The first laparoscopic renal procedure was performed at Washington University in St. Louis in the late spring of 1990 [1]. This approach was conceived and engineered by Dr. Ralph Clayman. For several years leading up to the event, Dr. Clayman had a laparoscopic set sitting in the corner of his office. Many a resident who sat in the office heard Dr. Clayman opine that someday that equipment would be used to remove a solid organ. They smiled politely although most thought it was an impossible harebrained scheme.

By 1990 laparoscopy had been around for over 80 years [2]. The technique was first introduced by gynecologists for diagnosing pelvic pathology . For over 60 decades, very little interventional work was attempted with this equipment. The available tools were very rudimentary, and allowed for potentially moving ovaries away or placing a clip on the fallopian tube. With the advent of laparoscopic cholecystectomy and advances in the camera technology, the environment was ripe for more advanced intervention [3].

In the late 1970s, Dr. Kurt Semm, a gynecologist at the University of Kiel began developing instruments for intervention [4]. He had some very basic equipment constructed for oophorectomy and myomectomy. In 1982, he performed a laparoscopic appendectomy , and this set off a challenge in surgical culture. For the majority of the twentieth century, surgeons focused on techniques that decreased mortality and morbidity. With these successes came a change in societal thinking and technological advances began allowing focus on addressing secondary concerns with patients such is postoperative discomfort, recuperation, and cosmesis.

A major breakthrough occurred in of 1985 when Erich Mühe performed the first laparoscopic cholecystectomy , in 2 h [5]. Report of this case quickly spread throughout Germany and France, and eventually around the world. Indeed within 2–3 years of its introduction at the SAGES meeting in 1988, laparoscopic cholecystectomy became the preferred approach in the United States.

Laparoscopic cholecystectomy was the accelerant for the development improved manipulative equipment. Instrument companies focused on producing novel devices as well as those that mirrored traditional open instruments. A variety of graspers, dissecting and hemostatic tools were born. On the disposable front, companies worked on developing automated clip systems and staples.

In parallel with instrument development were significant efforts aimed at improving video camera technology . Traditionally, endoscopy was performed via direct ocular vision through a rigid lens. The surgeon would hold a lens to view the abdomen in one hand and operate with a single hand. The development of video chips revolutionized endoscopic surgery. Video cameras allowed images to be viewed on a screen, thus allowing assistant to hold the camera and thus freeing up both the surgeon’s hands to hold instruments. The advent of the laparoscopic cholecystectomy both encouraged and was a product of patient centered surgery. The acceptance of laparoscopic cholecystectomy was astoundingly rapid. The preferred adaptation of this technique was a tour-de-force in patient’s ability to change global clinical care.

In urology through the 1980s, there were also technical revolutions taking place. Up until that point, the management of stone disease was for the most part via open surgical extrication or blind basketing. Advances in endoscopic technology and equipment gave birth to minimally invasive approaches such as ureteroscopy, percutaneous stone removal, and extracorporeal shock wave lithotripsy. There was the birth of minimally invasive urologists known as endourologists. They took very seriously, the patient’s desires to address secondary issues and put tremendous amount of research and innovation into making surgery less of a burden.

One of the young leaders of the Endourologic Society was Ralph Clayman. Ralph was on faculty at Washington University in Saint Louis. Arthur Smith, who many consider one of the fathers of Endourology, had mentored him at the University of Minnesota. Ralph subsequently moved to Dallas as an American Urological Association Cancer Research Fellow, however, his skill in percutaneous stone removal made him more valuable in teaching residents, fellows, and staff modern techniques for approaching stone disease. Following completion of his fellowship, he took a position at Washington University in Saint Louis in 1985.

Dr. Clayman was an incredibly innovative individual. He had come up with a number of novel approaches and devices to improve endoscopy and ureteroscopy. He was very much intrigued by the potential benefits of laparoscopy to urology. He was able to convince Stortz Incorporated to loan him a laparoscopic cholecystectomy set, which he set aside in the corner of his office. To any resident who entered his office, he would regale them of his vision of removing the kidney laparoscopically. Many of the residents including myself dismissed this as fantasy.

In parallel with the events, the University of San Antonio, Texas, recruited Thierry Vancaillie, from Europe who was an expert in gynecologic laparoscopy. He spent some time at a small hospital outside of San Antonio, Southeast Baptist Hospital. One day while he was sitting in the doctor’s lounge, he met William Schuessler, a urologist. Dr. Schuessler was not an academic urologist, but a community urologist. They began talking, and the question came up as to whether there would be utility in performing pelvic lymph node removal for staging patients with prostate cancer. At that time brachytherapy was a common modality for treating prostate cancer and imaging was insufficient to determine if patients had pelvic lymphatic involvement. A minimally invasive method to determine node status was believed to have utility in determining which patients may not benefit from local therapy.

The team embarked on a series of laparoscopic node dissections and presented the technique at the 1990 meeting of the American Urological Association. In the audience was Dr. Ralph Clayman, who now saw that the timing was right to perform a laparoscopic nephrectomy . Upon returning to St. Louis, he assembled a team of individuals to attempt this in the laboratory. Dr. Nathaniel Soper was a young general surgeon, who had been performing laparoscopic cholecystectomies. He gave insight into creation of the pneumoperitoneum and trocar placement. Also, working in the laboratory were myself, a young junior partner of Dr. Clayman, who was just recently out of residency as well as Dr. Sherburne Figenshau, who was doing a year of research in the laboratory with Dr. Clayman.