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On the Wonders of Urology

Dr. Drach with medical students

[read expert bio here]
by George W. Drach, MD

Is urology different from other medical and surgical specialties, and if so, what makes it different?

Yes, it is different. Let me begin by indicating the major difference: the breadth of urology is immense. Our patients begin with children in utero who have any one of multiple genito-urinary anomalies that can now be recognized during gestation. Thus we have at our yearly American Urological Association (AUA) meeting a sub-specialty meeting of the Society for Fetal Urology. After birth, more anomalies can become apparent, and we therefore see reasons for the large and well-developed sub-specialty of Pediatric Urology. As our patients become older, we enter into that phase of life when urinary stone disease becomes prevalent: late teens through age 40 or 50. Also, testicular cancers appear in this same group, at least up to age 30. After age 50, we begin to see development of prostate problems, benign and malignant. Then, as our patients reach the age of 60 or 65, they become afflicted with problems of incontinence, or urinary tract infections (especially in women). Bladder and kidney cancers become more prevalent. Males complain of erectile dysfunction.

If we put together the above two poles of urology (pediatric and geriatric), we find that urologists see perhaps the largest numbers of patients of any surgical specialty within these two groups. Especially for geriatrics, urologists see in their offices (in the USA) the third largest proportion of patients age 65 or over, about 50%. Only medical cardiology and ophthalmology see more elderly patients.

And although many modern treatments for urinary incontinence or outlet obstruction now involve use of medications, urology still uses many gadgets and surgical approaches to treat problems. Hence, urology is different also because it is a unique combination of medical and surgical specialties within one discipline. Stones, for example, may first be treated by shock wave lithotripsy but then prevented by administration of oral agents such as thiazides. Or kidney or ureteral stones may be treated by using percutaneous nephroscopic techniques or transurethral retrograde ureteral telescopic methods.

That cornerstone of urology, outlet obstruction due to prostatic hyperplasia, is now most often treated initially with medications, but it also responds to many interventions other than the standard transurethral resection of the prostate. These new approaches include hyperthermia in the office, radio-frequency ablation, focused ultrasound ablation, laser ablation or enucleation.

Laparoscopic approaches to intra-abdominal urologic problems have increased greatly in the recent years. Robotic laparoscopic radical prostatectomy has become one of the most common cancer operations in the USA. Yet open urologic surgery continues to have its place in performance of major kidney surgery, in total cystectomy and diversion or in reconstruction after trauma. Few operations of any kind demand the attention and stamina required for cystectomy and diversion.

So if you want a huge diversity of diagnostic challenges, followed by treatments with an almost unlimited use of medications, elaborate gadgets or classical “Bard-Parker” surgery, then look carefully at the Wonders of Urology. As a general urologist arising in the morning, you will never know what to expect before you retire at night. The daily challenges will be exciting, and you will be able to improve your patient’s lives significantly by using the many methods shown above. It’s also fun and rewarding: you will never find a patient who loves you more than one from whom you have removed an obstructing and very painful ureteral stone.

George W. Drach, MD

Emeritus Professor of Surgery (Urology)

University of Pennsylvania