The Role of Robotic Surgery For Managing Complex Upper Urinary Tract Stone Disease: A Single Center Experience

Year 2023, Volume: 15 Issue: 3, 146 - 154, 30.09.2023

Murat Can Kiremit , Yakup Kordan

https://doi.org/10.54233/endouroloji.20231503-1350321

Abstract

Objective: The aim of this study is to present the outcomes of robotic surgery using a da Vinci robotic system (Intuitive
Surgical Incorporation, Sunnyvale, CA) in different clinical indications in patients with upper urinary tract stone disease.
Material And Methods: The data of 12 patients who underwent robotic stone surgery at our academic center
between July 2016 and July 2023 were retrospectively evaluated. The reason to perform robotic stone surgery was
large and/or impacted upper tract stone disease after a previous unsuccessful stone surgery (n=7), the need for a
partial nephrectomy due to simultaneously detected renal solid lesion (n=4), and the need for pyeloplasty resulting
from ureteropelvic junction obstruction (n=1).
Results: Out of 12 patients included in the study, 7 patients (58%) were male, and 5 patients (42%) were female with a
median age of 58 (IQR: 44 – 68) years. The median stone size was 38 mm (IQR: 16 – 53) as measured at a preoperative
computerized tomography (CT) scan. 7 out of 12 patients (58%) had multiple urinary stones while 5 patients (42%) had a
solitary stone. Assistance with flexible ureterorenoscopy was required in 7 out of 12 cases (58%). The median operation
time and estimated blood loss were 190 minutes (IQR: 126 – 148) and 50 ml (min:0, max: 300), respectively. In a case
who underwent concurrent partial nephrectomy, angioembolization was required due to postoperative bleeding. In
another case, prolonged drain activity (6 days) was observed which resolved spontaneously during follow-up. Stonefree
status was achieved in 11 out of 12 cases (92%). In the only case without stone-free status, the residual stone
was fragmented during JJ stent removal by the technique of retrograde intrarenal surgery (RIRS). After this additional
operation, stone-free status was achieved in all cases.
Conclusion: Robotic stone surgery with its high stone-free rate and low complication rate represents an alternative
approach in complex clinical scenarios considering the increasing experience of surgeons in robotic surgery.

Keywords

robotic surgery, flexible ureterorenoscopy, urolithiasis, complication

Project Number

Yok

Kompleks Üst Üriner Sistem Taş Tedavisinde Robotik Cerrahinin Rolü: Tek Merkez Deneyimi

Abstract

Amaç: Bu çalışmanın amacı, farklı endikasyonlar ile da Vinci robotik sistem (Intuitive Surgical Incorporation, Sunnyvale,
CA) kullanılarak yapılan üst üriner sistem taş hastalığı tedavilerinin klinik sonuçlarını paylaşmaktır.
Gereç ve Yöntemler: Temmuz 2016 ve Temmuz 2023 tarihleri arasında merkezimizde robotik taş cerrahisi yapılan 12
hastanın verisi retrospektif olarak incelenmiştir. Daha önce geçirilmiş başarısız taş cerrahisi olan hastalarda büyük ve/
veya impakte üst üriner sistem taşı olması (n=7), eş zamanlı saptanan renal kitle için parsiyel nefrektomi gerekliliği (n=4)
ve üreteropelvik bileşke (UPB) darlığına bağlı eş zamanlı pyeloplasti gerekliliği (n=1) sebebi ile robotik taş cerrahisi
planlanmıştır.
Bulgular: Çalışmaya dahil edilen 12 hastanın 7’si (%58) erkek, 5’i kadındı (%42) ve ortanca yaş 58 (IQR: 44–68) yıldı.
Preoperatif BT değerlendirmesinde taşların ortanca boyutu 38 mm (IQR: 16–53) olarak bulundu. Hastaların 7’sinde
(%58) çoklu taşlar var iken 5’inde (%42) soliter taş saptanmıştı. Hastaların 8’inde (%66,7) robotik pyelolitotomi ve/veya
nefrolitotomi uygulanırken dört hastada ise robotik üreterolitotomi uygulandı. Cerrahi esnasında hastaların 7’sinde
(%58) eş zamanlı fleksibl üreterorenoskopi ile endoskopik asistans gerekti. Ortanca ameliyat süresi ve tahmini kan kaybı
sırası ile 190 dk (IQR: 126–148) ve 50 ml (min:0, maks: 300) olarak saptandı. Eş zamanlı parsiyel nefrektomi yapılan
bir hastada hemoraji görülmesi üzerine transfüzyon ve ardından endoskopik psödoanevrizma embolizasyonu ihtiyacı
oldu. Robotik pyelolitotomi yapılan bir hastada ise kendiliğinden azalan uzamış dren aktivitesi (6 gün) görüldü. Ameliyat
sonrası yapılan tetkiklerde hastaların 11’inde (%92) tam taşsızlık sağlandığı görüldü. Rezidü taş görülen hastada ise
JJ stent çekilmesi esnasında retrograd intrarenal cerrahi (RIRC) yapılarak 8 mm boyutundaki rezidü kalkül fragmante
edilerek mutlak taşsızlık sağlandı. İlave girişim sonrası hastaların tamamında mutlak taşsızlık görüldü.
Sonuçlar: Kompleks klinik senaryolarda robotik cerrahi, tek seansta yüksek mutlak taşsızlık ve düşük komplikasyon
oranları yanında cerrahların artan robotik böbrek cerrahisi deneyimi de düşünüldüğünde büyük böbrek taşlarının
tedavisinde de alternatif olarak hastalara sunulabilir.

Keywords

robotik cerrahi, flexible üreterorenoskopi, ürolitiyazis, komplikasyon

Ethical Statement

Koç Üniversitesi Etik Kurulu, onay numarası: 2023/307.IRB1.103.

Supporting Institution

Yok

Project Number

Yok

Thanks

Yok

References

• 1. Hasan O, Reed A, Shahait M, Crivellaro S, Dobbs RW. Robotic Surgery for Stone Disease. Curr Urol Rep. 2023;24(3):127-33. https://doi.org/10.1007/s11934-022-01131-8
• 2. Simforoosh N, Aminsharifi A. Laparoscopic management in stone disease. Curr Opin Urol. 2013;23(2):169-74. https://doi.org/10.1097/MOU.0b013e32835d307f
• 3. Jensen PH, Berg KD, Azawi NH. Robot-assisted pyeloplasty and pyelolithotomy in patients with ureteropelvic junction stenosis. Scand J Urol. 2017;51(4):323-8. https://doi.org/10.1080/21681805.2017.1300188
• 4. Suntharasivam T, Mukherjee A, Luk A, Aboumarzouk O, Somani B, Rai BP. The role of robotic surgery in the management of renal tract calculi. Transl Androl Urol. 2019;8(Suppl 4):S457-S60. https://doi.org/10.21037/tau.2019.04.06
• 5. Badani KK, Hemal AK, Fumo M, Kaul S, Shrivastava A, Rajendram AK, et al. Robotic extended pyelolithotomy for treatment of renal calculi: a feasibility study. World J Urol. 2006;24(2):198-201. https://doi.org/10.1007/s00345-006-0099-6
• 6. King SA, Klaassen Z, Madi R. Robot-assisted anatrophic nephrolithotomy: description of technique and early results. J Endourol. 2014;28(3):325-9. https://doi.org/10.1089/end.2013.0597
• 7. Geraghty RM, Davis NF, Tzelves L, Lombardo R, Yuan C, Thomas K, et al. Best Practice in Interventional Management of Urolithiasis: An Update from the European Association of Urology Guidelines Panel for Urolithiasis 2022. Eur Urol Focus. 2023;9(1):199-208. https://doi.org/10.1016/j.euf.2022.06.014
• 8. Preminger GM, Assimos DG, Lingeman JE, Nakada SY, Pearle MS, Wolf JS, Jr., et al. Chapter 1: AUA guideline on management of staghorn calculi: diagnosis and treatment recommendations. J Urol. 2005;173(6):1991-2000. https://doi.org/10.1097/01.ju.0000161171.67806.2a
• 9. Xue W, Pacik D, Boellaard W, Breda A, Botoca M, Rassweiler J, et al. Management of single large nonstaghorn renal stones in the CROES PCNL global study. J Urol. 2012;187(4):1293-7. https://doi.org/10.1016/j.juro.2011.11.113
• 10. el-Nahas AR, Eraky I, Shokeir AA, Shoma AM, el-Assmy AM, el-Tabey NA, et al. Factors affecting stone-free rate and complications of percutaneous nephrolithotomy for treatment of staghorn stone. Urology. 2012;79(6):1236-41. https://doi.org/10.1016/j.urology.2012.01.026
• 11. Desai M, De Lisa A, Turna B, Rioja J, Walfridsson H, D'Addessi A, et al. The clinical research office of the endourological society percutaneous nephrolithotomy global study: staghorn versus nonstaghorn stones. J Endourol. 2011;25(8):1263-8. https://doi.org/10.1089/end.2011.0055
• 12. Swearingen R, Sood A, Madi R, Klaassen Z, Badani K, Elder JS, et al. Zero-fragment Nephrolithotomy: A Multi-center Evaluation of Robotic Pyelolithotomy and Nephrolithotomy for Treating Renal Stones. Eur Urol. 2017;72(6):1014-21. https://doi.org/10.1016/j.eururo.2016.10.021
• 13. Taylor Z, Keating K, Rohloff M, Maatman TJ. Robotic management of large stone disease: a case series. J Robot Surg. 2020;14(6):855-9. https://doi.org/10.1007/s11701-020-01060-z
• 14. Schulster ML, Sidhom DA, Sturgeon K, Borin JF, Bjurlin MA. Outcomes and peri-operative complications of robotic pyelolithotomy. J Robot Surg. 2020;14(3):401-7. https://doi.org/10.1007/s11701-019-01004-2
• 15. Francavilla S, Veccia A, Dobbs RW, Zattoni F, Vigneswaran HT, Antonelli A, et al. Radical prostatectomy technique in the robotic evolution: from da Vinci standard to single port-a single surgeon pathway. J Robot Surg. 2022;16(1):21-7. https://doi.org/10.1007/s11701-021-01194-8
• 16. Scarcella S, Tiroli M, Torino G, Mariscoli F, Cobellis G, Galosi AB. Combined treatment of ureteropelvic junction obstruction and renal calculi with robot-assisted laparoscopic pyeloplasty and laser lithotripsy in children: Case report and non-systematic review of the literature. Int J Med Robot. 2021;17(3):e2246. https://doi.org/10.1002/rcs.2246
• 17. Esposito C, Masieri L, Blanc T, Lendvay T, Escolino M. Robot-assisted laparoscopic surgery for treatment of urinary tract stones in children: report of a multicenter international experience. Urolithiasis. 2021;49(6):575-83. https://doi.org/10.1007/s00240-021-01271-5
• 18. Roth JD, Gargollo PC, DaJusta DG, Lindgren BW, Noh PH, Rensing AJ, et al. Endoscopic-assisted robotic pyelolithotomy: a viable treatment option for complex pediatric nephrolithiasis. J Pediatr Urol. 2020;16(2):192 e1- e5. https://doi.org/10.1016/j.jpurol.2019.12.007
• 19. D'Agostino D, Corsi P, Giampaoli M, Mineo Bianchi F, Romagnoli D, Crivellaro S, et al. Mini-invasive robotic assisted pyelolithotomy: Comparison between the transperitoneal and retroperitoneal approach. Arch Ital Urol Androl. 2019;91(2). https://doi.org/10.4081/aiua.2019.2.107
• 20. Ghani KR, Rogers CG, Sood A, Kumar R, Ehlert M, Jeong W, et al. Robot-assisted anatrophic nephrolithotomy with renal hypothermia for managing staghorn calculi. J Endourol. 2013;27(11):1393-8. https://doi.org/10.1089/end.2013.0266
• 21. Rajiv Y, Kumar A, Poonam Y. Bilateral simultaneous robot-assisted pyelolithotomy for large (>6 cm) kidney stones: technique and review of literature. J Robot Surg. 2015;9(3):263-6. https://doi.org/10.1007/s11701-015-0524-1
• 22. Lingeman JE, Newman D, Mertz JH, Mosbaugh PG, Steele RE, Kahnoski RJ, et al. Extracorporeal shock wave lithotripsy: the Methodist Hospital of Indiana experience. J Urol. 1986;135(6):1134-7. https://doi.org/10.1016/s0022-5347(17)46016-2
• 23. Wong VKF, Que J, Kong EK, Abedi G, Nimmagadda N, Emmott AS, et al. The Fate of Residual Fragments After Percutaneous Nephrolithotomy: Results from the Endourologic Disease Group for Excellence Research Consortium. J Endourol. 2023;37(6):617-22. https://doi.org/10.1089/end.2022.0561
• 24. Suarez-Ibarrola R, Hein S, Miernik A. Residual stone fragments: clinical implications and technological innovations. Curr Opin Urol. 2019;29(2):129-34. https://doi.org/10.1097/MOU.0000000000000571
• 25. Brain E, Geraghty RM, Lovegrove CE, Yang B, Somani BK. Natural History of Post-Treatment Kidney Stone Fragments: A Systematic Review and Meta-Analysis. J Urol. 2021;206(3):526-38. https://doi.org/10.1097/JU.0000000000001836
• 26. Ganpule A, Desai M. Fate of residual stones after percutaneous nephrolithotomy: a critical analysis. J Endourol. 2009;23(3):399-403. https://doi.org/10.1089/end.2008.0217
• 27. Olvera-Posada D, Ali SN, Dion M, Alenezi H, Denstedt JD, Razvi H. Natural History of Residual Fragments After Percutaneous Nephrolithotomy: Evaluation of Factors Related to Clinical Events and Intervention. Urology. 2016;97:46-50. https://doi.org/10.1016/j.urology.2016.06.049
• 28. Scoffone CM, Cracco CM, Cossu M, Grande S, Poggio M, Scarpa RM. Endoscopic combined intrarenal surgery in Galdakao-modified supine Valdivia position: a new standard for percutaneous nephrolithotomy? Eur Urol. 2008;54(6):1393-403. https://doi.org/10.1016/j.eururo.2008.07.073
• 29. Grasso M, Nord R, Bagley DH. Prone split leg and flank roll positioning: simultaneous antegrade and retrograde access to the upper urinary tract. J Endourol. 1993;7(4):307-10. https://doi.org/10.1089/end.1993.7.307