The Emerging Role of Robotics and Laparoscopy in Stone Disease

doi:10.1016/j.ucl.2012.09.005

Urologic Clinics of North America

Volume 40, Issue 1, February 2013, Pages 115-128

https://doi.org/10.1016/j.ucl.2012.09.005 Get rights and content

Section snippets

Key points

•
The prevalence of open surgical procedures has decreased dramatically with the advent of minimally invasive and endourologic procedures in the United States and world wide.
•
When endourologic procedures fail, laparoscopic or robot-assisted techniques offer patients significant benefits over open surgery.
•
In certain clinical circumstances such as abnormal anatomy, the need for concomitant reconstruction efforts, the unavailability of endoscopic equipment or experience, robotic or laparoscopic

Historical perspective

Urolithiasis has plagued mankind since before recorded history; in 1901 a stone was extracted from an Egyptian mummy dating to 4800 BC.¹ During Hippocrates' era, specific surgical interventions, although crude by modern standards, were described to relieve the symptoms of stone disease.² The reports of successful stone surgery were rare in the subsequent millennia, with most procedures resulting in death and significant morbidities. In 1879, Heinke described the first pyelotomy incision with

Patient considerations

The prevalence of open surgical procedures has decreased significantly with the advent of minimally invasive and endourologic procedures. In the United States in 2000, only 2% of Medicare patients were treated with open surgery when they required a stone operation.²⁰ Internationally, when alternative equipment and expertise are available, open surgery is done in only 1% to 5.4% of all patients requiring stone surgery.20, 21, 22, 23, 24, 25, 26, 27 Even in developing countries, the prevalence of

Approaches for ureteral stones

The advent of flexible active deflection and semirigid ureteroscopes, digital image resolution, advances in lithotripsy devices such as the holmium:yttrium-aluminum-garnet laser, and the introduction of SWL has simplified the means and improved the outcomes for most patients requiring stone surgery while minimizing risks. The bevy of accompanying ureteroscopic instrumentation including nitinol baskets, ureteral access sheaths, retropulsion devices, and stents have further decreased the role of

Approaches for kidney stones

The particular techniques of laparoscopic or robot-assisted management of nephrolithiasis can be placed into one of several broad classifications of technique: pyelolithotomy, nephrolithotomy, or combined procedures (concomitant ureteropelvic junction [UPJ] repair, calyceal diverticula ablation, or partial nephrectomy). The data associated with each type of procedure will be described next.

Combined laparoscopic and endourologic procedures

Occasionally, rare and complex cases require more than one treatment modality to achieve the greatest level of success for the patient. Laparoscopic and robot-assisted techniques can be and are often combined with endourologic procedures for those individuals with complicated stone disease and underlying urinary abnormalities, usually for assistance in retrieving fragments.⁸⁷ Eshghi and associates reported the first use of laparoscopic guided percutaneous removal of a staghorn calculus in a

Summary

The surgical approach to most cases of urolithiasis is defined by endourogic techniques and technology including SWL, PNL, or URS. However, despite the numerous advantages and advances in endourology, open surgical approaches cannot be entirely replaced. Laparoscopic and robot-assisted urological surgery is increasingly replacing open surgery as a result of accumulated surgical experience. The need for open surgical management is shrinking, especially when equivalent outcomes can be achieved

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Cited by (19)

Robotic stone surgery – Current state and future prospects: A systematic review
2018, Arab Journal of Urology
Citation Excerpt :
Robot-assisted surgery for urolithiasis, one of the most common diseases in urology, is rare. One reason for this is that most patients with kidney or ureteric stones are treated with modern endourological interventions or extracorporeal SWL and, therefore, only a few indications for open or laparoscopic surgical interventions in urolithiasis remain [14–17]. Only in the few cases, where minimally invasive treatment options are not applicable or particular circumstances hamper their use, do urologists have the option to perform open surgery, laparoscopic surgery, or robot-assisted stone treatment.
To provide a comprehensive review of robot-assisted surgery in urolithiasis and to consider the future prospects of robotic approaches in stone surgery.
We performed a systematic PubMed© literature search using predefined Medical Subject Headings search terms to identify PubMed-listed clinical research studies on robotic stone surgery. All authors screened the results for eligibility and two independent reviewers performed the data extraction.
The most common approach in robotic stone surgery is a robot-assisted pyelolithotomy using the da Vinci™ system (Intuitive Surgical Inc., Sunnyvale, CA, USA). Several studies show this technique to be comparable to classic laparoscopic and open surgical interventions. One study that focused on ureteric stones showed a similar result. In recent years, promising data on robotic intrarenal surgery have been reported (Roboflex Avicenna™; Elmed Medical Systems, Ankara, Turkey). Initial studies have shown its feasibility and high stone-free rates and prove that this novel endoscopic approach is safe for the patient and comfortable for the surgeon.
The benefits of robotic devices in stone surgery in existing endourological, laparoscopic, and open treatment strategies still need elucidation. Although recent data are promising, more prospective randomised controlled studies are necessary to clarify the impact of this technique on patient safety and stone-free rates.
Retrograde flexible nephrolithotomy in the management of large lithiasic masses as an alternative to percutaneous nephrolithotomy
2016, Urologia Colombiana
Citation Excerpt :
The most common complication was urine leak (0–20%), followed by narrowing (1.4–5.2%).10 Training, technology, and costs limit the use of this technique that will continue to be an alternative option for the modern surgical approach to urolithiasis.11 The advances in the instruments for endoscopic procedures in the last twenty years or so, have led to an increase in their use in patients with large-sized calculi.
Recent advances in flexible ureteroscopy, as well as the development of various accessories and the implementation of Holmium laser as a fragmentation mechanism, consisting of flexible retrograde laser nephrolithotomy (FRLN), is an attractive alternative for the management of large lithiasic masses. The analysis of the evidence available to date is essential to establish the benefits and limitations compared to other therapies, such as percutaneous nephrolithotomy.
A systematic search was performed in MEDLINE and SCIENCEDIRECT data bases. The search was limited by language to articles published in English and Spanish, and limited in time to articles published in the last 10 years. A total of 30 articles of interest to the topic and a case report on a large lithiasic mass handled with FRLN are included.
Percutaneous nephrolithotomy is considered the gold standard for the management of renal stones larger than 2 cm, with stone free rates of 76–95% with 1.9 procedures. However, complication rates have been reported between 8 and 45%, and decreased GFR between 9 and 34% was recorded in the post-operative period. On the other hand FRLN provides an stone free rates of 86–95% in about 1.6 procedures, and complication rates ranging from 10 to 20%.
The FRLN has become an effective alternative for the management of large lithiasic masses, with stone free rates similar to those obtained with percutaneous nephrolithotomy, but with fewer complications. Its usefulness is most evident in special cases, such as large stones associated with significant comorbidity, obesity, failure renal, spinal malformations, or a single kidney.
Los recientes avances en la ureteroscopia flexible, como el desarrollo de diversos accesorios y la aparición del láser holmio como mecanismo de fragmentación, hacen de la nefrolitotomía retrógrada flexible láser (NRFL) una alternativa atractiva para el manejo de grandes masas litiásicas. El análisis de la evidencia disponible hasta el momento resulta fundamental para establecer sus beneficios y limitaciones frente a terapias establecidas como la nefrolitotomía percutánea.
Se realizó una búsqueda sistemática en bases de datos MEDLINE y SCIENCEDIRECT. La búsqueda fue limitada por idioma para artículos publicados en inglés y español, y limitada en tiempo para artículos publicados en los últimos 10 años. Se incluyen 30 artículos de interés para el tema y el reporte de caso de gran masa litiásica manejada con NRFL.
La nefrolitotomía percutánea es considerada el patrón de oro para el manejo de cálculos renales mayores de 2 cm con tasas libres de cálculo del 76–95% con 1,9 procedimientos, sin embargo, las tasas de complicación se han descrito entre el 8–45%, y la disminución de la TFG en el periodo postoperatorio se ha registrado entre 9–34%. Por otro lado la NRFL ofrece tasas libres de cálculo del 86–95% con 1,6 procedimientos, y tasas de complicación que oscilan entre el 10–20%.
La NRFL se convierte en una alternativa eficaz para el manejo de grandes masas litiásicas con tasas libres de cálculo similares a las obtenidas con nefrolitotomía percutánea aunque con menor índice de complicaciones; su utilidad es más evidente en casos especiales tales como cálculos grandes asociados a comorbilidad importante, obesidad, falla renal, malformaciones óseas, espinales o riñón único.
Retrograde flexible nephrolithotomy in the management of large lithiasic masses as an alternative to percutaneous nephrolithotomy
2016, Urologia Colombiana
Los recientes avances en la ureteroscopia flexible, como el desarrollo de diversos accesorios y la aparición del láser holmio como mecanismo de fragmentación, hacen de la nefrolitotomía retrógrada flexible láser (NRFL) una alternativa atractiva para el manejo de grandes masas litiásicas. El análisis de la evidencia disponible hasta el momento resulta fundamental para establecer sus beneficios y limitaciones frente a terapias establecidas como la nefrolitotomía percutánea.
Se realizó una búsqueda sistemática en bases de datos MEDLINE y SCIENCEDIRECT. La búsqueda fue limitada por idioma para artículos publicados en inglés y español, y limitada en tiempo para artículos publicados en los últimos 10 años. Se incluyen 30 artículos de interés para el tema y el reporte de caso de gran masa litiásica manejada con NRFL.
La nefrolitotomía percutánea es considerada el patrón de oro para el manejo de cálculos renales mayores de 2 cm con tasas libres de cálculo del 76-95% con 1,9 procedimientos, sin embargo, las tasas de complicación se han descrito entre el 8-45%, y la disminución de la TFG en el periodo postoperatorio se ha registrado entre 9-34%. Por otro lado la NRFL ofrece tasas libres de cálculo del 86-95% con 1,6 procedimientos, y tasas de complicación que oscilan entre el 10-20%.
La NRFL se convierte en una alternativa eficaz para el manejo de grandes masas litiásicas con tasas libres de cálculo similares a las obtenidas con nefrolitotomía percutánea aunque con menor índice de complicaciones; su utilidad es más evidente en casos especiales tales como cálculos grandes asociados a comorbilidad importante, obesidad, falla renal, malformaciones óseas, espinales o riñón único.
Recent advances in flexible ureteroscopy, as well as the development of various accessories and the implementation of Holmium laser as a fragmentation mechanism, consisting of flexible retrograde laser nephrolithotomy (FRLN), is an attractive alternative for the management of large lithiasic masses. The analysis of the evidence available to date is essential to establish the benefits and limitations compared to other therapies, such as percutaneous nephrolithotomy.
A systematic search was performed in MEDLINE and SCIENCEDIRECT data bases. The search was limited by language to articles published in English and Spanish, and limited in time to articles published in the last 10 years. A total of 30 articles of interest to the topic and a case report on a large lithiasic mass handled with FRLN are included.
Percutaneous nephrolithotomy is considered the gold standard for the management of renal stones larger than 2 cm, with stone free rates of 76-95% with 1.9 procedures. However, complication rates have been reported between 8-45%, and decreased GFR between 9-34% was recorded in the post-operative period. On the other hand FRLN provides an stone free rates of 86-95% in about 1.6 procedures, and complication rates ranging from 10-20%.
The FRLN has become an effective alternative for the management of large lithiasic masses, with stone free rates similar to those obtained with percutaneous nephrolithotomy, but with fewer complications. Its usefulness is most evident in special cases, such as large stones associated with significant comorbidity, obesity, failure renal, spinal malformations, or a single kidney.
Robotic Management of Bladder Stones in Children
2022, Minimally Invasive Techniques in Pediatric Urology: Endourology, Laparoscopy and Robotics
Robotic Pediatric Renal Surgery
2022, Robotic Urologic Surgery: Third Edition
Systematic assessment of information about surgical urinary stone treatment on YouTube
2021, World Journal of Urology

View all citing articles on Scopus

: There are no financial relationships to disclose as it pertains to this article.

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The Emerging Role of Robotics and Laparoscopy in Stone Disease

Section snippets

Key points

Historical perspective

Patient considerations

Approaches for ureteral stones

Approaches for kidney stones

Combined laparoscopic and endourologic procedures

Summary

First page preview

Urol Clin North Am

Urology

J Urol

J Urol

J Urol

J Urol

J Urol

J Urol

Lancet

J Urol

J Urol

Surg Clin North Am

J Urol

J Urol

Urol Clin North Am

J Urol

J Urol

J Urol

J Urol

J Urol

Int J Surg

J Urol

Prog Urol

J Urol

Eur Urol

J Urol

J Urol

J Urol

J Urol

Urology

J Urol

J Urol

Prog Urol

J Urol

J Urol

History of urolithiasis

Clin Rev Bone Miner Metab

Urology, from antiquity to the 20th century

History of urology. Prepared under the auspices of the American Urological Association

Percutaneous pyelolithotomy: a new extraction technique

Scand J Urol Nephrol

Percutaneous trocar (needle) nephrostomy in hydronephrosis

JAMA

The evolution of ureteroscopy: a modern single-institution series

Mayo Clin Proc

Robotic surgery claims on United States hospital websites

J Heatlhc Qual

Current management of urolithiasis: progress or regress?

J Endourol

Current surgical approaches to nephrolithiasis

Endocrinol Metab Clin North Am

Indications for open stone removal of urinary calculi

Urol Int

Long-term results of intrarenal surgery for branched calculi: is surgery still valid?

BJU Int

Changing indications of open stone surgery

Urology