Endourology

Endourology in Türkiye is a collection of advanced technology-based minimally invasive surgeries in which natural openings or millimetric access points are used instead of large surgical incisions in the treatment of kidney stones, benign prostate enlargement, and urological cancers. Current clinical practices minimize patients’ recovery times while preserving bodily integrity through methods such as HoLEP, ThuLEP, RIRS, and robotic surgery. Türkiye has become a global authority in this field, particularly by combining technological innovations such as the Thulium Fiber Laser with evidence-based protocols. Thanks to high-resolution imaging systems, this specialty brings surgical interventions to a safer, bloodless standard with high success rates.

What Is Endourology and Which Health Advantages Does It Offer Patients?

In its most basic explanation, endourology is the treatment of diseases involving the urinary tract and kidneys from within, entirely with the help of special camera systems and very thin instruments, without creating large incisions in the body. To visualize the situation, you can think of a home’s plumbing system. In the past, to find a blockage or leak in the pipes, it was necessary to break walls, remove tiles, and create a large construction area. Today, however, plumbers can identify the problem exactly where it is with small cameras sent through the pipe and open the blockage from the inside without breaking the wall at all. The procedure performed in minimally invasive kidney, bladder, and prostate surgeries is similar to this.

These procedures, which are performed by entering through the body’s natural channels (the urinary opening) or by opening tiny holes on the skin only the size of a pencil tip, do not damage the patient’s anatomical structure, muscles, or tissues. Since the patient’s problem is resolved directly at its source and with minimal trauma, the recovery process generally accelerates considerably. In open surgeries, the inner parts of the body come into contact with air and the external environment, so the risk of infection is higher; however, this risk is very low with minimally invasive methods. Patients generally get back on their feet on the day of surgery, are discharged the next day, and can return to their normal daily lives and jobs within a few days.

The most prominent advantages offered to patients by minimally invasive surgical methods are:

• Fast recovery and early return to daily life
• Minimum pain and reduced need for painkillers
• Low risk of infection and bleeding
• Short hospital stay
• Aesthetic appearance (Scarless or very small-scar surgery)

How Has the Historical Development of Endourology Practices Progressed in Türkiye?

The development of urology practice in Türkiye has progressed simultaneously with the technological revolution in the world and at a remarkably proud pace. When we take a short journey back in time toward the beginning of the 2000s, we can see that traditional open surgeries were still being performed at very high rates in hospitals in our country for the treatment of very common diseases such as benign prostate enlargement or kidney stones. Research conducted at that time revealed that open surgery rates had fallen to very low levels in northern European countries, while they were still high in our country. This situation demonstrated the need to renew the technological infrastructure and train physicians in the use of new equipment.

Over the past twenty years, a surgical revolution has taken place in Türkiye thanks to intensive training programs organized by medical associations and specialty organizations. The world’s most advanced laser devices, robotic surgery platforms, and endoscopic towers have been installed in hospitals across the country. At the point reached today, physicians in Türkiye not only use these technologies at world standards but also guide the international medical literature with new surgical techniques they have developed themselves. Many procedures that once required patients to remain hospitalized for days have now become more routine, standardized, and same-day minimally invasive surgeries.

How Are Urinary Tract Diseases Diagnosed Within the Scope of Endourology?

Correct treatment is possible only with a precise diagnosis that leaves no room for doubt. The greatest strength of minimally invasive urological methods is that they not only provide treatment but also allow the inside of the urinary tract to be viewed live on high-resolution screens. Although advanced MRI or ultrasound devices show the inside of the body very well from the outside, directly observing a millimetric change on the inner surface of an organ provides greater diagnostic certainty.

Cystoscopy is one of the leading methods used for this purpose. During cystoscopy, the inside of the bladder is examined by entering through the urinary canal with a very thin fiber-optic camera that has a light source at its tip. This examination is of great importance for patients who see blood in their urine or are suspected of having bladder cancer. If a suspicious redness or swelling is seen while viewing with the camera, a tissue sample (biopsy) can immediately be taken from that area with the help of tiny forceps sent through the same instrument. When it is necessary to examine the inside of the kidneys, nephroscopy is performed by entering the kidney through a small tunnel opened from the back. In this way, stones, tumors, or congenital strictures inside the kidney are detected immediately.

The main endoscopic devices used during diagnosis are:

• Cystoscope (For bladder examination)
• Urethroscope (For urinary canal examination)
• Nephroscope (For examination inside the kidney)
• Ureterorenoscope (For examination of the canal between the kidney and bladder)

Which Minimally Invasive Methods Are Used in Kidney Stone Treatment With Endourology?

Kidney stones are a health problem that is very common in our society because of our country’s geographical location, climate, and dietary habits, and they can cause patients excruciating pain. In the past, to remove a large stone, a huge incision was made in the patient’s flank, the muscles were cut, and the kidney was split in two to remove the stone. This caused serious damage to the kidney. Today, however, completely personalized minimally invasive methods are used in kidney stone treatment according to the size, location, and hardness of the stone.

Percutaneous Nephrolithotomy (PNL) is the standard method especially in the treatment of large stones larger than two centimeters that completely fill the kidney. In this method, a tunnel only as thin as a pencil is opened from the patient’s back toward the kidney. Thanks to cameras sent through this tunnel, the stone is located, broken inside with special fragmentation devices, and removed through the same opening. After the procedure is completed, the tiny hole in the back is closed with one or two stitches. Since the patient’s kidney does not experience major surgical trauma, the recovery process is extremely fast.

The techniques applied according to the diameters of the tunnels opened with the development of technology are:

• Standard PNL
• Mini PNL
• Ultra-mini PNL
• Micro PNL

How Is a Kidney Stone Broken With a Laser Through the Urinary Canal in Endourology Practice?

The most delicate method in kidney stone treatment, in which no incision is made anywhere on the body and the risk of bleeding is close to zero, is Retrograde Intrarenal Surgery ((RIRS or Flexible URS). This method uses the body’s natural urinary tract channels entirely. Extremely thin camera-equipped instruments with tips that can bend and curve in every direction are inserted through the urinary opening, passed through the bladder, and advanced through the thin canal extending to the kidney (ureter), entering the kidney’s chambers one by one. When the stone is located thanks to the camera at the tip of the instrument, it is struck and broken with a laser wire sent through the instrument.

The real secret of the procedure lies in the laser technology used. Traditional lasers divide the stone into small pieces, and these pieces then need to be removed with special baskets (tiny nets). However, new-generation devices such as the Thulium Fiber Laser (TFL), which have begun to be used in recent years, turn the stone into a cloud of dust by pulverizing it rather than merely breaking it. In medical terminology, this procedure is called “dusting.” When the stone becomes dust, the patient can pass this sand naturally without any pain. The firing frequency of TFL technology helps even hard stones to be turned into dust in a very short time. Moreover, the risk of the stone escaping into hard-to-reach corners of the kidney during this procedure is also significantly reduced.

What Are the Endourology and Laser Methods Used in the Treatment of Benign Prostate Enlargement?

Prostate enlargement, which is a natural part of the aging process in men, is a condition that compresses the urinary tract, interrupts sleep at night, causes difficulty urinating, and seriously reduces quality of life. For many years, methods in which the prostate was scraped away piece by piece from the inside (TUR-P) or removed through open surgery if it was very large were used in the treatment of this disease. However, with the discovery in recent years of the remarkable effects of laser energy on tissue, methods called HoLEP (Holmium Laser Enucleation of the Prostate) and ThuLEP (Thulium Laser Enucleation of the Prostate) have come to the forefront.

To understand these laser methods, we can compare the prostate to a thick-skinned orange. When the prostate enlarges, it is actually the fruit portion inside that orange that grows and compresses the urinary canal running through the center. In older scraping methods, the inside of the orange was hollowed out with a small spoon. However, some of the fruit always remained behind, and years later that tissue could grow again. In the HoLEP and ThuLEP methods, the enlarged fruit portion is completely separated and peeled away from its shell (capsule) at the exact boundary using laser energy. This large tissue, pushed into the bladder, is then reduced in size with a special device called a morcellator and removed with fluid. In this way, the possibility of tissue remaining behind is minimized.

What Does the Use of Endourology and Laser in Prostate Surgeries Provide the Patient?

The use of laser in prostate surgeries offers advantages that significantly support the patient’s recovery process and quality of life. In particular, the tissue penetration depth of the Thulium laser used in the ThuLEP method is approximately one-quarter of a millimeter. In other words, the laser creates a millimetric effect only on the surface it touches and does not penetrate deeper tissues. The greatest advantage of this is that it prevents the muscles responsible for urinary continence (sphincter) or the nerves controlling sexual functions, which pass immediately beneath the prostate, from being damaged by heat.

In addition, bleeding control is highly successful with these laser methods. While cutting the tissue, the laser simultaneously seals the ends of the blood vessels. This feature provides remarkable safety for elderly patients, those with heart disease, and patients who must use blood-thinning medications. Since laser devices do not cut tissue directly with electric current, having a pacemaker generally does not constitute an obstacle to this surgery. The time the patient spends with a catheter placed in the urinary tract after the procedure is also very short; the catheter is usually removed after one day, and the patient begins to urinate comfortably.

The main benefits that laser prostate surgeries provide to patients are:

• Bleeding control and high safety
• Low risk of recurrence
• Short catheter duration
• Preservation of erection and urinary continence functions
• Rapid discharge

Why Is Removing the Tumor in One Piece Important Within the Scope of Endourology in Bladder Cancer Treatment?

Bladder cancer is a common disease, especially associated with smoking, and presents with painless blood in the urine. In the early stages, before the disease has progressed into the deep muscle layers of the bladder, the standard treatment is minimally invasive removal of the tumor through the urinary tract (TUR-BT). In the traditional method, the tumor was scraped away in small pieces with the help of a wire loop carrying electrical current. However, scientific studies showed that fragmenting the tumor inside could cause cancer cells to spill onto and attach to healthy areas of the bladder wall (seeding).

To minimize this risk, a new approach called En-bloc Resection (ERBT) is used today. In this technique, instead of scraping away the tumor piece by piece, it is removed from its root as a single piece and complete mass together with the muscle tissue beneath it, leaving a certain amount of healthy tissue around it. This both prevents cells from spreading around and allows the pathology specialist to see the depth of the tumor much more clearly under the microscope. Knowing how deeply the cancer has invaded is vital in deciding whether the patient will later receive chemotherapy or other treatments.

How Do Endourology and Robotic Surgery Preserve the Kidney in Kidney Cancers?

The greatest goal of modern medicine in the treatment of tumorous masses detected in the kidney is to completely remove the cancerous tissue while leaving the patient’s healthy kidney tissue in place. In the past, the entire kidney was removed even for a small mass, whereas today, “Partial Nephrectomy,” meaning surgery in which only the diseased part of the kidney is removed, has become standard. Keeping both kidneys in place is critical for heart health, blood pressure balance, and avoiding the need for dialysis later in life.

Preserving the kidney as an organ is technically a very challenging surgery because the kidney is an organ with very high blood flow. The bleeding that begins as soon as the tumor is cut and removed must be stopped very quickly with very secure sutures. This is exactly where robotic surgery systems come into play. Robotic arms placed through small holes opened in the patient’s abdomen reproduce, with millimetric precision inside the body, the finger movements made by the surgeon from a console. The robot’s camera displays the area in three dimensions and high resolution, while the arms filter out physiological hand tremor, provide high maneuverability even in very narrow spaces, and facilitate repair of the kidney.

What Comfort Do Endourology and Robotic Surgery Provide in Kidney Canal Strictures?

The urine produced by the kidneys is carried to the bladder through a thin tube system called the ureter. At the point where the kidney joins this tube (Ureteropelvic Junction/UPJ), strictures may sometimes occur because of congenital muscular structure disorders and sometimes because of blood vessels pressing externally on that area. This stricture prevents the urine produced by the kidney from flowing downward, causes the kidney to swell, and over time leads it to deteriorate and completely lose its function.

The surgery performed to open this stricture is called pyeloplasty. Robotic surgery is ideally suited for this operation. Thanks to the extraordinary visual capability provided by the robot, the surgeon clearly sees the narrow area causing the blockage, cuts and removes it, and reconnects the renal pelvis and urinary canal. The watertightness of this suture line is essential for the success of the surgery. The robotic system enables a watertight and wide connection (anastomosis) to be created, completely restoring the patient’s urinary flow to normal. In the past, this surgery required a long incision across the patient’s flank, whereas now the patient regains health through only a few small openings.

What Should Be Considered for Rapid Recovery (ERAS) Before and After Endourology Surgeries?

In minimally invasive surgeries, how the patient is managed before, during, and after the operation is as much a key to success as the surgeon’s technical skill. In this process, known in medicine as perioperative management, meticulous evidence-based protocols are applied. For example, long-term antibiotic use for infection control has been completely abandoned; instead, the risk of bacteria entering the bloodstream is prevented with a single dose of the correct antibiotic administered immediately before surgery. Especially in patients using blood thinners, bridging methods are applied, such as stopping the medication days before surgery and replacing it with injections that are rapidly eliminated from the body, thereby protecting the patient from both bleeding and clot formation.

ERAS (Enhanced Recovery) protocols are applied to accelerate postoperative recovery. In the past, patients were kept without food or water from midnight before surgery. Today, however, patients are given special carbohydrate-containing fluids until a few hours before surgery to maintain high body resistance. After surgery, patients are not asked to remain in bed for a long time; on the contrary, strong but non-sedating painkillers are used to encourage them to get up and walk on the same day.

Some methods applied within the rapid recovery protocol are:

• Carbohydrate loading (Preoperative energy support)
• Early mobilization (Walking after surgery)
• Catheter removal (As soon as possible)
• Fluid management
• Early nutrition

Where Are Endourology Training and Future Technologies Taking Us in Türkiye?

No matter how advanced all these high-technology devices are, they cannot provide treatment on their own; what brings them to life and transforms them into a healing force is the knowledge and experience of the physician using them. Minimally invasive kidney, bladder, or prostate surgeries have a very steep learning curve in surgical training. Looking at a screen and performing millimetric procedures deep inside the body with long instruments in your hands requires very long training periods and repetition.

Various associations and institutions in our country continuously organize training programs using simulation devices, special models, and structured fellowship programs so that specialist physicians can master these challenging techniques perfectly. Young surgeons must actively participate in a certain number of operations and conduct scientific research in this field to receive certification. These strict training standards ensure that patients can access modern, reliable healthcare of the same high quality no matter which city in Türkiye they are in. In the future, the success rates of these procedures are expected to increase further with the more frequent use of tissue-preserving small laser systems and artificial intelligence software that guides the surgeon in operating rooms.

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