Category: Robotic Surgery: Upper Tract - Benign
Introduction & Objective : The management of nephrolithiasis in ectopic kidneys present several unique challenges. The orientation of the renal pelvis can make ureteroscopic stone removal difficult with low stone free rates. Pyelolithotomy has been proposed as an alternative to treatment in these patients. Here we report our experience with robotic pyelolithotomy in an ectopic pelvic kidney with a large stone burden.
A 58 year old female presented initially with recurrent urinary tract infections. A CT scan demonstrated a left pelvic kidney with a 15 x 11 mm stone in a midpole calyx, along with several other smaller stones. An outside urologist attempted shock wave lithotripsy and ureteroscopy, but was unable to reach the stones due to difficultly navigating the ureteral anatomy. She was then referred for more definitive stone management.
A robotic approach was selected due to the pelvic location of the kidney. The patient was placed into the dorsal lithotomy position and robotic trocars were placed for standard pelvic exploration. This provided excellent visualization of the left pelvic kidney and hilum. A hydronephrotic renal pelvis was dissected free of surrounding structures and opened. In order to minimize trauma to the renal pelvis, a flexible cystoscope was passed through an assistant trocar and maneuvered into position with robotic instruments. The large midpole stone was then easily visualized through a stenotic infundibulum and extracted intact with a robotic grasper. A ureteral stent was placed antegrade and the renal pelvis closed with absorbable suture. Estimated blood loss was approximately 50 mL. There were no complications, and the patient was discharged home on post-operative day one.
The complex anatomy associated with ectopic pelvic kidneys can make traditional endoscopic management of stones challenging. We found that a robotic approach to pyelolithotomy provides excellent visualization while being safe and effective. This approach should be considered in the management of large renal stones in ectopically located kidneys.
Daniel Rittenberg– Urology Resident, Stony Brook Urology, Stony Brook, New York
William Berg– Urology Resident, Stony Brook Urology, Stony Brook, New York
Joseph Jamal– Urologist, NYU Winthrop Hospital, Mineola, New York
Deepak Kapoor– Urologist, NYU Winthrop Hospital, Mineola, New York