Marshall L. Stoller, Maxwell V. Meng-Urinary Stone Disease

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PAUL K. PIETROW, MD • Director of Minimally Invasive Urology, Hudson Valley Urology,

Poughkeepsie, NY

GLENN M. PREMINGER, MD • Professor, Division of Urology, Director, Comprehensive Kidney Stone

Center, Duke University Medical Center, Durham, NC

ANUP P. R AMANI, MD • Assistant Professor, Director of Laparoscopy, Department of Urology,

University of Minnesota Medical School, Minneapolis, MN

BERENICE Y. REED, PHD • Renal Division, Department of Medicine, University of Colorado Health

Sciences Center, Denver, CO

MARTIN I. RESNICK, MD • Lester Persky Professor and Chairman, Department of Urology,

Case Western Reserve University, Cleveland, OH

COLONEL NOAH S. SCHENKMAN, MD • Chief, Department of Urology, Director, Endourology

and Urology Stone Center, Walter Reed Army Medical Center, Washington, DC

RADLEY F. S CHWARTZ, DO, FACS • Director, Center for Urologic Laparoscopy and Endourology,

Associate Professor of Urology, Southern Illinois University School of Medicine,

Springfield, IL

JOSEPH W. S EGURA, MD • Department of Urology, Mayo Clinic, Rochester, MN (Deceased)

OJAS SHAH, MD • Assistant Professor, Director, Endourology and Stone Disease, Department of Urology,

New York University Medical Center, New York, NY

BIJAN SHEKARRIZ, MD • Associate Professor, Director of Laparoscopy and Minimally Invasive Surgery,

Department of Urology, Upstate Medical University, State University of New York,

Syracuse, NY

ARTHUR D. SMITH, MD • Chairman, Professor of Urology, Department of Urology, Long Island Jewish

Medical Center, New Hyde Park, NY

G. BENNETT STACKHOUSE, MD • Clinical Instructor, Department of Urology, University of California,

San Francisco, San Francisco, CA

MARSHALL L. STOLLER, MD • Professor, Department of Urology, University of California,

San Francisco, San Francisco, CA

STEVAN B. STREEM, MD • Glickman Urological Institute, The Cleveland Clinic Foundation,

Cleveland, OH (Deceased)

DANIEL SWANGARD, MD • Director, PREPARE, Assistant Professor, Department of Anesthesia and

Perioperative Care, University of California, San Francisco, School of Medicine,

San Francisco, CA

BENG JIT TAN, MD • Department of Urology, Long Island Jewish Medical Center,

New Hyde Park, NY

YEH HONG TAN, MD • Consultant, Department of Urology, Singapore General Hospital, Singapore

RAJU THOMAS, MD • Professor and Chairman, Department of Urology, Tulane University School

of Medicine, New Orleans, LA

RUBEN URENA, MD • Department of Urology, Tulane University School of Medicine,

New Orleans, LA

RONALD M. YANG, MD • Resident in Urology, Department of Urology, Kaiser Permanente Medical

Center, Los Angeles, CA

Contributors xiii

About the Editors

MARSHALL L. STOLLER

Dr. Stoller is currently Professor and Vice-Chairman in the

Department of Urology at the University of California San

Francisco. He is an expert in the management of urinary stone

disease and has made numerous contributions to both the fun-

damental understanding of urolithiasis as well as advancing

the standards of care for patients with the disease. In addition,

he has been a pioneer in minimally invasive surgical tech-

niques, neural modulation of voiding dysfunction, and holds

multiple patents with medical as well as nonmedical applica-

tions.

Dr. Stoller received his undergraduate degree from the Uni-

versity of California at Berkeley and medical degree from the

Baylor College of Medicine. His surgical and urologic training

was obtained at the University of California San Francisco and with a fellowship at the University

of New South Wales in Sydney, Australia.

MAXWELL V. MENG

Dr. Meng is currently Assistant Professor of Urology at the

University of California San Francisco. He received his training

in urologic surgery, laparoscopy and endourology, and urologic

oncology at UCSF. Prior to this, he studied biochemical sciences

at Harvard College and received his medical degree from the

Johns Hopkins School of Medicine.

His primary areas of interest are minimally invasive surgery,

urologic cancers, and the combination of the two disciplines.

In addition, he is investigating prostate cancer biomarkers and

the utility of decision analysis for a variety urologic questions.

Dr. Meng has received numerous teaching awards and is

actively involved with the American Urological Association

and American College of Surgeons.

BACKGROUND

From: Current Clinical Urology, Urinary Stone Disease:

A Practical Guide to Medical and Surgical Management

Edited by: M. L. Stoller and M. V. Meng © Humana Press Inc., Totowa, NJ

Stone Nomenclature and History

of Instrumentation

for Urinary Stone Disease

Viraj A. Master , MD, Maxw ell V. Meng, MD,

and Marshall L. S toller , MD

CONTENTS

INTRODUCTION

NOMENCLATURE OF STONES

HISTORY OF INSTRUMENTATION

REFERENCES

Key Words: Instrumentation; nephrolithiasis; nomenclature; stones.

“The physicians…can defend themselves when unfortunate, but if we lithotomists have

a mishap, we must run for our lives”

–Pierre Franco, 16th century itinerant lithotomist

INTRODUCTION

Urinary stone disease has afflicted mankind for millennia. The oldest renal stone on

record was described by Shattock in 1905 and was found in an Egyptian mummy in a

tomb dating to approx 4400 bc (1). This 1.5-cm calciferous calculi lay beside the first

lumbar vertebra. The description of urinary stones has been a process of intense scien-

tific investigation culminating in a burst of activity in the 19th century, when essentially

all urinary stones seen commonly today were described and named. The first part of this

chapter addresses some history that underlies the current names we use for urinary

calculi.

The treatment of urinary stones has been the story of heady success, incorporating

numerous advances in engineering, materials science, optics, physics, and, above all, the

sheer inventiveness in trying to treat a pervasive disease. The second part of the chapter

highlights some of the work that has gone on in the developing instrumentation applied

4 Master, Meng, and Stoller

to urinary stone disease, with particular emphasis on early instrumentation. Not every

advance in instrumentation is reported owing to space constraints.

NOMENCLATURE OF STONES

The word “crystal” is derived from the Greek work krystallosus, which means “ice”

and is used to refer to the solid phase of substances having a specific internal structure

and enclosed by symmetrically arranged planar surfaces. The Latin word calculus

means “pebble”. The crystalline constituents of urinary calculi in the human are varied.

Some of these occur geologically, whereas others are found only in the animal kingdom.

A subset is found in human beings. This chapter reviews fascinating, previously pub-

lished work regarding the nomenclature that underlies stone disease. The reader is

especially directed to recent work by Luesmann and a comprehensive mineralogy web-

site maintained by the Mineralogical Society of America. (http://www.mindat.org/ and

http://www.minsocam.org/) (2).

Although stone disease has been documented in ancient mankind (3) and indeed was

avidly investigated by physicians and surgeons thousands of years ago, much of the

scientific analysis that rigorously investigated and accurately determined the compo-

nents of urinary stone disease was carried out only within the past 200 years.

Whewellite CaC

· H

Calcium oxalate monohydrate, also known as whewellite, and occasionally synony-

mous with oxacalcite, is named after Professor William Whewell of Cambridge,

England (Fig. 1). William Whewell (1794–1866) was one of the most important and

influential figures in 19th-century Britain. Whewell, a polymath, wrote extensively on

numerous subjects, including mineralogy, geology, mechanics, astronomy, political

economy, theology, and architecture, in addition to his works that remain the most well

known today, those in philosophy of science, history of science, and moral philosophy.

In his own time his influence was acknowledged by the major scientists of the day, such

as Charles Darwin and Michael Faraday, who frequently turned to Whewell for philo-

sophical and scientific advice, and, interestingly, for terminological assistance. Whewell

invented the terms “anode,” “cathode,” and “ion” for Faraday. On the request of the poet

Coleridge in 1833 Whewell invented the English word “scientist”; before this time the

only terms in use were “natural philosopher” and “man of science.” Interestingly,

Whewellite was first described by Henry James Brooke (1771–1857), a London wool

trader and amateur mineralogist, who also discovered brookite. At Brooke’s time, min-

eralogy nomenclature forbade individuals from attaching their names to two minerals.

Whewellite is extremely rare in nature. It is known to occur in septarium nodules from

marine shale near Havre, MT, with golden calcite at Custer, SD, and as a fault filling with

celestite near Moab, UT. It is found in hydrothermal veins with calcite and silver in

Europe, and it often occurs in association with carbonaceous materials like coal, particu-

larly in Saxony. It is one of the most common kidney stone minerals, however, where it

typically occurs as small, smooth, botryoidal to globular, yellow-green to brown, radi-

ally fibrous crystals and is traditionally hard to fragment, as is well known to urologists.

Weddellite CaC

· 2H

Calcium oxalate dihydrate, also known as weddellite, is named for the Weddell Sea,

off Antarctica. The Weddell Sea is named after James Weddell, a great explorer, who

Chapter 1 / Stone Nomenclature and History 5

explored the most southerly portion of Antarctica in the early 19th century. There,

millimeter-sized crystals were found in bottom sediments in the 1930s, and the mineral

was named for the region in 1942 (4). The sharp yellow crystals that urinary weddellite

forms are often much larger than that however. The yellow crystals are commonly

deposited on the outer surface of a smooth whewellite stone. Like whewellite, weddellite

is a calcium oxalate. They differ in the amount of water that is included in their crystal

structures, and this gives them very different crystal habits. Occasionally, weddellite

partially dehydrates to whewellite, forming excellent pseudomorphs of grainy whewellite

after weddellite’s short tetragonal dipyramids.

Struvite MgNH

· 6H

Magnesium ammonium phosphate hexahydrate, also known as struvite, is credited to

Heinrich Christian Gottfried von Struve (1772–1851). Struve, also known as Baron von

Struve, was a Russian diplomat and naturalist, who lived in Germany. His scientific

interests included geology and mineralogy. The name struvite was coined in his honor

in 1845 by Georg Ludwig Ulex, a Swedish geologist. Before that time, magnesium

ammonium phosphate was sometimes referred to as guanite because the mineral was

detected in bat guano. However, from the clinical realm, the scenario of the combination

of phosphate stones with alkaline, ammoniacal urine and putrefaction was recognized by

Marcet earlier, in 1818. Certain dogs, especially Dalmatians, can produce remarkable

large, smooth, milky-white tetrahedrons of well-crystallized struvite.

Fig. 1. Professor William Whewell, for whom whewellite is named, was professor of mineralogy

and long-time master of Trinity College in Cambridge, England.

6 Master, Meng, and Stoller

Newberyite MgHPO

· 3H

Magnesium hydrogen phosphate trihydrate, also known as Newberyite, is named for

James Cosmo Newbery (1843–1895). Newbery, who was also known as Newberry, was

a 19th century Australian geologist and mineralogist, who did extensive work in the

Australian outback. He was the curator of the Melbourne Museum in the late 1800s.

There is an Aboriginal community named after him in Western Australia. Newberyite

is rare in kidney stones. Newberyite was first identified as a crystalline component of a

kidney stone in 1956 (5). When it does occur, it often occurs as tiny isolated globular

crystals on the surfaces of apatite–struvite stones. This probably reflects an alteration of

struvite to newberyite, or perhaps a change of conditions to more acidic solutions.

Apatite Ca

(PO

) · 6H

Hydroxyapatite, or hydroxylapatite, also known as apatite, is named from the Greek

word apatao meaning “I am misleading,” in allusion to its similarity to other more

valuable minerals such as the gems peridot and beryl. Apatite is a common mineral in

nature. Chemically it is a complex calcium phosphate with varied, attached molecules

of hydroxyl (OH), fluorine (F), and sometimes other elements. Apatite is the fundamen-

tal mineral component in bones and teeth, and when apatite has fluorine in its crystal

structure, it is stronger. This is why fluorine is added to water and toothpaste. In kidney

stones, the hydroxyl group is predominant, and carbonate (CO

) substitutes for some of

the phosphate, making a mineral that is relatively poorly crystallized. Apatite often

forms the nucleus on which other urinary minerals are deposited. Apatite is widely found

as a white powdery mineral deposit and crystallized apatite has been extensively used

for fertilizer. Transparent varieties of a fine color are sometimes used for gems, although

these are soft gemstones and not very valuable.

Brushite CaHPO

· 2H

Calcium hydrogen phosphate dihydrate, also known as brushite, was named in 1864

by G.E. Moore, in honor of George Jarvis Brush (1831–1912). Brush, something of a

child prodigy, first became interested in mineralogy at the age of 15 while attending

school in Connecticut. In 1855, Brush was elected full professor of metallurgy at the

recently established Yale Scientific School. Brushite is a calcium phosphate compound

that is very similar to the common mineral gypsum (calcium sulfate), which itself is

widely used in sheetrock for home construction. Brushite is found as a common cave

mineral in guano deposits and in phosphorites formed at low pH (acidic) by reaction of

phosphate-rich solutions with calcite and clay. It is a soft, silky mineral, usually honey-

brown and showing a fine radial fibrous structure.

Whitlockite Ca

(PO

)

Tricalcium phosphate, or whitlockite, was named in 1940 for Herbert Percy Whitlock

(1868–1948). Whitlock was a 20th century American mineralogist and curator of the

American Museum of Natural History in New York City. Whitlockite is very rarely

found in the urinary system and is usually found in prostate stones. It is a calcium

phosphate with small amounts of magnesium, Ca

(Mg,Fe)H(PO

)

, and its occurrence

may be stabilized by trace amounts of zinc, which perhaps accounts for its predilection

for the prostate gland, which has a relatively high zinc content. The mineral is a resinous,

brown material.

Chapter 1 / Stone Nomenclature and History 7

Lesser Known Minerals and Stones Without Eponyms

Some of the other minerals that occur extremely rarely in kidney stones include

monetite (calcium phosphate), calcite (calcium carbonate), aragonite (calcium carbon-

ate), and hannayite (magnesium phosphate). The chemical constituents of urinary cal-

culi were first determined with uric acid stones. It was originally called the acid of

calculus, or lithic acid (from the Greek, lithos, meaning stone), and was first isolated

from the urine in 1776 by Karl Wilhelm Scheele (1742–1786). Scheele was a conun-

drum, who had very little formal schooling and no training at all in science, yet was a

prodigious chemist, characterizing tartartic acid, murexide dye, and other substances.

Even more significant than his contribution to stone disease, he characterized oxygen in

1771, two years before Priestley, but was unrecognized for his discovery, which he

called “fire air” (6). Ostensibly, he was an apothecary, but used all of his time in scientific

experimentation and actually is believed to have died young because of his constant

exposure to toxic vapors from his experiments. The uric acid stone was renamed “acide

urique”

by Antoine François de Fourcroy (1755–1809) and Nicholas Louis Vauquelin

(1763–1829) in 1799 (7).

Cystine was first isolated from a urinary calculus in 1810 by Wollaston, who also

demonstrated it to be the first known amino acid (8). William Hyde Wollaston (1766–

1828) was, like Whewell, another true intellectual giant. Although he was formally

trained as a physician, he had broad-ranging insightful interests in chemistry, mineral-

ogy, crystallography, physics, astronomy, botany, physiology, and pathology and pub-

lished notable scientific advances in all of these fields. He was recognized for his

achievements by being elected President of the Royal Society. His secret method of

purifying platinum enabled financial independence from medicine in 1800, so he could

devote his time to scientific interests.

HISTORY OF INSTRUMENTATION

“Instrument” is defined by the Merriam-Webster dictionary as “a means whereby

something is achieved, performed, or furthered.” The discussion of instrumentation in

the treatment of urinary stone disease generally can be seen as an orderly progression

from potions and prayers to external treatments (bathing or drinking in healthful waters)

(9), to minimally invasive solutions (catheterization), to maximally invasive solutions

(surgery), back to minimally invasive solutions (endoscopy), and finally back to oral

“instruments” (medications and fruit juice) (10). Another way of viewing the history of

instrumentation for stone disease is a development of palliative (catheterization,

cystolithotomy), to diagnostic (cystoscopy), to destructive (nephrectomy for stone dis-

ease and the sequelae of stone disease), to curative (stone removal), and finally to

preventative treatments. This section highlights some aspects of the development of

instrumentation as applied to urinary stone disease. Table 1 lists these major events along

with some other contextual events in urology.

The ancient Egyptians removed urinary tract stones by dilating the urethra and suck-

ing out the stones. Sir Eric Riches described the procedure as follows:

“The urethra was dilated by a wooden or cartilaginous cannula as thick as the thumb

pushed in with great force alternating with blowing down the urethra; the stone was

pressed down into the perineum by the fingers in the rectum until it could be reached

from the urethra or sucked out by the mouth (11).”

8 Master, Meng, and Stoller

Table 1

Important Dates in Innovation and Instrumentation in Treatment of Urolithiasis

1500 BC The Ebers Papyrus was written. A systematic classification of remedies and medicines

used in ancient Egypt. It records the use of ‘bread in a rotten condition’ to treat bladder

diseases.

1000

BC Vesicolithotomy first described by Susruta of India.

460

BC Hippocrates born. He recognized the dangers of bladder stones and initiated the analysis of

urine by inspection and tasting.

BC The Greek physician Celsus was born. He wrote De Medicina and clearly described the

presence and symptoms of calculi, urologic surgery, insertion of a catheter, and extraction

of the stone with a lithotomy scoop.

129

AD Galen, the Roman physician, was born in Pergamum, Asia Minor.

936 AD Abucacis born near Cordoba. The greatest Islamic surgeon of the Middle Ages. He wrote

At-Tasrif, in which surgical procedures for bladder stones were described.

1000 Avicenna recommended insertion of a louse into the urethral meatus of patients with urinary

retention and this method was used for many centuries.

1535 Santo De Barletta Mariano born. An Italian surgeon who described the perineal median

operation for stone in the bladder.

1556 The suprapubic cystotomy procedure was first performed by French surgeon Pierre Franco.

1688 William Cheselden born. Chief surgeon at St. Thomas’ Hospital, London, who did extensive

studies in lithotomy.

1742 Robert Whytt published a paper on the possibility of dissolving bladder stones with lime

water and soap injections, and wrote a small book on the subject in 1752.

1795 Philip Syng Physick, the father of American surgery, was the first to perform a urethrotomy

or internal longitudinal incision.

1804 Phillip Bozzini invented a cystoscope for the bladder.

1879 Max Nitze, a German urologist, developed a lens system for the cystoscope.

1810 Cystine, the first amino acid described, was isolated from urinary calculi by an English

physician and chemist, Wollaston.

1815 James Archibald Jacques was born. He invented the first soft urethral catheter (Jacques

catheter) while production manager of a London rubber mill.

1822 The method of bruising a urinary stone with surgical instruments (lithotrity) was first

practiced.

1824 Civiale invented the definitive lithotrite.

1850 Ureteric catheterization was first performed in a woman by English surgeon Sir John Simon.

1852 Achille Etienne Malecot born. A French surgeon who designed a large-bore suprapubic

urinary catheter (Malecot catheter).

1860 The Hospital for Stone in London was opened.

1871 First planned nephrectomy for renal stones by Simon in Heidelberg.

1874 Daniel Joseph McCarthy born. New York urologist who designed a panendoscope, prostatic

electrotome, and several other instruments.

1877 First electrically lit cystoscope was devised by Berlin urologist Max Nitze.

1878 Rank Seymor Kidd born. London urologist who designed an operating cystoscope (Kidd

cystoscope) with an electrode.

1879 Hans Christian Jacobaeus born. Sweedish internist who used a modified cystoscope to

perform cautery division of pleural adhesions that led directly to the development of the

thoracoscope and other similar instruments.

1880 A procedure for nephrolithotomy, in which the renal stone was removed through a lumbar

incision, was performed by Sir Henry Morris of London.

Chapter 1 / Stone Nomenclature and History 9

Table 1 (Continued)

Important Dates in Innovation and Instrumentation in Treatment of Urolithiasis

1883 Henry Jacob Bigelow of Harvard modified Civiale’s lithotrite to crush larger and heavier

stones. He removed the fragments with a special metal catheter, to the outer end of which

was attached a rubber bulb evacuator with a glass container below to receive the fragments.

1886 Operative treatment for hydronephrosis was performed by Friedrich Trendelenburg of

Germany.

1887 Nitze’s cystoscope was fitted with Edison’s electric light by both Hartwig of Berlin and

Leiter of Vienna.

1890 Urology became a separate study course from general surgery, and the first professor of

urology was Guyon in Paris.

1893 The catheterization of male ureters was first done by James Brown of Johns Hopkins

Hospital.

1895 Early diagnosis of stone disease became possible after the discovery of X-rays, and in 1896

Mcintyre of Glasgow visualized a kidney stone with this method.

1900 Dilatation of the ureteral orifice as treatment for ureteric calculi was first performed by

Baltimore urologist H. W. Kelly.

1901 Kelling performs laparoscopy by introducing Nitze cystoscope directly through the

abdominal wall.

1904 Hugh Hampton Young, a prominent American urologist, among many other inventions,

devised new cystoscopes.

1906 The radiological method of visualization of the renal tract (pyelography) was introduced by

Alexander von Lichtenberg of Germany.

1912 Rigid ureteroscopy (unplanned) first performed by H. H. Young.

1921 Radiological visualization of the kidneys by injecting air into the retroperitoneal space

(retroperitoneal pneumatography) was devised by Rossentein and Carelli.

1929 Intravenous urography was introduced by German-born American urologist, Moses Swick.

1933 American urologist, Fredric E. B. Foley uses a double-lumened retention catheter with a

balloon on the end to keep it in the bladder.

1933 A technique for recording internal body images at a predetermined plane using X-rays

(tomography) was described by German physician, D. L. Bartellnk.

1933 Uroselectan, an agent in urography, was introduced by Moses Swick.

1954 Fiberoptic endoscope rod lens design is published in Nature by Harold Hopkins, a British

optical physicist.

1955 Percutaneous nephrotomy is described by Goodwin.

1960 Fuller Albright noted the association between renal calculi and hyperparathyroidism. He is

considered the father of endocrinology in America.

1961 Development of Nd:YAG. solid state laser.

1964 Flexible ureteroscopy described by Victor F. Marshall.

1967 Open ended silicone tubing used to bypass ureteral obstruction, described by Zimskind.

1972 Ultrasonic device to fragment kidney stones without causing bleeding (lithotripter) was

invented by a Munich group including Chaussey and Eisenberger.

1976 Percutaneous pyelolithotomy described by Fernstrom.

1978 Double J ureteral stent is described by Finney.

1979 Retroperitoneoscopy for ureterolithotomy.

1980 First patient treated with SWL using Dornier HM-1 lithotripter.

1986 A tiny television camera was added to the modern laparoscope.

1988 Ureteral lithotripsy with pulsed laser by Dretler, Wickham, and Segura.

1990 Electrohydraulic lithotripsy described by Denstedt and Clayman.

1991 Laparoscopic nephrectomy by Clayman.

1992 Swiss lithoclast described.