Skip to main content
Log in

Analysis of performance factors in 240 consecutive cases of robot-assisted flexible ureteroscopic stone treatment

  • Original Article
  • Published:
Journal of Robotic Surgery Aims and scope Submit manuscript

Abstract

Flexible ureteroscopy is the keystone of modern kidney stone treatment. Although a simple surgical technique achieves good clinical results and a low complication rate, there are high demands on the surgeon’s dexterity and ergonomic restrictions. Robotic-assisted flexible ureteroscopy (rfURS) could overcome these limitations. After 4 years of use of rfURS at a tertiary stone center, performance factors were analyzed to define the role of rfURS in kidney stone management. A rfURS system was installed in August 2014 at the SLK Kliniken (Heilbronn, Germany). Treatment data of N = 240 consecutive patients undergoing rfURS were prospectively collected and analyzed. The patient cohort represents typical stone formers. N = 240 renal units containing 443 stones with an average stone load of 1798 mm3 were treated. Surgical parameters as well as the peri- and postoperative complications were recorded, analyzed and compared to the current data in the literature. OR time 91 min, stone treatment time 55 min, stone treatment efficacy 33 mm3/min; perioperative complications 5.4%; robot times: preparation 5 min, docking 5 min, console time to stone contact 6 min, console time 75 min; postoperative complications 6.7%; postoperative length of stay 1.5 days; stone-free rate (residuals < 2 mm) 90% and re-treatment rate 8.75%. This consecutive series represents real-life data about the utilization of rfURS. The detailed analysis of performance factors revealed the successful utilization of the first generation of robotic systems in endourologic stone surgery, and indicates that the robot performs comparably to conventional flexible URS. Optimal ergonomics maintain the surgeon’s endurance in long-lasting surgeries.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Abbreviations

SWL:

Shock wave lithotripsy

RIRS:

Retrograde intrarenal surgery

PCNL:

Percutaneous nephrolitholapaxy

rfURS:

Robotic flexible ureterorenoscopy

cfURS:

Conventional flexible ureterorenoscopy

URS:

Ureterorenoscopy

UAS:

Ureteral access sheath

UPJ:

Ureteropelvic junction

SD:

Standard deviation

DJ:

Double-J catheter

References

  1. Desai MM, Aron M, Gill IS et al (2008) Flexible robotic retrograde renoscopy: description of novel robotic device and preliminary laboratory experience. Urology 72(1):42–46 (Epub 2008/03/29)

    Article  Google Scholar 

  2. Desai MM, Grover R, Aron M et al (2011) Robotic flexible ureteroscopy for renal calculi: initial clinical experience. J Urol 186(2):563–568 (Epub 2011/06/21)

    Article  Google Scholar 

  3. Saglam R, Muslumanoglu AY, Tokatli Z et al (2014) A new robot for flexible ureteroscopy: development and early clinical results (IDEAL stage 1-2b). Eur Urol 66(6):1092–1100 (Epub 2014/07/26)

    Article  Google Scholar 

  4. Astroza G, Catalan M, Consigliere L, Selman T, Salvado J, Rubilar F (2017) Is a ureteral stent required after use of ureteral access sheath in presented patients who undergo flexible ureteroscopy? Cent Eur J Urol 70(1):88–92 (Epub 2017/05/04)

    Google Scholar 

  5. Dindo D, Clavien PA (2008) What is a surgical complication? World J Surg 32(6):939–941 (Epub 2008/04/17)

    Article  Google Scholar 

  6. Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213 (Epub 2004/07/27)

    Article  Google Scholar 

  7. Geavlete P, Saglam R, Georgescu D et al (2016) Robotic flexible ureteroscopy versus classic flexible ureteroscopy in renal stones: the initial romanian experience. Chirurgia (Bucur) 111(4):326–329 (Epub 2016/09/09)

    Google Scholar 

  8. de la Rosette J, Denstedt J, Geavlete P et al (2014) The clinical research office of the endourological society ureteroscopy global study: indications, complications, and outcomes in 11,885 patients. J Endourol 28(2):131–139 (Epub 2013/10/24)

    Article  Google Scholar 

  9. De Coninck V, Keller EX, Rodriguez-Monsalve M, Audouin M, Doizi S, Traxer O (2018) Systematic review of ureteral access sheaths: facts and myths. BJU Int 122(6):959–969. https://doi.org/10.1111/bju.14389(Epub 2018/05/13)

    Article  Google Scholar 

  10. Schoenthaler M, Buchholz N, Farin E et al (2014) The Post-Ureteroscopic Lesion Scale (PULS): a multicenter video-based evaluation of inter-rater reliability. World J Urol. 32(4):1033–1040 (Epub 2013/10/19)

    Article  Google Scholar 

  11. Traxer O, Thomas A (2013) Prospective evaluation and classification of ureteral wall injuries resulting from insertion of a ureteral access sheath during retrograde intrarenal surgery. J Urol 189(2):580–584 (Epub 2012/09/18)

    Article  Google Scholar 

  12. Breda A, Territo A, Lopez-Martinez JM (2016) Benefits and risks of ureteral access sheaths for retrograde renal access. Curr Opin Urol 26(1):70–75 (Epub 2015/11/12)

    Article  Google Scholar 

  13. Tokas T, Herrmann TRW, Skolarikos A et al (2019) Pressure matters: intrarenal pressures during normal and pathological conditions, and impact of increased values to renal physiology. World J Urol 37(1):125–131. https://doi.org/10.1007/s00345-018-2378-4(Epub 2018/06/20)

    Article  Google Scholar 

  14. Jung H, Osther PJ (2015) Intraluminal pressure profiles during flexible ureterorenoscopy. Springerplus 4:373 (Epub 2015/07/29)

    Article  Google Scholar 

  15. Buttice S, Proietti S, Dragos L, Traxer O (2017) Are you familiar with the flow of the Roboflex avicenna pump? Allow me to explain. J Endourol 31(4):418–419 (Epub 2017/01/06)

    Article  Google Scholar 

  16. Sener TE, Cloutier J, Villa L et al (2016) Can we provide low intrarenal pressures with good irrigation flow by decreasing the size of ureteral access sheaths? J Endourol 30(1):49–55 (Epub 2015/09/19)

    Article  Google Scholar 

  17. Matlaga BR, Chew B, Eisner B et al (2018) Ureteroscopic laser lithotripsy: a review of dusting vs fragmentation with extraction. J Endourol 32(1):1–6 (Epub 2017/10/25)

    Article  Google Scholar 

  18. Humphreys MR, Shah OD, Monga M et al (2018) Dusting versus basketing during ureteroscopy-which technique is more efficacious? A prospective multicenter trial from the EDGE research consortium. J Urol 199(5):1272–1276 (Epub 2017/12/19)

    Article  Google Scholar 

  19. Tracey J, Gagin G, Morhardt D, Hollingsworth J, Ghani KR (2018) Ureteroscopic high-frequency dusting utilizing a 120-W holmium laser. J Endourol 32(4):290–295 (Epub 2017/12/15)

    Article  Google Scholar 

  20. Bultitude M, Smith D, Thomas K (2016) Contemporary management of stone disease: the new EAU urolithiasis guidelines for 2015. Eur Urol 69(3):483–484 (Epub 2015/08/26)

    Article  Google Scholar 

  21. Turk C, Petrik A, Sarica K et al (2016) EAU Guidelines on interventional treatment for urolithiasis. Eur Urol 69(3):475–482 (Epub 2015/09/08)

    Article  Google Scholar 

  22. Turk C, Petrik A, Sarica K et al (2016) EAU guidelines on diagnosis and conservative management of urolithiasis. Eur Urol 69(3):468–474 (Epub 2015/09/01)

    Article  Google Scholar 

  23. Finch W, Johnston R, Shaida N, Winterbottom A, Wiseman O (2014) Measuring stone volume—three-dimensional software reconstruction or an ellipsoid algebra formula? BJU Int 113(4):610–614 (Epub 2013/09/24)

    Article  Google Scholar 

  24. Rassweiler J, Fiedler M, Charalampogiannis N, Kabakci AS, Saglam R, Klein JT (2018) Robot-assisted flexible ureteroscopy: an update. Urolithiasis 46(1):69–77 (Epub 2017/11/25)

    Article  Google Scholar 

  25. Turna B, Stein RJ, Smaldone MC et al (2008) Safety and efficacy of flexible ureterorenoscopy and holmium:YAG lithotripsy for intrarenal stones in anticoagulated cases. J Urol 179(4):1415–1419 (Epub 2008/02/22)

    Article  Google Scholar 

  26. Proietti S, Dragos L, Emiliani E et al (2017) Ureteroscopic skills with and without Roboflex Avicenna in the K-box((R)) simulator. Cent Eur J Urol 70(1):76–80 (Epub 2017/05/04)

    Google Scholar 

  27. Amirabdollahian F, Livatino S, Vahedi B et al (2018) Prevalence of haptic feedback in robot-mediated surgery: a systematic review of literature. J Robot Surg. 12(1):11–25 (Epub 2017/12/03)

    Article  Google Scholar 

  28. Waters TR, Dick RB (2015) Evidence of health risks associated with prolonged standing at work and intervention effectiveness. Rehabil Nurs 40(3):148–165 (Epub 2014/07/22)

    Article  Google Scholar 

  29. Douk HS, Aghamiri MR, Ghorbani M, Farhood B, Bakhshandeh M, Hemmati HR (2018) Accuracy evaluation of distance inverse square law in determining virtual electron source location in Siemens Primus linac. Rep Pract Oncol Radiother 23(2):105–113 (Epub 2018/04/24)

    Article  Google Scholar 

  30. Talari HF, Monfaredi R, Wilson E et al (2017) Robotically assisted ureteroscopy for kidney exploration. Proc SPIE Int Soc Opt Eng 10135:1013512. https://doi.org/10.1117/12.2253862(Epub 2017/02/01)

    PubMed  PubMed Central  Google Scholar 

  31. Somani BK, Al-Qahtani SM, de Medina SD, Traxer O (2013) Outcomes of flexible ureterorenoscopy and laser fragmentation for renal stones: comparison between digital and conventional ureteroscope. Urology 82(5):1017–1019 (Epub 2013/09/05)

    Article  Google Scholar 

  32. York NE, Zheng M, Elmansy HM, Rivera ME, Krambeck AE, Lingeman JE (2019) Stone-free outcomes of flexible ureteroscopy for renal calculi utilizing computed tomography imaging. Urology 124:52–56 (Epub 2018/11/06)

    Article  Google Scholar 

  33. Cecen K, Karadag MA, Demir A, Bagcioglu M, Kocaaslan R, Sofikerim M (2014) Flexible ureterorenoscopy versus extracorporeal shock wave lithotripsy for the treatment of upper/middle calyx kidney stones of 10–20 mm: a retrospective analysis of 174 patients. Springerplus 3:557 (Epub 2014/10/22)

    Article  Google Scholar 

  34. Hyams ES, Munver R, Bird VG, Uberoi J, Shah O (2010) Flexible ureterorenoscopy and holmium laser lithotripsy for the management of renal stone burdens that measure 2 to 3 cm: a multi-institutional experience. J Endourol 24(10):1583–1588 (Epub 2010/07/16)

    Article  Google Scholar 

  35. Cohen J, Cohen S, Grasso M (2013) Ureteropyeloscopic treatment of large, complex intrarenal and proximal ureteral calculi. BJU Int 111(3 Pt B):E127–E131 (Epub 2012/07/05)

    Article  Google Scholar 

  36. Al-Qahtani SM, Gil-Deiz-de-Medina S, Traxer O (2012) Predictors of clinical outcomes of flexible ureterorenoscopy with holmium laser for renal stone greater than 2 cm. Adv Urol 2012:543537 (Epub 2011/07/09)

    Article  Google Scholar 

  37. Kandemir A, Guven S, Balasar M, Sonmez MG, Taskapu H, Gurbuz R (2017) A prospective randomized comparison of micropercutaneous nephrolithotomy (Microperc) and retrograde intrarenal surgery (RIRS) for the management of lower pole kidney stones. World J Urol 35(11):1771–1776 (Epub 2017/06/08)

    Article  Google Scholar 

Download references

Funding

The robotic device was provided by ELMED, Turkey.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Jan Klein.

Ethics declarations

Ethical approval

All procedures being performed were part of the routine care. Ethical approval was obtained by the local Ethical commitee.

Informed consent

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all patients for being included in the study.

Identifying information

No identifying information about patients is included in the article.

Conflict of interest

Jan Klein MD declares that he has no conflict of interest. Nikos Charalampogiannis MD declares that he has no conflict of interest. Marcel Fiedler MD declares that he has no conflict of interest. Gamal Wakileh MD declares that he has no conflict of interest. Ali Goezen MD declares that he has no conflict of interest. Jens Rassweiler MD declares that the Avicenna Roboflex system used in this study was provided by ELMED Medical Company (Ankara, Turkey).

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Klein, J., Charalampogiannis, N., Fiedler, M. et al. Analysis of performance factors in 240 consecutive cases of robot-assisted flexible ureteroscopic stone treatment. J Robotic Surg 15, 265–274 (2021). https://doi.org/10.1007/s11701-020-01103-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11701-020-01103-5

Keywords

Navigation