Transurethral Bladder Stone Treatment

From Ammonius to present day lasers

Although the ancient operation of lithotomy establishes the antiquity of urology as a speciality, it is lithotrity that marks the beginning of modern urology. Lithotrity is the treatment of bladder stones by destruction within the bladder and subsequent evacuation via the urethra. Lithotrity represents the earliest attempt at minimally invasive surgery.

The progress of transurethral surgery for bladder stones begins with early descriptions of possible attempts, then the invention of lithotrity in the first part of the nineteenth century, and its eponymous instrument, the lithotrite, the advance to the single stage litholapaxy in the 1870’s and finally the clarity of the cystoscope.

Timeline for Lithotomy & Lithotrity

Early descriptions of urethral stone surgery
C3rd BC	Ammonius of the Alexandrian school was given the title “Lithotomist” because he divided stones in the bladder before removing them.
936 - 1013	Albucasis a Moorish surgeon living in Spain describes the breaking up of a urethral calculus.
1506	Antonio Benevieni hooked a stone in the bladder of a nun and hit it with an iron rod to break it.
1519	Alsaharavius suggests breaking up small friable stones with an instrument but gives no further description.
1553	Alphonso Ferri, a Neapolitan surgeon, describes a new Musket Ball extractor; a three bladed instrument enclosed in a cannula and worked with a screw, it inspired the later work of both Civiale and Leroy.
1559	Sir Philip Crampton tells of a case of an Irish gentleman who broke his own stone with instruments passed up his urethra.
1561	Franco describes a four-branched instrument for removing calculi called the “quadrupulus vesicae” with a perforator for breaking the stone (an idea borrowed from Guido de Cauliac, 1546.)
1591	Prosper Alpinus describes a method of dilating the male urethra for the extraction of stone in his book, De Medicina Aegytiorum.
1671	Ciucci, an Italian surgeon, speaks of a “tenacula tricuspis” as the best way of extracting stones or seizing the calculus and breaking it into fragments.
1685	Wallis extracted stones from the female with forceps
1813	Gruithuisen proves that a straight tube (and thus straight instruments) can be passed into the male bladder
1819	Elderton, from Northampton , describes a curved instrument for crushing stones.
1820	Astley Cooper removes several small stones from the Rev. John Bullen, that were preventing him from going hunting. He dilated the urethra with bougies to assist the spontaneous passage of stones then attached a rubber catheter. When this blocked, and a stone was pulled out on its end he thought of an idea of purposely extracting stones directly. Mr Weiss the instrument maker of the Strand suggested altering a pair of bullet forceps for the purpose.
The race to develop the lithotrite
1822	Leroy d’Etoilles & Amussat both demonstrated instruments before the Academy of Surgery in Paris. Leroy presented the Lithoprione; two tubes holding four sprung wires to retain the stone. The stone was then drilled with a gimlet. Amussat’s instrument held the stone between two jaws and a ratchet closed them and crushed it.
1824	On 13 January 1824, Jean Civiale performed his first operation, in front of the commissioners of the Institute of Medicine in Paris. The patient was relieved of his stone in two sittings. A second patient was operated on 4 Feb, a third on 4 March. The commissioner, Baron Percy and Baron Chaussier considered that Civiale was the discoverer of lithotrity.
1824	Weiss invents his crushing instrument. The idea was discussed with Sir Benjamin Brodie.
1825	Dr Haygarth invented a sliding instrument for extracting small calculi. Mr Hodgson of Birmingham suggested adding a screw so it might be used for crushing.
1832	Baron Heurteloupe presents his “Percusser” a lithotrite that grasps the stone and is then hit with a hammer to break it!
The operation of litholapaxy
1878	With the knowledge of the work of Otis who showed the male urethra was larger than previously thought and using the new method of ether anaesthesia, Henry Bigelow, professor of surgery at Harvard, describes the new operation of litholapaxy where the stone is crushed and removed in a single sitting.
Adding the ability to see the stone
1910	Hugh Hampton Young invents a cystoscopic lithotrite, 28F with a 25F channel, but It was weak and broke on one occasion in the bladder.
1925	Lieut Colonel RW Anthony performed 2500 litholapaxies in India. For larger stones he used a hammer. This damaged the wheel mechanism so he got Weiss to make a lithotrite with a spring lock especially for hammering.
1928	Ravich describes a visual lithotrite with a scissor handle for crushing the stone, not dissimilar to those used today.

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