NARUS 2018: Robotic-assisted Laparoscopic Stone Extraction in the Challenging Patient: A Single-center Experience

Las Vegas, NV (UroToday.com)  Dr. Morris Jessop and his colleagues from West Virginia University Hospital presented their single center experience with robotic assistance for stone extraction in challenging patients. Indeed, large renal and ureteral stones >2 cm have traditionally been managed with percutaneous nephrolithotomy (PCNL) or staged ureteroscopy, however robotic assisted surgery for stone removal is an emerging technology for extracting large stone burden [1,2]. Challenging patient features such as morbid obesity, contractures, kidney anatomical variations, and/or need for concomitant renal surgery may make this option more ideal for certain patient populations. The objective of this study was to assess a single-center experience with robotic assisted stone extraction among challenging patients. 

For this study, the authors retrospectively review the medical records of all patients undergoing robotic assisted stone extraction by a single surgeon from 2012 to 2016. Data collected included demographics, surgical details/setup, length of stay, complications, and follow-up. The operative setup was similar for all patients with slight variation in port placement between the Xi and Si robotic system. For patients undergoing robotic assisted pyelolithotomy, the renal pelvis was opened longitudinally and the stone extracted with a combination of robotic instruments and/or flexible nephroscopy with stone basket retrieval. Following stone extraction, the authors report that they routinely place an antegrade ureteral stent, with closure of the pyelotomy using running suture and drain placement. For patients undergoing robotic assisted nephrolithotomy, a laparoscopic ultrasound was used to locate the stone and thinnest area of parenchyma; the nephrolithotomy was then performed “off-clamp.” After stone extraction, the calyceal diverticulum was fulgurated using monopolar energy, and renorrhaphy was performed using a running 2-O v-loc suture with Hem-o-lok clips. Gerota’s fascia was closed over the nephrolithotomy and a drain was placed. 

For this study, the author’s identified 10 procedures (9 patients including one staged bilateral removal). The mean BMI was 37.3, mean ASA was 2.7 and all patients had previously undergone abdominal surgery. The indications for robotic assistance included: need for concomitant kidney surgery such as pyeloplasty (n=4), severe morbid obesity with large stone burden (mean BMI 57; n=3), contractures limiting position for ureteroscopy or PCNL (n=1), calyceal diverticular stone (n=1), and patient preference (n=1). There were a mean 2.2 stones per side and a mean stone volume of 14.9 cm3 (range 0.8- 75 cm3). The mean operative time was 175 minutes, mean EBL was 54 cc, and mean length of stay was 3.2 days. Three patients had post-operative complications, including need for stent repositioning, stent replacement following removal, post-operative discharge on home oxygen. Over a mean follow-up of 58 days, the stent was left indwelling for a mean 42 days, and there were four patients with adequate post-operative imaging, 3 of which were completely stone free. 

The authors concluded that robotic assisted pyelolithotomy or nephrolithotomy are feasible in highly selected patients. 


Presented By: Morris Jessop, West Virginia University Hospital, Morgantown, WV

Co-Authors: Leor Arbel, Chad Crigger, John Barnard, Mohamad Salkini

Written By: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre, @zklaassen_md ,at the 2018 North American Robotic Urology Symposium, February 16-17, 2018 - Las Vegas, NV 

References: 

1. Swearingen R, Sood A, Madi R, Klaassen Z, et al. Zero-fragment nephrolithotomy: A Multi-center evaluation of robotic pyelolithotomy and nephrolithotomy for treating renal stones. Eur Urol 2017 Dec;72(6):1014-1021.
2. King SA, Klaassen Z, Madi R. Robot-assisted anatrophic nephrolithotomy: Description of technique and early results. J Endourol 2014;28(3):325-329.
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