The 1970s – The Beginning
Surgery in Singapore, in the early seventies, was faced with the twin problems of limited resources and an insufficient number of trained surgeons. Most surgeons practised general surgery and dealt with everything from craniotomies to urethroplasties. Surgery of the genito-urinary system was completely familiar to this generation of surgeons, so much so that even the late Dr Wong Nan Eong, FRACS (Urology), practised general surgery. His training had included transurethral surgery and he performed the first transurethralresection of the prostate gland (TURP) at the Toa Payoh Hospital in 1970. By 1973, he had performed 151 cases and reported this series at the 8th Singapore Malaysia Congress of Medicine. However, he regarded himself as a general surgeon and went on to establish and head the Department of Surgery at Tan Tock Seng Hospital in 1975. He nonetheless had planted the seeds for the development of urology.
The gardeners who tended the young plant were Dr Jimmy Beng and Dr Foo Keong Tatt from the University Department of Surgery. They had both acquired post-fellowship training in urology; Dr Beng in Australia in 1976 and Dr Foo in the United Kingdom in 1977. They were unusual in restricting their practice to primarily urology. Surprisingly, they succeeded; Dr Beng comfortably in private practice and Dr Foo, less so, at the university. Heads of Surgical Departments wielded great power and took a dim view of a separate urological speciality. They identified this as a threat which could lead to the disintegration of general surgery and insisted that general surgeons continue to do urology.
Indeed enterprising general surgeons regarded endourological surgery as a natural extension of their open surgical skills and even bought their own endourological equipment. The visibility provided by the optical systems of the day were poor, often resulting in significant post-operative haemorrhage. House officers would moan whenever a TURP was listed because postoperative instructions for hourly, 2-hourly and 4-hourly washouts for the first 24 hours were the norm.
The 1980s – The Struggle
The sapling of urology struggled to grow in the shadow of the giants of general surgery. Encouraged by Dr Foo, two young lecturers Dr Tung Kean Hin and Dr Tan Eng Choon, made forays into urology. They stayed on, to develop full-time urological practises. Very soon the benefits of transurethral surgery when performed by urologists became apparent, not only to house officers and the blood bank but also to referring physicians. The natural progression towards an independent speciality nevertheless met with great opposition. It was viewed as a heresy of no less a magnitude than that of ENT surgeons who performed thyroidectomy and gynaecologists who performed breast surgery.
It seemed odd to many intrepid general surgeons, accustomed to dealing with the liver, duodenum, great vessels and spleen, that the thin fascia of Gerota was an uncrossable boundary. Many general surgeons, acting purely on principle, refused to move aside. So, whilst cardiothoracic surgery, neurosurgery and plastic surgery had branched off quietly from general surgery in the sixties, urology, even in the early eighties, could not.
The tide turned as international urology led the new wave in endoscopic surgery. The clear advantages of transurethral surgery were acknowledged not only in papersfrom abroad but also at home. Local urologists were quick to learn transureteral surgery, primarily for the treatment of stones. Percutaneous nephrolithotripsy, a fore-runner of minimally invasive surgery, was first performed in 1984 and although difficult, quickly gained acceptance. On its heels, came a technological marvel, the shockwave lithotripter – a machine which could blast stones to smithereens from outside the body, without damage to adjacent tissues. By December 1985, the private American Hospital (now the East Shore) had acquired the Dornier lithotripter and a new era in stone therapy began in Singapore.
Perhaps inspired by this wonderful invention, a group of surgeons with primarily urological practices met and founded the Singapore Urological Association. There were 12 full members and six associate members in the founding group of local and immigrant urologists. The SUA’s purpose was unselfish — to improve the practice of urology for the benefit of patients. The SUA presented its views to the Ministry of Health and the National University of Singapore. Unofficially, a Division of Urology was established within the University Department of Surgery at Singapore General Hospital, under the leadership of Associate Professor Foo Keong Tatt. It received official recognition on 1 March 1987.
When the University Department of Surgery moved to the new university hospital at Kent Ridge, Associate Professor Foo became the first head of the first Department of Urology in Singapore, at the Singapore General Hospital. The Division of Urology was re-established at the National University Hospital (NUH) in 1989, under the leadership of Associate Professor Tung Kean Hin. In view of their common origin, both departments worked closely together. Both parties, with the invaluable assistance of the SUA, persuaded the University to acquire a lithotripter. They shared the lithotripter which was installed at NUH.
The SUA began by organising workshops on transurethral and endourological surgery, often with an international teaching faculty. This served to create an identity for urology in Singapore. It also drew together urologists from the neighbouring countries for the benefit of all. The Association also commenced joint meetings with the College of General Practitioners to update and improve primary urological care (see Diary of Events). These updates covered common diseases thoroughly. Dilemmas in urological care were highlighted through interesting, panel discussions which showed family doctors to appreciate divergent views. The purpose was to provide informative, enjoyable post-graduate education, with no self or institutional advertisement. In this the SUA succeeded; it avoided petty rivalry, remained focused and survived.
The 1990s – The Consolidation
The tree of urology had grown strong, spreading roots. In 1991, Toa Payoh Hospital formed a Division of Urology, led by the energetic Dr Peter Lim. Tan Tock Seng Hospital followed suit with a Section of Urology in 1993, led by Dr David Consigliere.
This period saw the establishment of urology as a recognised surgical subspeciality with its own Speciality Board to oversee the training of urologists. The completion of a four-year urological training programme was formally recognised with an Advanced Speciality Training Certificate in July 1991. Trainees were encouraged to continue the tradition of spending a year abroad in well-recognised institutes. Certification was jointly conductedby the Academy of Medicine of Singapore, the School of Postgraduate Medicine and the Ministry of Health. This certificate will become an admission requirement for the Register of Specialists when the Medical Registration Act is amended.
Completion of the training programme would not ensure certification. Each candidate’s practical training would be reviewed. The candidate would also undergoa viva by the members of the Speciality Board and an external examiner. The first interview was conducted in 1994 and continues till today. This formal training programme placed the practice of urology firmly in the hands of urologists. It set a new standard for urological training in Singapore.
With the formal recognition of urology as a surgical subspeciality, further developments in superspecialization within urology occurred. Under the Health Manpower Development Plan and the University’s training programme, trainees were sent abroad to famous centres to learn and to set up local programmes in endourology, uro-oncology, andrology and fertility, neurourology, reconstructive urology, female urology, transplant surgery and basic research. A continence clinic was opened at Toa Payoh Hospital; a neurourology clinic was set up at Tan Tock Seng Hospital; a male sexual dysfunction clinic was organised at the National University Hospital.
The Singapore General Hospital progressed even further; a central urology facility with ESWL, transrectal ultrasonography, transurethral thermotherapy for the prostate and urodynamic facilities were housed together and the services streamlined in 1998. Dr Li Man Kay, previously from Hong Kong, led the consolidation of the national renal transplantation programme. Today, the major hospitals offer a full breadth of urological services.
At the same time, the SUA became more active. Regular monthly scientific meetings were organised. Urologists from all the hospitals met for uroradiology rounds, journal club meetings and discussion of difficult cases. Dr Christopher Cheng initiated the Gillenwater Book Club for the younger urologists with SUA book subsidies. Despite the early bird slot, most of the younger members attended.
More symposia and workshops on important subjects were organised with internationally recognised guest speakers. Tremendous effort went into organising hands-on workshops and live surgery demonstrations. The symposia with general practitioners (GPs) became an annual event. This gradually evolved into a co-ordinated Update Series for GPs in 1995. This popular series consisted of lectures and demonstrations which provided a comprehensive coverage of urology for general practitioners.
Public knowledge of urological disease was poor; for example in a limited survey, 40 percent of older Singaporeans were ignorant of the existence of the prostate gland. To redress this, public forums were also held on common disease such as urinary stones, prostate diseases, bladder cancer, hematuria, neuropathic bladders and sexual dysfunction in paraplegics. Urologists also played a leading role in the development of the Society for Continence of Singapore under Dr Peter Lim. The public showed their interest through an ever-increasing audience. The SUA also formed committees to establish guidelines for the management of urinary stone diseases chaired by Dr Michael Wong, benign prostatic chaired hyperplasia by Prof Foo Keong Tatt and bladder cancer and andrology chaired by Dr Li Man Kay.
In the international arena, the SUA plugged into the global urological network. It developed close links with the Institute of Urology in the United Kingdom and several leading US Urology institutions. It supported the creation of the Federation of Asean Urological Associations comprising the associations of Indonesia, Malaysia, the Philippines, Thailand and Singapore. The SUA was honoured by the opportunity to host several important international meetings, namely the 10th World Congress of Endourology and ESWL, the 6th World Congress in Impotence, the Post-congress meeting of the 23rd Meeting of the Societe Internationale d’Urologie, Asia Congress in Urology in 1998, SIU in 2000, and the World Videourology Congress 2007. The tiny SUA had succeeded in forging local urologists into an internationally recognised entity.
The growing reserves of the SUA led to the creation of an SUA Foundation. The Foundation has an independant Board of Trustees to safeguard its reserves. Clinical research had improved in design, sophisticated and execution, resulting in well received papers. Clinical research in neuro-urology, prostate diseases and uro-oncology was conducted individually by the various institutions.
As the population rapidly ages, more will be required of Singapore’s urologists. Better services will be demanded, for less. The framework has been laid, the terms of reference clarified and the path set. Tomorrow’s urologists must use expensive new technology discerningly, and with the assistance of local guidelines. They will try to improve the public’s knowledge of urology; will continue to improve patient care through careful training programmes and checks, superspecialization and continuing medical education activities; and will continue to develop the infrastructure for research and contribute new knowledge to the field.
Last but not least, they will try to help communities abroad which lack basic urological services in acknowledgement that local urologists were not alone in developing urology in Singapore. Without the generous sharing of knowledge and encouragement from the regional and international urologists, urology in Singapore would not have come of age.