Managing staghorn calculi – a return to the dark ages of stone surgery with the aid of the robot
Reviewed by Hamid Abboudi

Khurshid Ghani and colleagues present a novel, yet all too familiar, approach to the management of patients with staghorn calculi, in the form of anatrophic nephrolithotomy - however with the aid of a robot. The aim of this study is to provide an alternative in cases where percutaneous nephrolithotomy (PCNL) is unlikely to achieve stone clearance with a single procedure. Three patients with staghorn calculi underwent robot assisted anatrophic nephrolithotomy (RANL), with ice slush renal hypothermia. The authors provide a step by step description for their new technique. Two patients had incomplete stone clearance with no intraoperative or postoperative complications. No patient required a blood transfusion or developed sepsis. Undoubtedly open anatrophic nephrolithotomy produces stone-free rates greater than PCNL, in the order of 80-100%; however it is rarely performed because of increased morbidity in the form of greater blood loss, pain and longer recovery. We are still striving for a procedure that allows complete stone removal in one sitting with minimal morbidity. Such a technique would provide a definitive and cost-effective alternative to current endourological treatments. The RANL failed to provide complete stone clearance in two out of the three patients. Furthermore the technique described, as with the open approach, requires dissection of the collecting system and with it associated urine extravasation and potential for urinoma formation. Furthermore, there are concerns pertaining to nephron function following this procedure and of course the cost element. For now PCNL remains the standard of care for treatment of patients with staghorn calculi. It is reassuring that surgical teams are pursing alternatives, however RANL requires further critical analysis in the form of intermediate and long-term data investigating cost, renal function and morbidity.

Robot-assisted anatrophic nephrolithotomy with renal hypothermia for managing staghorn calculi.
Ghani K, Rogers C, Sood A, et al.
JOURNAL OF ENDOUROLOGY
2013;27(11):1393-8.