Intracorporeal devices have been used over many centuries for removal of stones. This article discusses these methods and their progression to the modern devices that clinicians use for urinary tract stone removal today. Although the basic principles of stone removal have not changed considerably, our understanding of the technology behind these modern methods has resulted in drastic changes in the last several decades.

Egyptian mummies provide us with the first evidence of the endemic problem of stone formation, and there are many accounts of ancient Egyptian treatment methods. The first known method of intracorporeal treatment of stones was created to treat the problem of the bladder stone made of soft struvite. To remove these stones, a hollow reed was placed in the bladder with a diamond or hard rock secured to the end with gum or pitch. By having the patient walk around with the reed in the bladder, the struvite eventually crumbled and was voided. If, however, the stone was made of a harder material, such as calcium oxalate monohydrate or uric acid, then the treatment was less likely to be successful. Even today, as in ancient times, the fragility of a stone often influences the choice of methods of removal of bladder and ureteral stones.

The historical alternative to reed treatment was the method of open cystolithotomy. The suprapubic approach was attempted and abandoned because of frequent peritoneal injury and septic death. With the advent of general anesthesia being centuries away, procedures were done swiftly and with the assistance of several strong men to hold down the patient. This meant that the patient was invariably screaming and performing a Valsalva maneuver during the procedure. The peritoneum then would extend over the space of Retzius, covering the dome of the bladder more anteriorly. Suprapubic incisions caused many peritoneal perforations, and the subsequent occurrence of peritonitis was invariably fatal.

Because the suprapubic approach to bladder stones was a perilous route, an alternative was sought. In ad 30, the Roman physician Celsus described the method of the perineal lithotomy. This method produced a 50% mortality rate and a 50% successful stone removal rate, and the technique virtually was unchanged until the eighteenth century. With the help of many assistants, the sensitive perineum was entered with an incision through to the bladder, and the stone grasped, crushed, and extracted with a variety of forceps. The severity of symptoms must have been extraordinary for patients to subject themselves to this horror and poor odds.

In the eighteenth century there were many itinerant lithotomists throughout Europe, and the prolific and bon vivant writer Samuel Pepys gave a detailed account of his experience with a bladder stone. Having the problem of hematuria and severe pain, he considered the complications of the perineal approach: death; severe bleeding; sepsis; rectal perforation; urinary fistulae; incontinence; and, most importantly to him, impotence. When he could stand the pain no more, he summoned one of the fastest lithotomists in Europe to perform the procedure. Although his fastest lithotomy was reported to be 15 seconds, the procedure was performed in about 30. Pepys lived through the procedure without severe sequelae and, to his delight, retained his potency.<sup>26 Urquhart-Hay D. Samuel Pepys and his bladder stone Br J Urol 1992 ;  70 : 509

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In 1782, Colonel Martin, a physician in India, developed the first modern technique of transurethral treatment of bladder stones. He had a bladder stone that was resistant to the latest treatment, that being intravesical instillation of pigeon guano and lye. Having a thorough knowledge of the perineal lithotomy techniques of the day, he wished to avoid an open procedure at all costs. He devised a file that could be inserted into the urethra. By inserting the file and then leaning forward against a wall, he was able to feel the stone rubbing against the file. By using this file three times a day, he was able to remove the stone and all residual fragments within 6 months.<sup>25 Thornwald J.   The Century of the Surgeon New York: Pantheon Books (1957). 

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The next major advance in stone removal was a wire noose invented in 1813 by a Munich physician named Gruithuisen. A hollow tube was inserted into the bladder, and the stone was held to the end of the tube with the noose while he used a drill to bore a hole in the stone. This method, however, was fraught with problems, including bladder perforation and inability to fragment the stone because the drill bit was too fine.

By 1824, Civiale, a French surgeon, had made some improvements on the original techniques of Gruithuisen. He used a three-prong grasping forceps to grasp the stone firmly, and a screw was pressured into the stone, fragmenting even the harder stones. Practicing his techniques constantly, he became adept at the procedure by placing nuts in his pockets, and used only touch as a guide to locate and fragment them. When using this tactile technique in the bladder, he was able to determine the number and size of stones.

During the ensuing decades, improvements were made to improve the safety of stone removal or to attempt to increase its effectiveness. The two-arm lithotrite was a grasping tool that allowed one to hold and grasp stones. Bigelow invented an evacuator to remove stone fragments. At the Massachusetts General Hospital, with the successful advent of general anesthesia, suprapubic stone removal procedures were able to be performed without Valsalva. Radiograph techniques also aided in the diagnosis and localization of stones. In the early twentieth century the cystoscope was invented, enabling direct visualization of the stone and improving again the safety and efficacy of stone removal. The success rate, however, of removal of bladder stones by intracorporeal methods had improved only marginally during a 100-year period. The devices did enable more surgeons to remove stones, as the learning and skills for these techniques became less demanding.<sup>25 Thornwald J.   The Century of the Surgeon New York: Pantheon Books (1957). 

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One can see that clinicians have many devices at their disposal today for removing stones. The techniques have improved. Urologists have moved from nonvisualization of procedures to direct visualization, and then to indirect visualization with extracorporeal shock wave lithothripsy. The removal of stones has changed forms. Instead of removing bladder stones with an open technique, urologists can treat them using intracorporeal or extracorporeal techniques. Only recently has direct visualization of the ureter and renal pelvis allowed clinicians safely to remove stones from these locations, whereas they were removed for the most part via ureteral lithotomy or pyelolithotomy only a decade ago. The bladder stone is a good example of how technology has enabled clinicians to choose a wider variety of options for stone removal with miniaturized devices. The caution should come from the fact that the stones themselves have not changed. To remove a stone, it must be pulled out or broken, and a stone can be broken with a hammer. The first reinvention of the hammer came with the advent of the electrohydraulic lithotriptor (EHL).