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John M. Fitzpatrick

Department of Surgery, University College Dublin, Dublin, Ireland

The minimally invasive treatment of urological disease has advanced considerably in the last 25 years. Those of us who remember open nephrolithotomies being performed on the same kidney for the third or fourth time will have seen the full extent to which invasive surgery has in many areas become a thing of the past. The new dawn of minimally invasive surgery in urology was heralded by the advent of percutaneous nephrolithotomy developed by Wickham, Marberger, and Alken in Europe and Segura and Clayman in the Unites States. In a relatively short time, this became the standard way of removing stones from the kidney.

However, extracorporeal shock wave lithotripsy was introduced at almost the same time, and with this new, all-encompassing technology, we felt that nothing else was required to treat stones. However, it became clear that the best way of clearing the kidney of large stones was a combination of shock wave lithotripsy and percutaneous nephrolithotomy. In other words, minimally invasive surgery still had a very important role to play.

Laparoscopic surgery was popularized in general surgery and urology at more or less the same time. Clayman and his colleagues developed a technique for nephrectomy and nephroureterectomy, and Gill popularized the techniques of radical nephrectomy and partial nephrectomy. What became clear was that to learn these techniques required intensive training and mentoring. The fact that these techniques have become so widely popular is testament to the skill and patience of these opinion leaders.

The benefit to patients of the laparoscopic approach has been made clear in a large number of publications. The fact that laprascopic radical nephroureterectomy is, in fact, an endoscopic re-creation of the open procedure makes it easy to understand these advantages. The major limitation, apart from the loss of three-dimensional visualization and of tactile properties, is the use of a phrase that I do not likeā€”the "learning curve." I believe that most urologists realize that the concept of a learning curve can be avoided by careful tuition and mentoring.

In the future, it is likely that every department will have a section of laprascopic urology. My belief is that this will continue to grow and that the science will be developed with the improvement of technology. Whether robotic surgery will interfere with this progress remains to be seen. It behooves us all to encourage the development of laprascopic urology, which is definitely a benefit to our patients.


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