Concurrent Robotic Pyelolithotomy and Partial Nephrectomy: Tips and Tricks

Objective: With the evolution of robot-assisted surgery in the urology field, this technology is being applied to treat many genitourinary conditions.1 Although incidence of urolithiasis and renal neoplasm has increased, encountering both entities in a single kidney is noteworthy. Our video exhibits the concurrent management of a renal calculus and an ipsilateral renal neoplasm using a robotic platform. Materials and methods: A 53-year-old man was diagnosed with a 1.7-cm left renal pelvis calculus and a 4.7-cm enhancing ipsilateral upper pole renal mass (R.E.N.A.L score 8a) after an episode of flank pain. After reviewing preoperative imaging, a single-setting approach using a robotic platform was planned. Main steps of our robotic technique on the case included (1) kidney defatting and mobilization, (2) hilum and ureter dissection up to the renal pelvis, (3) intraoperative ultrasound for tumor demarcation and stone localization, (4) anterior robotic pyelolithotomy,2 (5) double J stent placement and pyelotomy closure, (6) excision of renal mass, and (7) renorrhaphy. Perioperative outcomes were recorded. Results: The operative time was 180 minutes and the estimated blood loss was 100 mL. Warm ischemia time was 17 minutes. There were no intra- or postoperative complications. The patient was discharged home on postoperative day 3. Final pathology reported a 3.4-cm mass consistent with a clear cell renal carcinoma, with a tumor, nodes, metastases (TNM) staging pT1aNx and negative surgical margin. The double J stent was removed after 4 weeks, and the patient remained asymptomatic at 1 month postoperatively. Conclusion: Pyelolithotomy and robotic partial nephrectomy can be performed effectively when treating patients with concurrent kidney mass and renal stone using the same surgical access. This minimally invasive approach should be contemplated as an option when managing patients with both conditions in an ipsilateral kidney. Furthermore, it will diminish the necessity of various surgeries while preserving renal function and maintaining oncological outcomes. We underline that the association of both procedures increases the likelihood of technical complications and risk for clot-related or stone-related ureteral obstruction, infection, and urine leak.