Zero-fragment Nephrolithotomy: A Multi-center Evaluation of Robotic Pyelolithotomy and Nephrolithotomy for Treating Renal Stones.

BACKGROUND: Robotic pyelolithotomy (RPL) and robotic nephrolithotomy (RNL) may be utilized for treating kidney stones as an alternative to percutaneous nephrolithotomy or flexible ureteroscopy. OBJECTIVE: To describe the techniques of RPL and RNL, and present multi-center outcome data for patients undergoing these procedures. DESIGN, SETTING, AND PARTICIPANTS: This study was a retrospective analysis of 27 patients undergoing RPL and RNL at five tertiary academic institutions between 2008 and 2014. SURGICAL PROCEDURE: RPL and RNL without use of renal ischemia. MEASUREMENTS: We assessed stone clearance by visual assessment and postoperative imaging. We also examined other factors, including complications (Clavien grade), estimated blood loss, operative time, and length of stay. RESULTS AND LIMITATIONS: Twenty-seven patients underwent 28 procedures for a mean renal stone size of 2.74cm (standard deviation: 1.4, range: 0.8-5.8). The mean stone volume was 10.2cm3. RPL accounted for 26 of these procedures. RNL was performed in one patient, while another underwent combined RPL-RNL. Indications included failed previous endourological management (13), staghorn calculi (five), gas containing stone (one), calyceal diverticulum (one), complex urinary tract reconstruction (two), and patient preference (four). The mean patient age was 35.6 yr and mean body mass index was 25.5kg/m2. Mean operative time/console times were 182min and 128min, respectively. The mean estimated blood loss was 38ml. The mean length of stay was 1.7 d. There was no significant change in preoperative and postoperative serum creatinine levels. The overall complication rate was 18.5% (Clavien 1=3.7%; 2=7.4%; 3b=7.4%). The complete stone-free rate was 96%. CONCLUSIONS: RPL and RNL are safe and reasonable options for removing renal stones in select patients. In particular, RPL allows the removal of stones without transgressing the parenchyma, reducing potential bleeding and nephron loss. PATIENT SUMMARY: The robotic approach allows for complete removal of the renal stone without fragmentation, thereby maximizing chances for complete stone clearance in one procedure.

Definitive Management of Failure After Pyeloplasty.

INTRODUCTION: Failure after pyeloplasty is difficult to manage. We report our experience managing pyeloplasty failures. METHODS: We retrospectively reviewed the case log of a single surgeon, from August 1996 to August 2014, to identify all patients undergoing a surgical procedure after failed pyeloplasty. We excluded patients without follow-up exceeding 1 year from initial postpyeloplasty procedure. Failure was defined as a need for additional definitive intervention. RESULTS: Of 247 laparoscopic pyeloplasties, 68 endopyelotomies and 305 simple laparoscopic nephrectomies reviewed, 41 were performed after previous pyeloplasty and had sufficient follow-up. Laparoscopic nephrectomy was performed in nine patients. All three secondary laparoscopic pyeloplasties were successful. Of 29 secondary endopyelotomies, 10 (34%) were successful. Of the 19 failures after secondary endopyelotomy, 12 patients had tertiary pyeloplasty (5 laparoscopic and 7 open surgical), 5 (26%) underwent tertiary endopyelotomy, and 2 (11%) required nephrectomy. Our overall endopyelotomy success rate was 38% (13/34) vs 100% (11/11) for secondary or tertiary pyeloplasty (4 patients lost to follow-up). Median time to failure was 5 months for endopyelotomy. Median follow-up for patients free from intervention was 40.2 months. CONCLUSIONS: Secondary pyeloplasty (including both laparoscopic and open surgical approach) is more than twice as successful as endopyelotomy after failed pyeloplasty. Secondary pyeloplasty is an excellent alternative to endopyelotomy in select patients with failure after initial pyeloplasty.

Ureteroscopy for nephrolithiasis in transplanted kidneys.

INTRODUCTION: While percutaneous nephrolithotomy (PCNL) is often the procedure of choice for renal and ureteral calculi in transplant kidneys, retrograde ureteroscopy (URS) is a less frequently applied but excellent option if stone burden is small. We retrospectively examined nine surgical cases performed in seven patients in what appears to be the largest single institutional series reported to date. MATERIALS AND METHODS: Seven patients underwent nine retrograde URS between June of 2009 and September of 2013, by two endourologists. These cases were reviewed retrospectively. RESULTS: Among the nine procedures, we were able to address the stone(s) endoscopically in seven. Among these procedures, laser lithotripsy was used in six cases, and basket stone extraction was applied in four procedures. Ureteral stents were placed following six procedures with ureteral access and treatment. Postoperative imaging revealed the patient to be stone free after five of the seven procedures with ureteral access and treatment. There were two postoperative urinary tract infections, and no major complications. Of the nine total procedures, six were outpatient, two were followed by observation stay < 24 hours, and one patient was admitted > 24 hours. Among the two failures, one underwent PCNL and the other had percutaneous nephrostomy (PNT) placed but expired from unrelated causes prior to the intended PCNL. CONCLUSIONS: Retrograde URS with laser lithotripsy and/or basket extraction is a reasonable option for treating small renal transplant stones, with most patients in our series being discharged as outpatients, having complete stone clearance and avoiding PCNL.