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in 10 (44%) patients. While routine use of CT may expose the
patient to unnecessary radiation exposure, it remains the
most sensitive study to determine complete stone clearance,
and it is possible that in patients undergoing ultrasound, a
small RF could have been missed. In the one patient where
stone clearance was incomplete (3 mm lower pole RF
detected on CT), it was when a concomitant lower pole
stone could not be identified and retrieved with the flexible
nephroscope. While it is important to assess the kidney for
residual stones with ultrasound, and flexible nephroscopy
can be used to retrieve stones, we consider RPL and RNL
better suited for patients with single stones to avoid these
issues. Further, this was a retrospective study, and as such
has the potential for reporting bias. Finally, our follow-up is
not long enough to assess repeat stone episodes or
interventions, which is an important marker for outcomes.
We also emphasize that the indication to perform robotic
surgery needs to take into account factors such as risk of
recurrence, and consequences of any re-do surgery in the
future. However, even in pediatric patients, robotic surgery
for kidney stones has been found to be safe and effective .
It is yet to be fully determined whether the da Vinci
system will have a significant role to play in the
management of complex stone disease. For the individual
urologist, utilization is likely to be based on the relationship
between three specific factors: skillset, logistics, and cost
. Obtaining percutaneous access can be quite challeng-
ing, and is one reason why the majority of urologists rely on
radiologists to get access . It is likely that the next
generation of urologists will be more comfortable and
skilled with robotics than at gaining percutaneous access.
Regarding logistical factors and access to equipment—
especially if the urologist has to rely on a radiologist—the
urologist is self-sufficient with robotics. However, there is
no doubt that robotics has high capital and instrument
costs, and in some centers which are not high-volume
robotic centers or do not have a robot it will be more
sensible to perform laparoscopy in these select patients.
Finally, further studies are required to determine the
efficacy of robotic surgery in comparison to the standard
of PCNL. A randomized controlled trial assessing the
comparative effectiveness of each procedure in respect to
SFR, morbidity and long-term retreatment may help define
future treatment algorithms.
5. Conclusion
RPL and RNL are safe and reasonable options for removing
large renal stones in select patients and for surgeons
experienced and comfortable with robotic kidney surgery.
RPL is ideal for single pelvic or partial staghorn stones,
whereas RNL is suitable for calyceal stones if the overlying
parenchyma is thin, providing a bloodless window into the
kidney. Advantages of both techniques include low risk of
sepsis and bleeding. More importantly, the robotic ap-
proach permits zero-fragment nephrolithotomy where the
stone is removed in toto thereby maximizing chances for
complete stone clearance, and avoiding the pitfall of future
retreatment due to retained fragments.
Author contributions: Khurshid R. Ghani had full access to all the data in
the study and takes responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: [11_TD$DIFF]Ghani, Madi, Elder, Hemal[4_TD$DIFF], Badani.
Acquisition of data: Swearingen, Sood, [12_TD$DIFF]Madi, Klaassen, Badani, Elder,
Wood, Hemal, Ghani.
Analysis and interpretation of data: [13_TD$DIFF] Ghani, Swearingen, Sood.
Drafting of the manuscript:[14_TD$DIFF] Ghani, Swearingen.
Critical revision of the manuscript for important intellectual content: [15_TD$DIFF]Madi,
Elder, Hemal, Badani, Ghani.
Statistical analysis: Swearingen.
Obtaining funding: Ghani.
Administrative, technical, or material support: Ghani, Madi, Badani, Elder,
Hemal.
Supervision: Ghani.
Other: None.
Financial disclosures: Khurshid R. Ghani certifies that all conflicts of
interest, including specific financial interests and relationships
and affiliations relevant to the subject matter or materials discussed in
the manuscript (eg, employment/affiliation, grants or funding,
consultancies, honoraria, stock ownership or options, expert testimony,
royalties, or patents filed, received, or pending), are the following:
None.
Funding/Support and role of the sponsor: None.
Appendix A. Supplementary data
The Surgery in Motion video accompanying this article
can be found in the online version at
and via
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