Robotic Mini-PCNL and Ureteroscopy: Advancing Kidney Stone Treatment "Presentation" - Jaime Landman
August 15, 2024
At the World Congress of Endourology and Uro-Technology, Jaime Landman presents the initial clinical experience with a combined robotic mini-percutaneous nephrolithotomy and ureteroscopic lithotripsy platform. The study demonstrates the procedure on a 49-year-old female with large kidney stones. Dr. Landman describes the Monarch Robotic Platform, which includes three robotic arms and a compact field generator for targeting. Dr. Landman highlights the system's ability to keep the urothelial surface clean and its effectiveness in completely removing both large and small stones.
Biographies:
Jaime Landman, MD, Urologist, Department of Urology, University of California Irvine, Irvine, CA
Biographies:
Jaime Landman, MD, Urologist, Department of Urology, University of California Irvine, Irvine, CA
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Development and Initial Clinical Experience of a Novel Endoscopic Robotic Platform: Monarch PCNL Presentation - Jaime Landman
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Development and Initial Clinical Experience of a Novel Endoscopic Robotic Platform: Monarch PCNL Presentation - Jaime Landman
Read the Full Video Transcript
Jaime Landman: Initial clinical experience with a combined robotic mini-percutaneous nephrolithotomy and ureteroscopic lithotripsy platform. We thank J&J, who sponsored this trial. The first case was a 49-year-old female with recurrent urolithiasis. As you can see, she had a very large stone burden in the left kidney. The larger stone was 39 by 10 by 19 millimeters, and a smaller stone in the upper pole was 6.1 by 4.3 by 5 millimeters. All evaluations were done with thin-sliced CT scans in the pre- and postoperative setting.
The Monarch Robotic Platform includes the robot, which has three arms. Two of the three arms are deployed below the patient's legs and control the robotic ureteroscope. The third arm controls the compact field generator for targeting. After deployment of the needle, as seen here using the graphic user interface, the needle is advanced. Once the circumferential line reaches the 12 o'clock position, the needle enters the system. This is then dilated with a standard Seldinger technique, and the upper arm is used to control the suction irrigation system.
Using a handheld controller, the surgeon controls both instruments. The suction is brought near the stone, and using the robotic ureteroscope, the stone is ablated. To make things easier, the stone can be brought to a more easily accessible location and then ablated. Ablation near the suction catheter allows the fragments to be immediately withdrawn from the patient. The patient is positioned in this modified supine position. As you can see, the posterior axillary line, the rib, and the anterior superior iliac spine have been marked. The robot is easily docked with two arms below and one above. This shows the robotic ureteroscope within the robotic arms.
Here, the compact field generator is placed near the patient. A site is then selected for the deployment of the needle, and the sheath is placed. The ureteroscope is used to target a specific papilla. The scope is then moved back several millimeters and marked again. Once the incision is made, the needle in the electromagnetic system is deployed. The electronic bubble is placed in the center, the needle advanced until the outer line reaches the 12 o'clock position, at which point you'll see the needle enter the center of the papilla.
Once the needle has entered, standard Seldinger technique with a wire and dilation to 18 French is achieved. The robot is then docked. Once the robot has been docked, the suction irrigation system can be deployed. There's a dedicated aspiration and suction associated with the robotic system. Here, the sheath as well as the suction catheter can be seen through the ureteroscope. The suction catheter is then brought to a location near the stone. The suction settings can be controlled by the surgeon. In what appears to be a very standard ureteroscopic ablation, the stone is broken down. The system is laser agnostic. In this case, a Moses holmium laser was used.
As you can see, fragments are brought to the suction catheter and are often ablated within the suction catheter. It's difficult to discern as it happens quickly, but small dust fragments are immediately aspirated. Rather than dispersing the stone around the kidney, the stone largely remains around the suction catheter where it can be ablated. Please note that around the catheter, the urothelial surface appears free of dust. After the kidney is completely cleared, we did note where Randall's plaques were located to document these. Again, the urothelium appears particularly clean after a large percutaneous nephrolithotomy due to the aspiration, which removes all the smaller fragments in real time as they are being ablated.
In this postoperative image, you can see the CT scan with both the coronal and axial views demonstrating a completely stone-free status, except for that very small Randall's plaque which was documented prior to exiting the kidney. Overall, the larger 3.9 centimeter stone and the 6.1 millimeter stone were completely removed. The patient left on postoperative day one without any complications. Thank you.
Jaime Landman: Initial clinical experience with a combined robotic mini-percutaneous nephrolithotomy and ureteroscopic lithotripsy platform. We thank J&J, who sponsored this trial. The first case was a 49-year-old female with recurrent urolithiasis. As you can see, she had a very large stone burden in the left kidney. The larger stone was 39 by 10 by 19 millimeters, and a smaller stone in the upper pole was 6.1 by 4.3 by 5 millimeters. All evaluations were done with thin-sliced CT scans in the pre- and postoperative setting.
The Monarch Robotic Platform includes the robot, which has three arms. Two of the three arms are deployed below the patient's legs and control the robotic ureteroscope. The third arm controls the compact field generator for targeting. After deployment of the needle, as seen here using the graphic user interface, the needle is advanced. Once the circumferential line reaches the 12 o'clock position, the needle enters the system. This is then dilated with a standard Seldinger technique, and the upper arm is used to control the suction irrigation system.
Using a handheld controller, the surgeon controls both instruments. The suction is brought near the stone, and using the robotic ureteroscope, the stone is ablated. To make things easier, the stone can be brought to a more easily accessible location and then ablated. Ablation near the suction catheter allows the fragments to be immediately withdrawn from the patient. The patient is positioned in this modified supine position. As you can see, the posterior axillary line, the rib, and the anterior superior iliac spine have been marked. The robot is easily docked with two arms below and one above. This shows the robotic ureteroscope within the robotic arms.
Here, the compact field generator is placed near the patient. A site is then selected for the deployment of the needle, and the sheath is placed. The ureteroscope is used to target a specific papilla. The scope is then moved back several millimeters and marked again. Once the incision is made, the needle in the electromagnetic system is deployed. The electronic bubble is placed in the center, the needle advanced until the outer line reaches the 12 o'clock position, at which point you'll see the needle enter the center of the papilla.
Once the needle has entered, standard Seldinger technique with a wire and dilation to 18 French is achieved. The robot is then docked. Once the robot has been docked, the suction irrigation system can be deployed. There's a dedicated aspiration and suction associated with the robotic system. Here, the sheath as well as the suction catheter can be seen through the ureteroscope. The suction catheter is then brought to a location near the stone. The suction settings can be controlled by the surgeon. In what appears to be a very standard ureteroscopic ablation, the stone is broken down. The system is laser agnostic. In this case, a Moses holmium laser was used.
As you can see, fragments are brought to the suction catheter and are often ablated within the suction catheter. It's difficult to discern as it happens quickly, but small dust fragments are immediately aspirated. Rather than dispersing the stone around the kidney, the stone largely remains around the suction catheter where it can be ablated. Please note that around the catheter, the urothelial surface appears free of dust. After the kidney is completely cleared, we did note where Randall's plaques were located to document these. Again, the urothelium appears particularly clean after a large percutaneous nephrolithotomy due to the aspiration, which removes all the smaller fragments in real time as they are being ablated.
In this postoperative image, you can see the CT scan with both the coronal and axial views demonstrating a completely stone-free status, except for that very small Randall's plaque which was documented prior to exiting the kidney. Overall, the larger 3.9 centimeter stone and the 6.1 millimeter stone were completely removed. The patient left on postoperative day one without any complications. Thank you.