Article

Robotic extended pyelolithotomy for treatment of renal calculi: a feasibility study.

Vattikuti Urology Institute, Henry Ford Hospital, K-9 Urology, 2799 W. Grand Blvd, Detroit, MI 48202, USA.
World Journal of Urology (Impact Factor: 2.89). 07/2006; 24(2):198-201. DOI: 10.1007/s00345-006-0099-6
Source: PubMed

ABSTRACT Percutaneous nephrolithotomy (PCNL) remains the treatment of choice for staghorn renal calculi. Many reports suggest that laparoscopy can be an alternative treatment for large renal stones. We wished to evaluate the role and feasibility of laparoscopic extended pyelolithotomy (REP) for treatment of staghorn calculi. Thirteen patients underwent REP for treatment of staghorn calculi over a 12-day period. Twelve patients had partial staghorn stones and one had a complete staghorn stone. All patients had pre-operative and post-operative imaging including KUB and computed tomography. All procedures were completed robotically without conversion to laparoscopy or open surgery. Mean operative time was 158 min and mean robotic console time was 108 min. Complete stone removal was accomplished in all patients except the one with a complete staghorn calculus. Estimated blood loss was 100 cc, and no patient required post-operative transfusion. REP is an effective treatment alternative to PCNL in some patients with staghorn calculi. However, patients with complete staghorn stones are not suitable candidates for this particular technique.

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    ABSTRACT: Robotic surgery today has made a successful transition into mainstream clinical urological practice, providing minimally invasive surgical treatment options for complex extirpative and reconstructive procedures. It has particularly dominated urologic pelvic surgery including radical prostatectomy, radical cystectomy, and many gynecologic procedures (Menon M, Hemal AK, J Endourol 18(7):611–619, 2004; Hemal AK, Abol-Enein H, Shrivastava A, Shoma AM, Ghoneim MA, Menon M, Urol Clin North Am 31(4):719–729, 2004; Hemal AK, Kolla SB, Wadhwa P, J Urol 180(3):981–985, 2008]. It has successfully been employed in kidney surgery as well, especially donor nephrectomy, partial nephrectomy, and pyeloplasty for ureteropelvic junction obstruction (UPJO) (Phillips CK, Taneja SS, Stifelman MD, J Endourol 19:441–445, 2005; Gettman MT, Neururer R, Bartsch G, Peschel R, Urology 60:509–513, 2002). While urolithiasis is largely treated with shock wave lithotripsy (SWL) and endourological surgery (ureteroscopy [URS] and percutaneous nephrolithotomy [PCNL]), the role of laparoscopy has been explored as an alternative tool in managing urinary stone disease.Laparoscopic ureterolithotomy proved to be a viable alternative to open surgery, helping avoid incision related morbidity in candidates with impacted, large ureteral calculi which had failed an attempt at endourological management (Hemal AK, Goel A, Kumar M, Gupta NP, J Endourol 15(7):701–705, 2001). Laparoscopic stone surgery soon gained acceptance as a complementary minimally invasive technique, specifically to be used in the occasional case considered for open surgery. Stones in anteriorly placed calyceal diverticulum, pelvic stones in ectopic kidneys, assisting percutaneous access in ectopic kidneys formed some of the other indications for laparoscopic stone interventions (Ramakumar S, Segura JW, J Endourol 14(10):829–832, 2000). The use of laparoscopic pyelolithotomy was avidly contested with some authors extolling its virtues as an alternative to PCNL in medium-sized renal calculi unsuitable for SWL therapy and unfavorable calyceal anatomy (Gaur DD, Trivedi S, Prabhudesai MR, Gopichand M, J Laparoendosc Adv Surg Tech A 12(4):299–303, 2002; Yagisawa T, Ito F, Kobayashi C, Onitsuka S, Kondo T, Goto Y, Toma H, J Endourol 15(5):525–528, 2001); while others, though demonstrating its feasibility, were unable to show its superiority over PCNL vis-à-vis operative time and skill required, cosmesis and relative invasiveness (Goel A, Hemal AK, Int Urol Nephrol 35(1):73–76, 2003).The enhanced reconstructive capabilities of the robotic platform added another dimension to laparoscopic management of stone disease. We first explored the use of robot-assisted renal pelvic calculi retrieval during a concomitant pyeloplasty in February 2003 in Egypt. The experience prompted the genesis of usage of robotic-assisted laparoscopic pyelolithotomy, which resulted in the first large series of robotic extended pyelolithotomy (REP) wherein we focused on stone extraction of large renal calculi (partial staghorn calculi), even a complete staghorn calculus (Badani KK, Hemal AK, Fumo M, Kaul S, Shrivastava A, Rajendram AK, Yusoff NA, Sundram M, Woo S, Peabody JO, Mohamed SR, Menon M, World J Urol 24:198–201, 2006). We were successfully able to deal with such large renal pelvic bulky partial staghorn calculi even in cases with intra-renal pelvis, duplicating the technique of extended pyelolithotomy by developing the intrasinus space of Gil-Vernet (Meria P, Milcent S, Desgrandchamps F, Mongiat-Artus P, Duclos JM, Teillac P, Urol Int 75(4):322–326, 2005). The versatility provided by the robot has allowed application of robot-assisted procedures in a variety of indications in managing urinary stone disease at different locations (Table 12.1). Herein we describe our technique of robotic pyelolithotomy and ureterolithotomy.
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    ABSTRACT: Objectives To review the current role of laparoscopy and robot-assisted laparoscopy for managing urinary lithiasis.ResultsThe contemporary indications for laparoscopic stone management are: anatomical variations in location or shape of the kidney (pelvic kidney, horseshoe kidney and malrotated kidney); coexisting pathologies, e.g. pelvi-ureteric junction obstruction; and stones in a renal unit with lower ureteric obstruction. The laparoscopic approach allows the simultaneous management of both the pathologies. Symptomatic stones in diverticula not amenable to endourological intervention can be treated with laparoscopy. Large impacted pelvic and ureteric calculi with a functioning renal unit are an indication for laparoscopic ureterolithotomy or pyelolithotomy. This review of current reports suggests that in a selected group of patients with complex stone disease the laparoscopic approach offers good success rates with minimal complications. There are few reports of robotic procedures in stone disease but existing data suggest that it is feasible.Conclusion Laparoscopic surgery is effective for complex renal stones and offers excellent stone clearance rates with minimal morbidity. Laparoscopic surgery is complementary in managing these stones. Robot-assisted laparoscopic technique of urinary tract stone management is in its early stage of implementation and randomised trials that compare robot assisted outcomes with other minimally invasive techniques are needed.
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    ABSTRACT: Minimal invasive surgery has made a major impact in the management of urolithiasis. This has been possible due to miniaturization of scopes and improvements in equipment, energy sources and imaging. Despite these advances, open stone surgery is the optimal choice in a number of situations. In most such situations, laparoscopy allows a minimally invasive option and, now, robotic assistance to laparoscopy has made this easier and efficacious. This is particulalrly true for situations requiring reconstruction. In this chapter, we review the current indications, techniques, pitfalls and their solutions for robotic surgery for urolithiasis.