Robotic Pyelolithotomy, Extended Pyelolithotomy, Nephrolithotomy, and Anatrophic Nephrolithotomy

Introduction: We are a reporting on the indications, techniques, and limitations of robotic surgery in the management of renal stones disease. Robotic surgery is a good tool to manage large kidney and ureteral stones, particularly in patients with anatomic anomalies. We describe three techniques in managing staghorn kidney stones: robotic anatrophic nephrolithotomy, robotic pyelolithotomy, and robotic nephrolithotomy. Material and Methods: Robotic pyelolithotomy (RP) is ideal for patients with large renal pelvis and partial staghorn stone with a wide extra-renal pelvis. Robotic nephrolithotomy (RN) is ideal for stones inside a calyceal diverticulum or a partial staghorn eroding into the renal parenchyma. Renal vascular control could be avoided in most of those surgeries. Robotic anatrophic nephrolithotomy (RAN) is the most complex procedure and is reserved for patients with complete staghorn stones when percutaneous approach was not successful or not feasible. Control of renal vasculature is required for RAN. Results: For robotic kidney surgeries, patients are positioned in a lateral decubitus position. Four or five ports are placed based on the stone location and surgeon's preference. We prefer the trans-peritoneal approach as it gives us the optimal exposure. For RP and RN, hilar control is usually not required. The renal pelvis/ renal parenchyma is incised, and the stones are carefully removed. If needed intra-operative flexible nephoscopy can be used to remove residual stones fragments. The collecting system is closed using an absorbable suture. DJ stent if needed is placed in an antegrade fashion. For RAN, the kidney is fully mobilized, and hilar control is required to avoid excessive bleeding. The kidney is incised along Brodel's line and the stones are extracted. The kidney parenchyma is then closed using 1 or 2 layers. We achieved an almost 100% stone free rate with RP and RN. RAN remains a challenging procedure with a success rate around 70%. Conclusion: Robotic surgery is a viable option to manage large renal and ureteral stones particularly in situations where endoscopic approach is not successful or feasible.