ENDOUROLOGY & LAPAROSCOPY

Early Results of Robot Assisted Laparoscopic Lithotomy in Adolescents
Lee RS, Passerotti CC, Cendron M, Estrada CR, Borer JG, Peters CA
Department of Urology, Children’s Hospital Boston, Boston, Massachusetts, and Department of Urology, University of Virginia, Charlottesville, Virginia
J Urol. 2007; 177: 2306-2310

• Purpose: The treatment of large stone burdens in children is difficult and often requires multiple procedures using a combination of therapies. Recently, laparoscopy has been shown to be effective in the management of larger stone burdens. We report our experience with robot assisted laparoscopic lithotomy in adolescents, and describe our technique.
• Materials and Methods: We retrospectively reviewed our experience with robot assisted laparoscopic pyelolithotomy in 5 patients operated on between 2002 and 2005. Mean patient age at surgery was 16.6 years, and mean followup was 15.4 months.
• Results: Cystine was the etiology in 4 patients with staghorn stones. The remaining patient had calcium oxalate stones and concurrent ureteropelvic junction obstruction. After pyelotomy stones were removed by a robotic grasper or by a flexible cystoscope introduced through a robotic port. One of the patients had an indwelling ureteral stent placed preoperatively, while 4 had stents placed robotically intraoperatively. Mean operative time was 315.4 minutes (range 165.0 to 462.0), and mean estimated blood loss was 19.0 ml (0.0 to 50.0). Mean hospital stay was 3.8 days (range 2.3 to 5.7), and mean narcotic usage was 2.1 mg/kg morphine (1.5 to 3.5). One patient with a cystine staghorn calculus required conversion to an open procedure because of inability to remove the stone. Of the 4 cases completed robotically 3 were rendered stone-free and 1 had a residual 6 mm lower pole stone.
• Conclusions: The early results of robot assisted laparoscopic lithotomy reveal that the procedure is safe and efficacious. Further prospective studies comparing other minimally invasive procedures used for similar stone burdens are needed to determine the benefits of this procedure and its role in stone management.
  
  
• Editorial Comment
  Laparoscopic assisted lithotomy procedures have been successfully described in the literature. With the advent of robotic surgery, the learning curve may be facilitated, especially in the reconstructive steps. The authors demonstrated their pioneering work emphasizing the technical feasibility and efficacy of robotic assisted lithotomy in adolescents with large stone burden. The investigators recognize that PCNL, ESWL and ureteroscopy are first line therapies in the management of pediatric renal stones. Nonetheless, this minimally invasive approach is another viable treatment option, particularly if the child has failed other minimally invasive techniques.

Dr. Fernando J. Kim
Chief of Urology, Denver Health Med Ctr
Assistant Professor, Univ Colorado Health Sci Ctr
Denver, Colorado, USA
E-mail: fernando.kim@uchsc.edu