Robotic Anatrophic Nephrolithotomy: an Alternative in Managing Complex Renal Stone

Background: While endourological approaches remained the predominant surgical modes for treating nephrolithiasis, robotic assisted surgery has emerged as an alternative approach in managing complex renal stone. The indications include failed former approaches, aberrant renal anatomy, unfavorable stone location or concurrent renal pathology. Objective: To describe our surgical technique of Robotic assisted Anatrophic Nephrolithotomy (RAN) in managing complex renal stone Design, setting and participants: We described a case of RAN for complex right complete staghorn calculi. This is a 41 year old gentleman who presented with extensive bilateral renal, ureteric and bladder calculi. He had undergone multiple PCNL, RIRS and cystolitholapaxy for removal of the left renal, ureteric and bladder calculi. RAN was offered for his right complete staghorn calculi. Surgical procedure: Ureteric stenting was first performed. The patient was then repositioned in standard left lateral position. The 4-port Da Vinci Si System was used. 2 additional laparoscopic ports were placed for assistance and liver retraction. The key steps in RAN were as followed: 1. Colonic mobilization and hilar dissection 2. Renal mobilization and scoring 3. Vascular clamp and Anatrophic Nephrolithotomy 4. Renorrhaphy and Nephropexy. Outcome measurements and statistical analysis: Intraoperative and postoperative clinical outcomes were recorded. Results and limitations: The operating time was 190 min and blood loss was 150 ml. The warm ischemic time was 28 min. There was no peri‑operative complications and patient was discharged on post-operative day 3. Renal function remained normal post-operatively. Post-operative radiograph showed >90% stone clearance and the ureteric stent was removed on day 14. Stone analysis revealed calcium oxalate. Patient was diagnosed with primary hyperparathyroidism and managed separately after. Conclusion: Robotic assisted surgery serves as an additional armamentarium in managing complex renal stone. Comparable stone clearance can be achieved while reaping benefits of minimally invasive surgery.