Robot-assisted anatrophic nephrolithotomy: description of technique and early results

Medical dissolution of presumptive upper urinary tract struvite uroliths in 6 dogs (2012-2018)

BACKGROUND

Minimally invasive approaches are the standard for treatment of upper urinary tract uroliths in humans.

OBJECTIVE

To describe the medical dissolution of upper urinary tract uroliths in a series of dogs and report clinical outcomes.

ANIMALS

6 female dogs (9 kidneys).

METHODS

Retrospective case series. A review of medical records in dogs that underwent medical dissolution of upper urinary tract uroliths utilizing diet, administration of antibiotics, and double-pigtail ureteral stent(s) placement, when indicated, was performed. Medical management was generally continued for 4 weeks beyond urolith dissolution. Information on biochemical, microbiological, imaging, and clinical outcomes before and after dissolution were recorded.

RESULTS

Six dogs (9 kidneys) were included with bilateral (3) or unilateral (3) nephrolithiasis, ureterolithiasis, or a combination. A ureteral stent(s) was placed endoscopically in 5/6 dogs (6/9 kidneys) for obstructive ureterolithiasis (n = 5) or a nonobstructive massive nephrolith (n = 1). All dogs had a positive urine culture of Staphylococcus pseudintermedius with a median urine pH of 7.25 (range, 6.5-8) and 4/5 had pyonephrosis. All dogs had initial evidence of urolith dissolution at a median of 1.1 months (range, 0.42-5.9), with complete dissolution of ureteroliths at a median of 3.9 months (range, 1.5-7.6), nephroliths at 5.3 months (range, 1.5-7.6), and lower urinary tract uroliths at 0.87 months (range, 0.42-5.9). Stents were removed in 3/6 once dissolution was documented. The median follow-up time was 519 days (range, 177-2492 days).

CONCLUSION AND CLINICAL IMPORTANCE

Medical dissolution and decompression of upper urinary tract struvite uroliths should be considered a minimally invasive treatment for dogs before more invasive options.

Robotic pyelolithotomy for the treatment of large renal stones: a single-center experience over seven years

BACKGROUND

Urolithiasis prevalence varies globally between 1-20%, influenced by regional factors. Robotic pyelolithotomy (RPL) presents an interesting alternative to PCNL, considered the gold standard for symptomatic stones smaller than 20 mm, as it carries a risk of significant complications. However, studies on RPL are limited, especially in anatomically complex cases, where RPL proves to be particularly useful. The study aims to update and review outcomes of RPL in a high-volume robotic center.

METHODS

A retrospective analysis of 153 patients treated with RPL for staghorn kidney stones at a single center from February 2016 to December 2023 was conducted. Data including demographics, preoperative renal function, stone characteristics, operative and postoperative outcomes, and costs were collected. Stone-free rates (SFR) and complications were assessed at follow-up intervals up to 12 months post-surgery.

RESULTS

The study showed an initial 3-month stone-free rate (SFR) of 93.5%, which decreased to 83.5% at 12-months. This trend may reflect new stone formation rather than procedure failure. Sub-analysis revealed a significant difference in SFR between patients with pelvic and pyelocalyceal stones at each follow-up. Multivariate regression analysis identified in the pyelocalyceal group that higher BMI and larger stones were associated with higher failure rates at both 6 and 12 months.

CONCLUSIONS

RPL is a safe and effective treatment for large renal stones, offering a high SFR and low complication rate. It is particularly beneficial in cases with complex anatomy or requiring concurrent renal procedures. However, patient selection is crucial, considering factors like stone location and size. Further research is needed to compare RPL with other treatment methods.

International Alliance of Urolithiasis (IAU) guideline on staghorn calculi management

BACKGROUND

The stone burden based management strategy reported in the guidelines published by different associations is well known for a long time. Staghorn calculi, representing the largest burden and most complex stones, is one of the most challenging cases to practicing urologists in clinical practice. The International Alliance of Urolithiasis (IAU) has released a series of guidelines on the management of urolithiasis.

PURPOSE

To develop a series of recommendations for the contemporary management management of staghorn calculi and to provide a clinical framework for urologists treating patients with these complex stones.

METHODS

A comprehensive literature search for articles published in English between 01/01/1976 and 31/12/2022 in the PubMed, OVID, Embase and Medline database is performed. A series of recommendations are developed and individually graded following the review of literature and panel discussion.

RESULTS

The definition, pathogenesis, pathophysiology, preoperative evaluation, intraoperative treatment strategies and procedural advice, early postoperative management, follow up and prevention of stone recurrence are summarized in the present document.

CONCLUSION

A series of recommendations regarding the management of staghorn calculi, along with related commentary and supporting documentation offered in the present guideline is intended to provide a clinical framework for the practicing urologists in the management of staghorn calculi.

Robotic Surgery for Stone Disease

PURPOSE OF REVIEW

To evaluate recent literature regarding the role of robotic technology in the treatment of nephrolithiasis with particular attention to complex technical procedures.

RECENT FINDINGS

Robotic platforms including single-port robotics have been widely adopted in urological practice for the treatment of both malignant and benign conditions and has led to an expansion of the utilization of robot-assisted surgery to tackle challenging clinical scenarios such as bladder neck reconstruction, upper urinary tract reconstruction, and more recently complex stone disease. Presently, the American Urological Association guidelines on the surgical management of stones advise against using robotic, open, or laparoscopic techniques as a first-line approach for most patients with stone disease with the exception for patients with anatomical abnormalities, large or complex stones, or patients requiring a concomitant reconstructive operation. Clinicians have demonstrated the safety and feasibility of surgical robotics in the treatment of stone disease for a variety of operations including robotic pyeloplasty, pyelolithotomy, ureterolithotomy, and surgical interventions in urinary diversions as well as novel technologies for robotic ureteroscopy and percutaneous access. Numerous clinicians have demonstrated the safety and feasibility of using robot-assisted surgery to treat nephrolithiasis, mainly in complex renal anatomy. Further research is necessary to identify the best candidates for utilization of robotics in complex stone disease, and further technological developments will continue to further advance the use of these platforms in the treatment of nephrolithiasis.

Robot-assisted anatrophic nephrolithotomy for complete staghorn stone

To assess the efficacy and safety of robot-assisted anatrophic nephrolithotomy (RANL) as a choice of minimally invasive treatment for patients with complete staghorn stone. In a single-tertiary referral center retrospective study, 10 consecutive patients underwent RANL for complete staghorn stone. After dissection to the renal hilum and clamping of the renal vessels, an incision was made along the Brodel line and exposed the collecting system to extract the stone. Then, the collecting system and parenchyma were closed in layers. The outcomes included reduction of the stone burden, short- and long-term postoperative kidney function, and pain score. The average age of patients was 54.6 years and body mass index was 27.58 kg/m2. Mean warm ischemia time was 28.40 minutes, mean robotic console time was 137 minutes, and mean estimated blood loss was 83 mL. The mean length of stay was 5.4 days and there were no severe perioperative complications. Eight of 10 patients had >90% reduction in stone burden and 5 (50%) patients were completely stone-free. There was no significant decrease in postoperative estimated glomerular filtration rate compared with preoperative values after 1 month and 1 year. Our experience with RANL demonstrated efficacy and safety in the minimally invasive treatment of complete staghorn stone in short- and long-term follow-up periods.

Urinary lithiasis - conventional open surgery

The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize producers to assist the reasoning and decision-making of doctors. The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical status of each patient.

Robotic management of large stone disease: a case series

The gold standard for urologic management of large stone disease traditionally has been percutaneous nephrolithotomy (PCNL). An alternative to PCNL is robotic pyelolithotomy (RP), which continues to gain traction. This study is a retrospective review of ten cases performed over a 2 year period presenting operative outcomes for large stone disease treated with RP. The mean and standard deviation were calculated for age, body mass index, stone volume, stone diameter, pre-operative creatinine, operative time, robot-docked time, length of stay, post-operative creatinine, and estimated blood loss. In addition, results were collected for post-operative complications and secondary procedure requirements. Complete stone clearance was successful in 9 of 10 cases. The average renal function remained stable from a pre-operative creatinine of 0.917 mg/dL to a post-operative creatinine level of 0.943 mg/dL. This case series demonstrates that robotic assisted surgery has practical application when managing large stone disease.

Robot-assisted laparoendoscopic single-site surgery for the simultaneous management of multiple urinary tract calculi: a case report and experience sharing

Background

Urolithiasis is a clinically common benign disease in urology. Surgical treatments that are widely used in urolithiasis are percutaneous nephrolithotomy, rigid/flexible ureteroscopy, laparoscopic surgery, and endoscopic combined intrarenal surgery. The da Vinci surgical system is rarely used in the treatment of urolithiasis. In the current study, we report a case of multiple urinary tract calculi treated by robot-assisted laparoendoscopic single-site (RA-LESS) surgery.

Case presentation

A 49-year-old male patient was admitted to our hospital and diagnosed with multiple urinary tract calculi. He previously underwent right ureterolithotomy, laparoscopic cholecystectomy, and extracorporeal shockwave lithotripsy. Computed tomography (CT) scan and three-dimensional reconstruction CT image showed that multiple calculi were located in the right kidney, right upper ureter, and bladder. The preoperative glomerular filtration rate (GFR) were 17.81 ml/min (right kidney) and 53.11 ml/min (left kidney). We utilized the da Vinci system docking with a single-site port to perform pyelolithotomy, ureterolithotomy, and cystolithotomy, simultaneously. The operative time was 135 min and estimated blood loss was 30 ml. The postoperative hospital stay was 5 days. Three months after surgery, the serum creatinine and urea nitrogen levels dropped to a normal range, and no residual fragments were found in the CT scan. The postoperative GFR were 26.33 ml/min (right kidney) and 55.25 ml/min (left kidney).

Conclusions

RA-LESS surgery is a safe and effective surgical procedure in the treatment of multiple urinary tract calculi; however, further investigation is needed to validate its long-term therapeutic effect.

The role of robotic surgery in the management of renal tract calculi

The role of robotic assisted surgery in contemporary urolithiasis management is in its infancy. The mainstay in the management of renal tract calculi remains ureterorenoscopy (URS), extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrolithotomy (PCNL). However, in rare clinical circumstances, such as large impacted pelvic and ureteric calculi, endo-urological techniques may not be adequate. Furthermore, patient may have a synchronous pathology such as pelvi-ureteric obstruction which preferably should be concurrently treated with the renal calculi in a single sitting. Robotic assisted laparoscopic ureterolithotomy (RALU), robotic assisted laparoscopic pyelolithotomy (RPL) with or without concurrent pyeloplasty and Robotic assisted laparoscopic anatrophic nephrolithotomy have all been described for complex stones. Additionally, technical challenges with a flexible ureteroscopy (FURS) have led to the development of robotic assisted flexible ureteroscopes. In the article we summarize the role of robotic assisted surgery in complex renal tract calculi.

Utilizing da Vinci® surgical system to treat challenging urinary stones

Introduction:

A worldwide mounting in the incidence and prevalence of urolithiasis has been observed. The standard treatment of urologic stone disease (USD) has changed from open surgery to extracorporeal shock wave lithotripsy, percutaneous nephrolithotomy (PCNL), or ureteroscopy depending on the size and location of the stone. We are sharing our experience in utilizing Da Vinci^® robotic surgical system to treat patient with urolithiasis instead of open surgical approach.

Patients and Methods:

We reviewed prospectively collected data of 19 patients who underwent robotic-assisted stone surgery (RSS) between January 2010 and March 2018 at our institute for USD involving 22 nephroureteral units.

Results:

A total number of 22 RSS were accomplished with no conversion to open. Three patients had bilateral stone and needed to have RSS on each side separately. Eleven RSS were performed on the right. The indications for RSS included as follows: morbid obesity (n = 8, mean body mass index 56.4 kg/m²), need for concurrent renal surgery (n = 3) severe contractures limiting positioning for retrograde endoscopic surgery or PCNL (n = 2), symptomatic calyceal diverticular stone with failed endoscopic approach (n = 4), and after failed PCNL (n = 2). Twenty nephrouretral unit (91%) were rendered stone free on the first attempt with complication occurring after four cases (18%).

Conclusion:

RSS is viable options in the treatment of challenging urologic stone with high success rate and low risk of complication. The need for open stone surgery was eliminated by RSS at our center.

Update on Surgical Management of Pediatric Urolithiasis

Urolithiasis has always been a fascinating disease, even more so in children. There are many intriguing facets to this pathology. This article is a nonsystematic review to provide an update on the surgical management of pediatric urolithiasis. It highlights the pros and cons of various minimally invasive surgical options such as extracorporeal shockwave lithotripsy (ESWL), retrograde intrarenal surgery (RIRS), percutaneous nephrolithotomy (PCNL), laparoscopy, and robotics. This article also describes the various intracorporeal disintegration technologies available to fragment the stone, including the newer advancements in laser technology. It also emphasizes the cost considerations especially with reference to the emerging economies. Thus, this manuscript guides how to select the least-invasive option for an individual patient, considering age and gender; stone size, location, and composition; and facilities and expertise available.

Robotic pyelolithotomy for the treatment of large renal stones: a single-center experience

BACKGROUND

Few studies have reported robotic pyelolithotomy (RPL) series; furthermore, the most of all have reported small and single-center series. Herein we report our experience from 70 cases of complex kidney stones treated with RPL at our surgical center; this study reports the largest series of RPL in a minimal invasive experienced center.

METHODS

Between February 2016 and March 2018, 70 patients with complex renal stones (Guy's Stone Score: 4) underwent RPL and included in a prospectively maintained institutional database. Baseline characteristics, clinical data, perioperative data, postoperative data and stone free status were assessed by descriptive statistics.

RESULTS

Of 70 patients, 72.85% presented renal pelvis stones. The mean maximum stone diameter was 33.1±14.5 mm (median 30 mm; interquartile range 22-40 mm). Mean total operative duration was 122.5±34.4 min (median 120 min; interquartile range 105-135 min). In two patients (2.8%), a grade III complications were noted; no major complications (grade IV-V) were noted. The complete SFR, after a single robotic procedure, was 92.8%.

CONCLUSIONS

Our findings suggest that RPL is a safe, reproducible and minimally invasive approach as treatment of large renal stones when endoscopic treatment failed or was not available. RPL permits to achieve an excellent stone free status, in a single definitive procedure.

Contemporary best practice in the management of staghorn calculi

Staghorn calculi are complex renal stones that occupy the majority of the renal collecting system. These stones are associated with high morbidity and can lead to recurrent urinary tract infections, urosepsis, renal deterioration, and death if left untreated. Managing patients with staghorn calculi can be challenging. Fortunately, advances in technology and endourology techniques have enabled urologists to effectively treat these stones with minimal morbidity to the patient. This article describes the contemporary best practices in the initial evaluation, management, and follow up of patients with staghorn calculi to help the practicing urologist navigate this complex condition.

Anatomic and Radiologic Study of Renal Avascular Plane (Brödel's Line) and Its Potential Relevance on Percutaneous and Surgical Approaches to the Kidney

OBJECTIVE

The aim of the present anatomic and radiologic study was to evaluate the location, extension, and characteristics of the Brödel's plane and eventually define its different patterns.

MATERIALS AND METHODS

We evaluated 15 human normal kidneys sampled from unembalmed cadavers without clinical history or anatomical evidence of renal diseases. Kidneys with the surrounding perirenal fat tissue were removed en bloc with the abdominal segment of the aorta. The renal artery was injected with acrylic and radiopaque resins. A CT examination of the injected kidneys was performed. After the imaging acquisition, the specimens were treated with sodium hydroxide for removal of the parenchyma to obtain the vascular casts. All the CT images were elaborated using dedicated three-dimensional (3D) software with the aim to improve the possibility to identify the Brödel's plane. The avascular plane was identified directly on the vascular casts and confirmed on the corresponding 3D images.

RESULTS

The avascular plane was located in all cases medially to the lateral convex border of the kidneys. The recorded mean distance was 2.04 cm (range 1.8-2.4 cm). Three patterns of distribution of the Brödel's line were identified. In five (33.3%) cases the avascular plane was extended from the apical to the inferior segment of the kidneys (type 1); in six (40%) from the superior to the inferior segment (type 2); and in four (26.7%) from the apical to the middle segment (type 3). Fourth and fifth order vessels crossing the Brödel's line were detected in all the analyzed cases.

CONCLUSIONS

The renal avascular plane showed a different extension allowing us to cluster three different patterns. Preoperative identification of the Brödel's line patterns could help surgeons to minimize hemorrhagic complications during percutaneous and surgical procedures requiring an incision of the renal parenchyma such as traditional or robot-assisted nephrolithotomy or partial nephrectomy for endophytic renal tumors. Radiologic studies validated that the described patterns in the clinical practice are strongly needed.

Robotic Management of Urolithiasis in the Pediatric Population

A variety of surgical techniques exist for the management of urolithiasis. Minimally invasive techniques have replaced open surgery in the last few decades. For complex stone management, robotic-assisted laparoscopic surgery (RALS) has emerged as a safe and feasible alternative in adults. The literature for RALS for urolithiasis (RALS-UL) in the pediatric population is scarce. Herein, we present a review of the literature in both adult and pediatric patients as well as our experience using RALS-UL at our institutions. Special attention is given to the synchronous management of urolithiasis when surgery is performed for other conditions such as ureteropelvic junction obstruction (UPJO), and a supplemental video is provided.

Expanding the indications of robotic surgery in urology: A systematic review of the literature

Objectives

To evaluate the recent developments in robotic urological surgery, as the introduction of robotic technology has overcome many of the difficulties of pure laparoscopic surgery enabling surgeons to perform complex minimally invasive procedures with a shorter learning curve. Robot-assisted surgery (RAS) is now offered as the standard for various surgical procedures across multiple specialities.

Methods

A systematic search of MEDLINE, PubMed and EMBASE databases was performed to identify studies evaluating robot-assisted simple prostatectomy, salvage radical prostatectomy, surgery for urolithiasis, distal ureteric reconstruction, retroperitoneal lymph node dissection, augmentation ileocystoplasty, and artificial urinary sphincter insertion. Article titles, abstracts, and full text manuscripts were screened to identify relevant studies, which then underwent data extraction and analysis.

Results

In all, 72 studies evaluating the above techniques were identified. Almost all studies were retrospective single-arm case series. RAS appears to be associated with reduced morbidity, less blood loss, reduced length of stay, and comparable clinical outcomes in comparison to the corresponding open procedures, whilst having a shorter operative duration and learning curve compared to the equivalent laparoscopic techniques.

Conclusion

Emerging data demonstrate that the breadth and complexity of urological procedures performed using the da Vinci® platform (Intuitive Surgical Inc., Sunnyvale, CA, USA) is continually expanding. There is a gaining consensus that RAS is producing promising surgical results in a wide range of procedures. A major limitation of the current literature is the sparsity of comparative trials evaluating these procedures.

Long-term effects of anatrophic nephrolithotomy on selective renal function

To evaluate the long-term changes of selective renal function after anatrophic nephrolithotomy (ANL). A retrospective study was conducted for patients who underwent ANL between January 1995 and December 2016. Inclusion criteria were availability of preoperative and follow-up (1 year or more) radio-isotopic renal scans. Stone-free status was evaluated after 1 month with KUB and ultrasonography or NCCT. Renal isotope scans using 99mTc MAG3 were performed to measure the changes in selective function of the affected kidney (GFR%). Eligible patients were classified into two groups, group 1 patients with stable or improved function and group 2 patients with deteriorated function (> 5% decrease in GFR%). Univariate and multivariate analyses were performed to determine risk factors for deterioration of renal function. The cutoff value for any significant variable was determined using ROC curve. The study included 50 patients with mean age 43.8 + 13.9 years. Complications developed in 26 patients (52%), and stone-free status was documented in 42 patients (84%). After a median follow-up of 2.7 years (range 1-11), mean GFR% of all cases significantly decreased from preoperative value of 52.7% + SD 20 to 45.4% + SD 25% during follow-up (P < 0.001). Deterioration of GFR% was documented in 21 kidneys (42%). Cold ischemia time with a cutoff value 50 min was the independent risk factor (RR 3.986, 95% CI 1.069-14.869, P 0.039). The results of this study support limiting ANL to a selected group of patients and taking all the possible efforts to minimize cold ischemia time below 50 min.

Laparoscopic and robotic surgery for stone disease

Treatment for stone disease has evolved drastically during the past 3-4 decades. Ureteroscopy, percutaneous nephrolithotomy along with SWL, provides the means to treat practically all urinary tract stones with minimal invasion to the patients. However, for complex stone case scenarios where open surgery is being considered, a less invasive and better tolerated option such as laparoscopy (robot assisted or not) can be performed. The present manuscript reviews role of laparoscopic and robotic surgery in treating urinary tract stones.

Robotic stone surgery - Current state and future prospects: A systematic review

Objective

To provide a comprehensive review of robot-assisted surgery in urolithiasis and to consider the future prospects of robotic approaches in stone surgery.

Materials and methods

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.

Results

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.

Conclusions

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.

Anatrophic Nephrolithotomy in the Management of Large Staghorn Calculi - A Single Centre Experience

INTRODUCTION

With advances in endourology, open stone surgery for staghorn calculi has markedly diminished. Anatrophic Nephrolithotomy (AN) is performed for complex staghorn stones which cannot be cleared by a reasonable number of Percutaneous Nephrolithotomy (PNL) attempts.

AIM

To assess the indications and outcomes of AN in the modern era.

MATERIALS AND METHODS

Between April 2008 and July 2015, AN was done in 14 renal units in 13 patients. In this retrospective study, demography, stone characteristics, operative details, clearance and long term outcomes were assessed.

RESULTS

AN was performed for complex staghorn calculi involving pelvis and all calyces in 10 patients, infundibular stenosis in two patients and failed PNL in one patient. Mean (SD) in situ cold ischemia time was 47.64 (5.27) minutes. Retroperitoneal drain and double J stent were placed in all 13 patients. Median (IQR) estimated blood loss was 130 (75) ml. There was no perioperative mortality. Surgical site infection was seen in 2 patients and urosepsis in 2 patients. Drain was removed at a mean (SD) of 9.11 (6.15) days. Mean (SD) postoperative length of hospitalization was 15.44 (7.14) days. Stent removal was done in all patients between 2-8 weeks. Median (IQR) clearance was 95 (7.5%). There was no renal failure or new calculi during the follow up period {median (IQR): 1(3) years}.

CONCLUSION

AN is effective in management of large staghorn calculi failed minimally invasive approaches and achieves 80%-100% clearance without much need for secondary interventions. Renal function is preserved and with emergence of laparoscopy and robotics, postoperative stay is minimized with expedited recovery and comparable results with open surgery.

Robotic Anatrophic Nephrolithotomy Utilizing Near-infrared Fluorescence Image-guidance: Idea, Development, Exploration, Assessment, and Long-term Monitoring (IDEAL) Stage 0 Animal Model Study

OBJECTIVE

To test the feasibility of robotic anatrophic nephrolithotomy (RANL) using near-infrared fluorescence (NIRF) image-guidance for treating staghorn stones, in an in vivo stone surgery model.

METHODS

We developed a novel technique of RANL in a preclinical setting following guidelines on safe surgical innovation from the Idea, Development, Exploration, Assessment, Long-term monitoring (IDEAL) collaborative. We performed 2 RANL procedures on 2 live Yorkshire porcine females (IDEAL stage 0 study). The robot was docked in the flank position and a mini-GelPOINT was placed periumbilically as an assistant port. A model staghorn "stone" was created in vivo by injecting low-viscosity DenMat precision material into the renal pelvis. NIRF image-guidance, following clamping of the posterior renal artery, was used to determine if an anatrophic plane could be identified. One procedure was assessed under cold ischemia, with ice-slush injected onto the renal surface via the mini-GelPOINT.

RESULTS

Both porcine subjects underwent RANL successfully. Replica staghorn models could be created reliably (mean size 5.1 cm; solidification time 2-3 minutes). NIRF image-guidance afforded clear vascular demarcation for precise scoring of an anatrophic plane in both kidneys. The staghorn models were removed in toto through the anatrophic incision in both subjects. Mean blood loss was 160 cc. Mean console and ischemia times were 114 minutes and 34.5 minutes, respectively; ice-slush hypothermia led to a renal surface temperature of 15.4°C.

CONCLUSION

In this IDEAL stage 0 preclinical study, we demonstrated that NIRF image-guidance is able to accurately identify the renal avascular plane, thus permitting an anatrophic approach for robotic excision of staghorn stones.

The management of large staghorn renal stones by percutaneous versus laparoscopic versus open nephrolithotomy: a comparative analysis of clinical efficacy and functional outcome

The objective of this study was to analyze the outcome of percutaneous nephrolithotomy (PCNL), laparoscopic and open anatrophic nephrolithotomy (AN) for management of patients with large staghorn renal stones. We analyzed the peri-operative parameters, overall treatment costs and changes in the function of the affected kidney on technetium-99 dimercaptosuccinic acid renal scintigraphy, done before the operation and before the final follow-up visit, in 45 adults who underwent PCNL (n = 16) versus laparoscopic (n = 15) versus open (n = 14) AN for large staghorn renal stones. All three groups had statistically similar preoperative characteristics, including the function of the operated kidney on renal scan. On the discharge day, the PCNL group had the lowest stone-free rate (43.75 %) compared to the laparoscopic (80 %) and open AN groups (92.85 %) (P = 0.009). After a mean follow-up period of 12.1 months, the decrease in the function of the operated kidney was greatest in the open AN group (-8.66 ± 4.97) compared to the laparoscopic AN (-6.04 ± 6.52) and PCNL group (-2.12 ± 2.77) (P = 0.003). The need for ancillary procedures to manage residual stones was greatest in the PCNL group and lowest in the open AN group. A similar trend was seen in overall treatment costs (P < 0.001). For management of large staghorn renal stones, the more invasive the procedure, the higher the one-session stone-free rate and the lower the need for ancillary procedures; however, greater renal functional loss can be anticipated. The need for ancillary procedures is a major determining factor in the overall cost of treatment, which was highest in the PCNL group.

Review on renal recovery after anatrophic nephrolithotomy: Are we really healing our patients?

The main goals for urinary stone treatment are to preserve renal function, reduce or avoid complications related to calculi, and to render the patient free of calculi as soon as possible. Anatrophic nephrolithotomy (ANL) is a valid and useful alternative for conventional staghorn calculi excision. Although excellent stone free rates can be achieved with ANL there are some drawbacks that may be of concern. Morbidity related to intraoperative and postoperative complications is one of them. Another, great concern is the possibility of reduction on renal function related to the procedure itself. This may be related to nephron injury during nephrotomy and parenchymal closure or to ischemic injury. In this review we assess functional results after anatrophic nephrolithotomy.

[Single procedure treatment of complex nephrolithiasis: about a modern series of anatrophic nephrolithotomy]

PURPOSE

Advances in endourology have significantly reduced indications of open surgery in the treatment of staghorn calculi. However, in our experience, open surgery is still the treatment of choice in some cases. This study presents the results of a series of selected patients and discusses the results in terms of efficacy and morbidity.

MATERIALS

A cohort of 26 patients underwent anatrophic nephrolithotomy by lombotomy to treat a complex staghorn calculus.

RESULTS

The mean stone size was 68,5mm, 70% were complete staghorn calculi. The operative time was 100minutes. Blood loss was 225mL, with a postoperative transfusion rate of 15.4%. The hospital stay was 8.4 days. The stone free rate following the procedure was 92%. The creatinine clearance (MDRD) at 3 months was improved from 5.9mL/min/m(2) on average over the entire series.

CONCLUSION

There are clearly still indications for open surgery in staghorn stones management, with good results in this contemporary series on both stone removal and nephronic preservation. Yet, it appears that this technique is no longer taught.

LEVEL OF EVIDENCE

5.