Category: Laparoscopic/ Robotic: Other
Introduction & Objective :
The use of robotic-assisted treatment modalities for complex staghorn kidney stones has recently been reported in the literature. We report our initial experience and outcomes with robotic anatrophic nephrolithotomy (RAN), robotic pyelolithotomy (RP), robotic ureterolithotomy (RU), and robotic radical nephrolithotomy (RRN) for treatment of complex kidney stones.
Methods : Between October 2011 and June 2016, 20 patients underwent 21 robotic surgeries for complex kidney stones (RAN n=11; RP n=7, RU n=1, RRN n=2). One patient underwent bilateral RP in a single setting for bilateral renal pelvic stones. RAN was mostly performed in patients with full staghorn stones, and RP was offered to patients with large stones and partial staghorn stones located in an extrarenal pelvis. One patient had concurrent RP with pyeloplasty to repair a UPJ obstruction. One patient underwent RU for two large proximal ureteral stones more amenable to an antegrade approach. Two patients underwent RRN for large stones located near the parenchymal surface. Most patients failed previous endoscopic intervention or had an anatomic variation that precluded such intervention. Variables of interest included demographic information and perioperative creatinine, glomerular filtration rate, warm ischemia time (WIT), console time, operative time, estimated blood loss, length of stay), residual stone burden, and the need for additional procedures. Stone free rates and median follow-up are reported.
Results : Among 20 patients undergoing robotic procedures, the median age was 52 (22-67) years, BMI was 31 (21-49) kg/m2 and preoperative Cr was 0.84 (0.32-2.60) mg/dL. Operatively, median WIT was 36 (24-44) min (for RAN patients only), console time was 153 (61-260) min, and EBL was 100 (5-800) mL. Median LOS was 1 (1-5) day, post-op day 1 Cr was 1.08 (0.32-2.31) mg/dL, change in GFR at discharge (ΔGFR) was -1.2 (-46.8, 35.6) mL/min/1.73 m2, and all patients undergoing RP, RU, and RRN were completely stone-free, while 36% of patients undergoing RAN were stone-free after one procedure. Three of six patients undergoing RP had known kidney anomalies (pelvic kidney, cross fused renal ectopia, and UPJ obstruction).
Conclusions : Robotic-assisted surgery of complex kidney stones is an emerging minimally invasive modality. Our RAN experience is encouraging, however early results suggest subsequent procedures are necessary to achieve complete stone free rates in complex cases. Patients undergoing RP, RU, and RRN in our study have excellent stone free rates. Specifically, this approach may be indicated in patients with anatomic renal anomalies that are not amenable to traditional endoscopic options.
Alan Carnes– Resident, Augusta University, Augusta, Georgia
William Hughes– Augusta University, Augusta, Georgia
Zachary Klaassen– Augusta University, Augusta, Georgia
Rabii Madi– Professor of Urology, Medical College of Georgia at Augusta University Health, Augusta, Georgia