Maximilian Carl-Fridrich Nitze (1848–1906) was a general practitioner who thought that if an instrument could be introduced with ease, minimal pain, and relative safety that the endoscopes must be smaller [34] (Fig. 2.2d). His idea was to place lenses into the tubes at prescribed distances to focus the image at an ocular. In addition, his early version used a platinum wire in a glass jacket with water cooling methods. He began clinical investigations with this cystoscope in 1877. By 1879, Nitze’s design team was aware of Edison’s invention of the filament globe and they immediately miniaturized it to fit into the tip of the cystoscopes [46]. But Nitze’s reputation not only included his brilliance and dedication to the development of the cystoscope, he was also well known for his dark side, biting sarcasm and intolerance for any modifications that were not his own. In telling statements by Hugh Hampton Young, the fifth President of the A.U.A in 1908, “And I decided to go to Berlin for study and experience. I spent two months at the clinic of Dr. Leopold Casper who had devised the most practical cystoscope for ureter catheterization. It was not difficult to learn to use his instrument, and I profited greatly by his lectures and the large number of cases I saw at his clinic. Nitze had devised a retrograde cystoscope with a complicated system of lenses and a mirror to look backward and view the neck of the bladder. He had never been successful, because the mirror became clouded. Working with a lens-maker, I constructed a four-sided prism with which we could replace Nitze’s mirror. A cystoscope was constructed with a prism in place gave an excellent retrograde view of the bladder. Casper was delighted that I had been able to improve an instrument made by Nitze. When I proposed to take it to the father of cystoscopy, Casper said: ‘Don’t do it. He will insult you.’ Nitze had broken with almost everyone with whom he worked. He brought lawsuits against Leiter, who constructed his first cystoscope, Hartwig who made several others for him, and Heinemann who had also worked with him. When Casper brought out his catheterizing cystoscope, Nitze had sued him for a large sum” [47]. The first actual use of the Edison incandescent lamp for cystoscopic application was by Newman (Glasgow, 1883), followed by Nitze (1887), Leiter (1887), and Dittel (1887) [25]. Modern methods of cystoscopic development and utilization would now follow the pathway to its current utilization in urology- the extension of the urologist, and now often times by physician-extenders as a diagnostic and therapeutic in everyday practice (Fig. 2.2e). Nitze stated, “The writing presents only a framework, the complete construction of which will be accomplished over the course of years through the joint work of numerous researchers. We are dealing here with a large new field of work which assuredly harbors untold treasures of knowledge” [46].

The modern instrument was now only steps away from both development as well as utilization and innumerable workers in the field of urology entered into a frenzied developmental cycle of creation and improvement utilizing now the major manufacturers of instruments in Germany, France, England and the United States. Just following the turn of the twentieth century urology as a specialty was ready for full fledged speciality status. Rapid advances in radiology improved upon the ability of X-rays to image the urinary tract. Listerian antiseptic methods of surgery allowed the virtual unlimited potential of surgery to intervene on the entire genito-urinary system. Anesthesia made tremendous strides for patient management during ever more complex surgical interventions. Now the full potential for the cystoscope was poised to bring the next phase to the complex pathway for the development of modern urology. We will utilize one relatively obscure hospital, not Johns Hopkins, to make this point about the potential of the cystoscope and its profound impact on the direction of urology- the Mount Sinai Hosptial in New York City [48]. This was originally the Jew’s Hospital founded in 1852 on West 28th Street by Israel Moses and Alexander Mott. No coincidence was the fact that one of the early specialists in New York City, William Holme Van Buren married Mott’s daughter and became one of the first urinary specialists at Bellvue Hospital where F. Tilden Brown would eventually emigrate. A dermatology/venereal disease clinic began at Mt. Sinai in 1890 with Sigmund Lustgarten and Hermann Goldenberg who became chief of urology, when this service was started in the Department of Surgery in 1895 [49]. William Fluhrer took the reigns after joining the Hospital in 1880. The chief of surgery was Howard Lilienthal, himself to bcome famous also practiced cystoscopy. George Brewer was the first to use rubber gloves in surgery in 1899 at Mt. Sinai. Hermann Goldenberg utilized the cystoscope to diagnose and treat urethral polyps [49]. F. Tilden Brown did his internship at Mount Sinai but Leo Buerger became the young urologist of note by 1908, considered the protégé of Emanuel Libman the premier clinician of his time in New York [50, 51]. Buerger developed his own modified cystoscope in 1908 and began extensive investigations and writing from this time onward [51]. Edwin Beer joined the team and developed a pediatric cystoscope in 1911 and then went on to become chief as well as develop new methods of treating bladde cancer by electrodessication and then resection [52, 53]. Maximillian Stern was appointed in 1910 and developed the Stern-McCarthy resectoscope by 1926. He was the Chief of Urology from 1911 to 1937 [54]. Moses Swick joined the house staff in 19924 after working in Berlin on fellowship funds gifted by Libman to work in Berlin with von Lichtenberg and modern urinary tract radiology developed following the perfection of intravenous pyelography. By the time the Hospital upgraded its primitive cystoscopy suite in 1933, 1800 cystoscopies were performed annually [48]. In 1939 this increased to 2900. In 1935 the urology group was performing about 1000 transurethral prostate resections annually [15]. Modern urology had come into existance.

The role that cystoscopy was about to have can also be seen by reference again to Hugh Young, who describes the use of the cystoscope in clinical practice at Johns Hopkins, “Before long the American Surgical Society met at the Johns Hopkins Hospital. I was invited to appear before the meeting in the amphitheater and to catheterize the ureters of a male patient. Dr. Howard A. Kelly was to do the same in a female. Kelly’s patient, under deep anesthesia, was brought in; she was in the knee-chest position. He introduced his cystoscope, which was an open tube with external illumination from a head mirror, but without lens system. The bladder was distended with air; Dr. Kelly quickly inserted a catheter first up one ureter and then up the other amid the applause of the audience. I was nervous when I brought in my patient, who was not anesthetized. Introducing Casper’s cystoscope, I too had little difficulty finding the ureters and promptly catheterized them. The audience had their watches out. The contest was close, and each of us required only two or three minutes” [47].

Throughout this time, urologists have managed to extend the limits of visualized access to the recesses of the urinary tracts though early cystoscopes were expensive and did not give an adequate view (Fig. 2.3a). There have been improvements in optical imaging systems, both rod-lens and fiber optic. Illumination systems provided unprecedented color and brightness secondary to halide lamps. Minimization of the trauma of access is the result of smaller and smaller endoscopes. Finally, by moving the surgeon’s eye away from the ocular, video camera systems allow the urologist the freedom to control complex endoscopic interventions. Electronics is now the key to many of these newer innovations. The charged coupled device was invented by George Smith and Willard Boyle at the Bell Laboratory on October 17, 1969 for electronic video recording. This was rapidly applied to fiber optic technology initially by Welch Allyn in 1983. Japanese makers Olympus, Fuji and Pentax all introduced video-endoscopy in the early 1980s [55]. The digital cystoscope that are now almost universally utilized by many modern urologists makes the performance of this task even easier on our patients. Though initially perceived as having a longer learning curve than rigid cystoscopy, the fact that skilled secondary medical providers are now capable of performing some routine cystoscopic tasks probably represents the future. Virtual reality cystoscopy is undoubtedly possible by newer imaging modalities, but the lower urinary tract remains complex and there is some distinct probability that some sort of direct imaging system might still need to be deployed for compete visualization for some time to come [56].