V03-12: Treatment of large kidney stones by using robotic assisted flexible ureteroscopy.
International guidelines universally recommend PCNL as the treatment of choice for large renal stones. In the past decade, many centers have reported on classical retrograde intra-renal surgery for large renal stones. Recently Robotic Assisted Retrograde Intrarenal Surgery provides better stone free rates with some more advantages for the patient, user and the endoscopic device.
This video demonstrates the step-by-step technique and advantages of Avicenna Roboflex robotic assisted retrograde intra-renal surgery (RA-RIRS), the latest iteration of master-slave robotics in this field. Due to reduced invasiveness, the patient, a 50 year old Iraqi general surgeon, preferred this approach over PCNL. Non-contrast CT showed a large (2941.5mm3) left renal stone, with 1076 bone window Hounsfield units. Our previous studies have shown: a) an upper stone volume limit of 4000mm3 with HU of 1000 for RA-RIRS, yielding 89% single-session stone free rate; b) that ureteral access sheath size >11/13Fr allows 35 ml/min. irrigation without raising intra-renal pressure >25 cm water, optimizing safety and vision, while allowing irrigant and dust efflux compared to smaller sheaths.
The RA-RIRS procedure was uncomplicated. Optimized efficiency led to single stage complete stone fragmentation (stone dusting time 74 minutes, fragmentation efficiency 32 mm3/min). RA-RIRS benefits to the surgeon included improved comfort + ergonomics, touch-screen adjustable endoscope motion scaling, laser fiber positioning, control of respiratory excursion + irrigation flow and less fatigue (no lead protection required).
The Avicenna Roboflex allows safe, efficient single stage treatment of renal stones larger than is recommended by current international guidelines. Key design features optimize patient safety and instrument longevity significantly compared to manual operation and by reducing surgeon fatigue, optimizes potential for efficiency.