Initial Clinical Experience with a Combined Robotic Mini-Percutaneous Nephrolithotomy And Ureteroscopic Lithotripsy Platform “Presentation”

May 4, 2024

Jamie Landman presented initial clinical experience with a combined robotic mini-percutaneous nephrolithotomy (mini-PCNL) and ureteroscopic lithotripsy platform for treating a large left-sided kidney stone burden. The Monarch Robotic Platform, featuring a robot with three arms, enables precise control of the ureteroscope and percutaneous instruments. The procedure involves robotic ureteroscopy, stone ablation using suction irrigation, and extraction of fragments. Minimal fluoroscopy is used, with the axis primarily guided by a magnetic system. The patient is positioned in a modified flank position, and the robot is docked to perform the procedure. The system allows for efficient stone ablation and extraction, with minimal residual fragments observed in postoperative imaging. The presentation demonstrates the effectiveness and precision of the combined robotic approach in treating complex kidney stone cases.


Jaime Landman, MD, Urologist, Department of Urology, University of California Irvine, Irvine, CA


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Jamie Landman: Initial clinical experience with a combined robotic mini-percutaneous nephrolithotomy and ureteroscopic lithotripsy platform. The patient is seen here on CT scan has a large left-sided stone burden, with the stone measuring 3.9-centimeters in longitudinal greatest diameter. Additionally, there are some small Randall's plaques. The Monarch Robotic Platform consists of the robot with three arms, two to control the ureteroscope in one percutaneously, which deploy as as seen here. The ureteroscope is a robotic ureteroscope, and the irrigation and suction system works from above. Targeting is with an electromagnetic system, as demonstrated here with this graphic user interface. Once the needle has been deployed, standard dilation is performed. As seen here, the irrigation and aspiration system is controlled as is the ureteroscope robotically. Standard ureteroscopic stone ablation is performed using suction from the suction irrigation system. The stone can be mobilized to another site, which may make for simpler ablation. An extraction of fragments is via the aspiration catheter.

In this case, the patient is in a flank position, which has been modified with a bolster and the arm draped over the side. The robot is paced and docked by placing the two arms below and the one above. The two lower arms control the robotic ureteroscope, as seen here. Robotic ureteroscopy is driven via a console. And here, once entering the kidney, the stone can be seen. There are a few Randall's plaques throughout the kidney as well. The compact field generator is set up on the outside of the patient. Minimal fluoroscopy is used for initial targeting, but the axis is largely gained with the compact field generator magnetic system. The papilla is marked, a second site for observation is then marked, and once the system is ready, an incision can be made in the skin posterior to the posterior axillary line. The needle is accessing and using the graphic user interface by keeping the digital bubble in the center. When the outside ring reaches the 11 o'clock position, the needle is noted to enter the calyx, in this case through the center of the papilla.

Standard dilation is used to place an 18-French sheath, and then the robot is docked. Once the robot has been docked, the suction and irrigation catheter, which is robotically driven, is deployed. A purpose-made suction irrigation system is attached, and then the ureteroscope can be used for optics. Here, the sheath is in position. The suction catheter is then placed near the stone, and ablation is performed in a standard ureteroscopic manner using the robotic ureteroscope. In this case, a standard holmium laser is applied. As fragments are formed, they often immediately are brought to the suction catheter, where they can be immediately aspirated. Occasionally, fragments land on suction catheter and require additional ablation as well. This large stone burden was rapidly ablated and extracted using this system.

As you'll see, there are very few stone fragments which leave the area of ablation, as the smaller fragments are immediately extracted, and larger fragments more slowly extracted. After complete stone ablation, we surveil the entire kidney for residual fragments and also document all Randall's plaques so that these will not be considered residual fragments in the postoperative assessment. As you can see, the kidney, unlike with typical ablation, does not have significant dust or stone material, but rather clean urothelium. In the post-op imaging, there were no fragments other than a few very tiny Randall's plaques, as documented during the procedure. In this reconstruction, you can see that the 3.9-centimeter stone and the 6.1-millimeter upper pole stone have completely resolved, with no residual stone documented on this evaluation as well.

Thank you.