A personal perspective on the origins of endourology and the endourological society.

DURING MY TRAINING in South Africa, it was the urologist’s duty to drain a renal cyst and sclerose it and to drain a massively hydronephrotic kidney with a percutaneous nephrostomy tube. In 1977, I moved to the VA Hospital in Minneapolis and attempted to do the same thing at that institution. I found out that in the United States, these procedures were commonly performed by radiologists. At that time, in the VA Hospital, Paul Lange was the Chief of Urology, Bob Miller was the interventional radiologist, and Donovan Reinke was the Chairman of Radiology. After some discussion, we agreed that these procedures could be shared by the urologists and radiologists. I then had a patient with carcinoma of the prostate gland who had obstruction of one ureter that did not respond to hormonal treatment, and I elected to reimplant the ureter. Several days postoperatively, the patient developed a urinary leak, and I thought the only solution to the problem would be to stent the ureter. The only stent available at that time was the Gibbons design, and it was very difficult to insert a Gibbons stent up a reimplanted ureter. We felt that the only solution to this problem would be to pull the stent up from above. Bob Miller and I came up with a plan whereby a percutaneous tube was placed antegrade down the ureter, and I retrieved this catheter in the bladder. With a series of tubes and sutures, I was able to leave the patient with a stent extending from the renal pelvis to the bladder and thus allow the urinary leak to seal.1 Bob Miller and I really enjoyed this collaboration, and we came up with several other ideas involving this technique of advancing a catheter from the kidney down the ureter and attaching various instruments to it. The instruments we used in this way included a meatotomy catheter, stone baskets, and various other tubes.2–6 When it came time to submit these odd cases for an AUA exhibit in 1978, I needed to find some way to embody the whole principle. I discussed this with Elwin Fraley, the Chairman of the Department of Urologic Surgery at the University of Minnesota. He offered several names, and I selected the term “endourology,” which was defined as closed controlled manipulation within the genitourinary tract.7 Once my residents read this title, they—along with some of the radiologists—immediately changed it to “the end of urology.” At the University, I had the unique opportunity to work with Kurt Amplatz, Willy Castaneda, and their technical support. If one of us had an idea for a nephrostomy tube, it was immediately produced for us by the support staff. Initially, we used a filiform follower on the end of angiographic catheter to dilate a nephrostomy tract. This assembly proved difficult to manipulate over a guidewire, so we designed dilators to fit over the angiographic catheter. We then found that we were dilating the ureteropelvic junction and causing extravasation, so we placed a metal band at the tip of the dilator to differentiate the parts of the system (Fig. 1). We were also handicapped by our lack of knowledge of how far to dilate the tract, but I reasoned that a tract that would accommodate a 30F Amplatz sheath would allow us to remove a 1-cm stone intact. We noticed that sheaths that were simply round tubes tended to adhere to the renal pelvis, so we cut the tips at an oblique angle. Then we found that patients could suffer gram-negative septicemia from forcible renal irrigation, so we abandoned that technique. A series of articles traces our quest for a good way to rid patients of stones without open surgery (Fig. 2).8–15 In 1982, the concept of endourology became somewhat popular. One of the reasons was the ability to create a model with a pig kidney to allow the practicing urologist to get a feel for these procedures. Ralph Clayman came up with the pig kidney as a working model for nephroscopy and for ureteroscopy, and this concept formed the basis for innumerable courses in endourology that were conducted throughout the United States and internationally. Early that year, I edited the first publication devoted entirely to endourology: an issue of the Urologic Clinics of North America. 1982 was the year of the 1st World Congress in Endourol-