Editor's Note
The Tenders of the Tract
Urine is so unglamorous. Starting with the wet diapers of infancy through the race to the fraternity bathroom during college through the 2 a.m. sleep-disrupting trek of middle age, it just gets in the way. Unlike other bodily fluids, it seems more offensive—cut yourself and bleed and people flock to you worried; lose your urine and people back away from you. And it seems to have drawn the short straw in the metaphor lottery—blood can run hot, hearts can break, brains can light up. But urine … Yet it is a necessity that we keep making (except for the unlucky folks whose kidneys forsake them) and that flows through a system that needs tending. This month, we’re focusing on urology, the work of the urine tenders.
For some, urology has seemed a crude cousin to the more elegant nephrology, mere plumbing compared with the exploration of the exquisite filtration system that regulates the milieu of the body. Urologists pass tubes to open up tubes; nephrologists finely tune fluids and electrolytes. Urologists deal with anatomy; nephrologists with physiology.
Yet urology has catapulted way beyond merely deciding which size Foley to use. Extracorporeal shockwave lithotripsy, now a mature technology, is more a precise zapper than the blunderbuss blaster of earlier days. Stones in kidneys, ureters, and bladders come out by many means and routes, saving patients from open procedures in all but the rare cases (p. 36). More refined imaging localizes tumors and stones quickly and precisely (p.48). And urologists are controlling bladder contraction with new electrical stimulators, slings, and medicines (p. 22).
No longer are urologists one-tool workmen, wielding only a cystoscope. Today they still use those cystoscopes but can do more through them, shattering stones and paring and cooking and freezing prostates to treat BPH and cancer. The nemesis of prostate cancer continues to vex urologists and the medical community in general. Radiation, brachytherapy, and surgery certainly can eradicate many of the deluge of tumors discovered with current-day digital and PSA testing. But prostate cancer treatment is trapped in a black hole of statistics, trying to decide whether all those diagnostic and treatment tools really help patients (p. 39). The find-a-cancer-early-and-get-rid-of-it paradigm, so successful with colon cancer, doesn’t simply translate to prostate cancer. Who to treat, when to treat, and, even, who to screen are questions that fuel a debate not likely to cool down soon and that probably won’t be settled until new tests help define which prostate cancers are most likely to cause trouble in the future.
In medical school, I watched two tenders of the urinary system. David Roxe was a nephrologist who got an almost rapturous look on his face as he described a urinalysis, analyzing its hidden meanings and finding diagnostic clues few of his residents and students suspected. John Grayhack was a urologist who ruled his department by force of intellect and who was happiest sitting in the urology suite, surgical cap tilted to the side, peering through a cystoscope to decipher the mysteries of the bladder, urethra, and prostate. Roxe and Grayhack made a great team, united by the goal of keeping the urine pure and flowing.