BERKELEY, CA (UroToday.com) - Staghorn kidney stones represent a significant burden to both patients and the treating physicians. Historically, these complex stones have been managed by open anatrophic nephrolithotomy (OAN) or percutaneous nephrolithotomy (PCNL), which is currently the gold standard treatment modality for staghorn calculi. The advent of laparoscopy and subsequently robotic surgery in the United States and Europe as the preferred minimally-invasive approach to kidney surgery has expanded the boundaries of minimally-invasive complex stone surgery.
In the March issue of Journal of Endourology we reported our single surgeon, single-center outcomes of seven consecutive patients who underwent robotic anatrophic nephrolithotomy (RAN) for complex staghorn calculi. In this patient cohort, the mean patient age was 47 ± 16 years, mean body mass index was 31.9 ± 10.0 kg/m2, and 5 of 7 patients had complete staghorn calculi. Mean warm ischemia time was 35 ± 7 minutes, mean robotic time was 158 ± 51 minutes, and mean estimated blood loss was 121 ± 39 mL. Mean length of stay was 3.0 ± 1.7 days, and there was one perioperative complication. Five of 7 patients had > 90% reduction in stone burden, and two (29%) patients were completely stone free. Mean follow-up time was 5.1 ± 4.3 months, and there was no decrease in postoperative estimated glomerular filtration rate compared with preoperative values.
As with any new procedure, the outcomes will, and should, be measured against the gold standard, which in this case is PCNL. While no procedure can guarantee 100% complete stone-free rates, in experienced hands RAN may offer comparable stone-free rates to PCNL and provide the patient with additional treatment options. In our preliminary experience, we demonstrated that RAN might achieve complete stone-free rates with a single procedure, and with minimal operative blood loss and morbidity. RAN for the management of staghorn calculi is able to accomplish the tenets of open surgery in a less morbid fashion, and the stone-free rate is comparable to OAN. In the future, we plan on using laparoscopic ultrasonography to visualize adjacent calyces secondary to the inability to assess residual stone, burned with tactile feedback, in order to further increase stone-free rates.
No new procedure or technology is without limitations or drawbacks. Whether a robotic procedure for management of staghorn calculus proves to be cost-effective, compared to PCNL, remains to be determined. The potential cost-effective advantage of RAN is that it might offer a single procedure to render a patient completely stone free, particularly in cases where PCNL may take multiple procedures. We recommend that robotic surgeons who are comfortable with robot-assisted partial nephrectomy consider RAN in the appropriate patient, considering that there are duplicated steps common to both procedures, including the renal hilum exposure, renal vessel clamping, nephrotomy, collecting-system closure, and parenchymal closure. Longer follow-up is necessary to fully determine the effect of RAN on renal function, and further studies refining the technique will be welcomed to continue to legitimize RAN as a treatment option for complex staghorn calculi.
Written by:
Zachary Klaassen, MD; Sherita A. King, MD; and Rabii Madi, MD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Department of Surgery, Section of Urology, Medical College of Georgia-Georgia Regents University, Augusta, Georgia USA
Robot-assisted anatrophic nephrolithotomy: Description of technique and early results - Abstract
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