed over the public area; a current of 1000 milliampere was used. In addition, he developed a urethral electrode, in shape similar to a van Buren sound, but with an insulated shaft and tip and an exposed metallic portion in the curvature of the instrument that was to occupy the prostatic urethra. Current application was the same as for the prostatic electrode, and he states that he did obtain good results with the prostatic instrument and felt that the combination of these two could also be applied to inflammatory changes in prostate and seminal vesicles.

Stern’s Resectoscope – First Instrument with Electric Cutting Loop
Stern had worked for a couple of years on modifying the existing instruments for removal of prostatic tissue. As Young stated, “Stern, in 1926, modified myth punch by introducing a cystoscope and a platinum loop.” Clearly he refers to the instrument he had developed with Loewenstein 15 years earlier. Stern combined the ability of current to cut with the idea of the punch, namely shaving out a section of prostate tissue. With Wappler’s assistance, he created the first instrument that used an electric loop to cut prostatic tissue. As in all the previous punch instruments, the fenestra was near the tip but longer than in the punch instruments. He had a small moveable loop on a carrier that could be moved back and forth with a rack and pinion transport mechanism near the eyepiece. He presented this instrument to the genitourinary section of the New York academy of medicine in January of 1926, stating that his new invention was “capable of operating in a water medium…provide with a small moveable ring or loop of tungsten wire,…capable of removing a longitudinal spaghetti-like section of tissue…this instrument I have named …the Resectoscope.” The initial instrument had two lens systems; one of indirect vision for exam and diagnosis prior to surgery. Cutting was down towards the bladder. His power source, constructed by ACMI, was called resecto-therm, and was described as an apparatus delivering radio frequency current of low voltage that did not arc or jump across a gap, thus making it possible to employ a bipolar instrument. Stern’s report was made on a basis of 46 patents that he had operate on, all of them older men, with no pre selection made. He reported no bleeding of importance, or any other unfavorable outcome. In only 4 cases was a second treatment necessary (at least at the time of his report, which was 6 months later). He stated that he had no bleeding in his first 46 patients or any other unfavorable reaction, though all his patients were older men without patient selection. Four needed a second treatment.

Radio Frequency
Stern’s introduction of radio frequency to endscopy stands as one of the most important milestones. Stern’s resectotherm delivers a radio frequency current of low voltage and is peculiar in that it can be delivered in a continuous flow through the cutting loop under water, by virtue of the fact that it does not arc nor jump across a gap, thus making it possible to employ a bipolar instrument.

Stern’s reports about bleeding are a bit suspect b/c others at the time who used his device as he indicated got totally different outcomes, lots of bleeding. Others reported that while it did reduce bleeding “considerably,” it did not seal larger arterioloes. Later, others modified this type of device to correct for all of this. Others reported that they did find his instrument “vastly superior to all methods that had preceded it.”

Joseph McCarthy
Since approximately 1923, Joseph McCarthy of New York made several significant improvements to cystosocpes and resectoscopes. Some of his first innovations include a foroblique lens system that widened the visual field considerably, an improved irrigating cystoscope, and a punch resectoscope, among just a few. However, his most sophisticated and well known of resectoscope, introduced in 1931, became one of the most important contributions for the endoscopic treatment of prostate disease. Referred to as the Stern-McCarthy scope (for its use of many principles established by Stern earlier), featured the latest in dual current units for cutting and coagulating (as advanced by Stern and Davis, among others). He was also one of the first in America to incorporate a non-conducting Bakelite sheath, and added a lever to move the electric-arc cutting loop. This device was described in detail as the following:

“The McCarthy resectoscope and loop can take longer bites and more pieces in a shorter time than the punch. According to McCarthy himself, his was superior because it provided the most precise visualization of the prostatic urethra and had the greatest possible flexibility of manipulation under vision of the cutting loop and that ample electrical power to excise under water while at the same time allowing for minimal hemorrhaging and coagulation, interchangeability of electrodes for the closure of bleeding points, and the fact that only one introduction of his instrument was needed, including even to add the indwelling catheter. If oozing still occurs, his system also provided for one could at the end or later, add a balloon bag which was filled with water to apply pressure inside the urethra for a couple of hours. McCarthy was realistic in his understanding of post-operative bleeding and admitted that ‘secondary hemorrhage ….is to be expected in a small number of cases in any type of coagulation hemostasis’.”

McCarthy’s lens system remained popular for a long time. It was considered the first practical cutting-loop resectoscope, and it quickly replaced fulguration (as had Beer’s earlier) to become the most popular method used to diagnose and surgically treat bladder neoplasms for the rest of the 20th Century. The literature well into the 1930s and 1940s demonstrates that many of the cystoscopes (even many in Europe) had either the entire Mccarthy-Stern operating unit, or at minimum had the McCarthy lens system. Numerous modifications of the Stern-McCarthy resectoscope followed, but they were all based on his original designs (along with Stern’s). Although transurethral resection of the prostate (TURP) has given way to newer methods, transurethral resection of bladder tumors (TURB) remains today a mainstay operation for these lesions.

Theodore Davis
“…brilliant as this work is, progressive as it is, curative as it is, we are not going to fall head-over-heels in love with it.”
–example of criticism of TURP, circa 1930s

Theodore M. Davis, born in Greenville, SC, in December of 1889, was the next American urologist to make crucial breakthroughs in electro-cautery technologies, which not only substantially improved the safety and efficacy of TURP methods, but also ultimately influenced all disciplines of endoscopy.

Indeed Davis’ introduction to a unit which had separate currents (collaborating with the famous American engineer, Bovie of Bovie current fame), one for cutting and one for coagulation (high and low frequency) was said to have “startled” the urologists of the time with the successes that he obtained with its use.

Davis first reported his resection technique in a movie that he presented to the AUA in 1931. In his presentation he made it clear that his aim was to “restore to a rightful heritage to the disinherited method of Stern.” He found the results with the new separated currents to be so impressive, that he stated transurethral surgery to have been “reduced to a minor surgical operation” and that hospitalization was reduced “to several days as compared to several weeks for prostatectomy.” Still, like so many cutting edge moments in the history of endoscopy, there were critics everywhere to scoff at new techniques. One critic of Davis’ work, A. Randall, made a revealing comment concerning the opposition to endoscopic methods, stating that “In perfect frankness that, brilliant as this work is, progressive as it is, curative as it is, we are not going to fall head-over-heels in love with it. I would rather caution you to let Dr. Davis alone go on with the technical side of it.”

1052 Clinical Cases!!!
Davis stands out for another important reason: he reported on one of the largest clinical trials of the time for TURP, with over 1052 cases being reported. Many of these early endo-urological pioneers actually had very little clinical success with their methods, despite what appeared to be glowing reports at congresses and in preliminary trials. This is why Davis stands out in this history especially. His 1052 cases stand as one of the most extensive clinical successes with any endoscopic method for his time. Davis also provided one of the few insights into the problems of complications, which were rarely mentioned in other reports of the time. He states that his technique “if carefully followed will enable others to accomplish with greater facility this operation that in the past has caused grief to both the operator as well as the patient.”

1938 – Reed Nesbit – Turning Point: One-Handed Resectoscopes
Reed Nesbit of Ann Arbor, Michigan, introduced in 1938 a modification of the Stern-McCarthy resectoscope, which resulted in a crucial turning point because it was one of the first functional resectoscopes to permit one-handed operation. His novel features included a handle to the sheath which had a thumbhole which rotated with the hand of the operator. With this, it was said that “the surgeon’s hand was freed and allowed the surgeon to perform excellent resections down to the prostatic capsule.”