In our article, we present our experience and outcomes with robotic pyelolithotomy (RPL) for the removal of complex kidney stones. Our stone free rates are comparable to PCNL for large complex stones with the added advantage of less bleeding and lower septicaemia in a single procedure without the need for open conversion. In addition, multiple other series have found the technique feasible and safe with good outcomes and reliable reproducibility. Though these series are relatively small, the number of articles and descriptions of the technique continue to increase each year in the literature.
Well defined indications for RPL are lacking with nearly all current literature describing the technique as a replacement for open stone surgery when URS or PCNL has failed or is not feasible. Additionally, indications include planned concomitant robotic upper tract reconstruction. The obesity epidemic is a major risk factor for stone disease, and large body habitus has also been described as an indication for RPL when PCNL may be challenging due to increased skin to stone distance or positioning. While we (and others) agree that PCNL is standard of care for large renal calculi, we feel that robotic stone removal can address some of the limitations and challenges of managing large complex stones in different populations.
Modern endourology evolved, in part, with the purpose of finding less invasive surgical techniques to treat stones disease, all with less morbidity and improved stone free outcomes. Why then shouldn’t robotic-assisted surgery to be looked upon as yet another extension of that ever-moving target? As the surgical paradigm continues to shift and robotic technology becomes more ubiquitous we believe that it will. This is evidenced by the multiple other technologies being developed and studied for stone management, including robotic-assisted flexible ureteroscopy and real-time three-dimensional imaging for PCNL.
Certainly, there are limitations to RPL such as availability and cost, however, these are familiar hurdles encountered with any technological advance, and will likely improve given the current trends. As the urologic workforce becomes increasingly more comfortable with robotic-assisted surgery, RPL is an approachable way to manage large complex stones. With the well-known rise of both stone disease and robotic surgical technology in the United States, it should be no surprise that these trends have intersected. As such, the continued use of new technology to assist in the treatment of stone disease will likely remain an inevitability.
Written by: Michael L. Schulster, MD, and Marc A. Bjurlin, DO
Department of Urology, NYU Langone Health, New York, NY, USA., Department of Urology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA.
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