The advance of robotics in surgery has become commonplace over the past several decades. While the penetration of robot-assisted surgery has reached many subspecialities, there are few where technology and innovation have evolved so rapidly as in urology. For example, in 2021 the standard for radical prostatectomy is robot-assisted surgery, and open procedures have been relegated to an afterthought or a minor representation of the total procedures being done in the United States. The penetration of robotics in urology is not limited to laparoscopic-assisted surgery or reconstruction, but is also seen in robotic and image guided treatments for benign prostate hyperplasia, high-intensity focused ultrasound (HIFU) for focal treatment of prostate cancer and now the promise of redefining how we consider the treatment of kidney stones.

There have been several inflection points that have changed the way we manage nephrolithiasis. Since Curtiss and Hirschowitz created the first flexible endoscope in 1957, which lacked irrigation or working channel(s) and deflection mechanisms, flexible ureteroscopy has come a long way.¹ Contemporary ureteroscopes offer a variety of enhancements from their predecessors, including miniaturization, single use, multiple working channels, passive and active deflection, digital imaging, rotating shafts and image enhancements, among other improvements. The goal of achieving minimally invasive “stone-free” outcomes for patients has been advanced with the co-development of laser lithotripsy and the development of endourological accessories. This armamentarium has advanced flexible ureteroscopy, where limitations are being challenged, allowing larger stone burdens to be treated with comparable stone-free rates. However, one must still consider the operative skills and mastery of the techniques to provide consistent translation of endoscopic abilities among all surgeons, not just endourological experts.

Robot-assisted surgery makes it possible to overcome some of these gaps and challenges, enabling the majority of surgeons to achieve mastery of complex surgical procedures. It offers a way to bypass the learning curve of ergonomically or technically demanding procedures, and increases efficiencies while providing consistency and capacity among providers. The result has been a recent evolution in robot-assisted ureteroscopy.

One of the first platforms tested was the robotic catheter system, Sensei® (Hansen Medical, Mountain View, California), which was adapted from its initial cardiovascular indications. The surgeon controlled 2-catheter system (outer catheter 14Fr/12Fr and inner catheter 12Fr/10Fr) allowed manipulation of both catheters independently and allowed 270-degree deflection in all directions. The first in human studies showed promise and capabilities,² but ultimately this technology was abandoned as Hansen Medical was eventually acquired by Auris™ surgical robotics (Redwood City, California) in 2016.

The next system reaching human use was the Avicenna Roboflex (ELMED™ Medical Systems, Ankara, Turkey), which is a robotic interface that docks and controls a standard flexible fiberoptic ureteroscope. This has implications for procedural fatigue and removes the surgeon from fluoroscopic exposure. It also provides scaling of motion as well as surgeon controlled accessory devices such as the laser fiber and fluidics. Emerging clinical experience has been encouraging, and the use of standard ureteroscopes and sheaths helps overcome sizing challenges seen with the Sensei platform.³

The most recent platform has yet to see human trials in urology. The Monarch® robotic endoscopic system (Auris Health, acquired by Johnson & Johnson, New Brunswick, New Jersey) is commercially available for robot-assisted bronchoscopy. The diagnostic yield for lung lesions using modern bronchoscopic techniques has been around 40%-70%.4 The robotic endoscopic system allows targeting of more peripheral lesions with electromagnetic field navigation, locking support sheath, enhanced maneuverability, imaging fusion and single surgeon control. A recent multicenter trial showed successful navigation in 88.6% of cases and a diagnostic yield of 69.1%-77% in 165 patients.⁵ The similarity to endourology is easy to imagine, and a purpose built second generation of the device is anticipated to be available in 2022 pending regulatory approval.

New developments in robot-assisted ureteroscopy will continue to drive the treatment of stones in new ways that will allow versatility, efficiency and advances to augment our perceptions. These may include automatic pressure monitoring and regulation, integrated energy solutions specific to the stone type, image overlapping/fusion and gating to respiratory movements. Artificial intelligence (AI) and machine learning will tell us when we have “dusted” stones into small enough fragments for easy passage or when they need additional treatment. AI will help with target acquisition and treatment precision to limit iatrogenic injury as well as the ability to operate remotely. The robotic evolution continues, and it will be up to the surgeon to define what comes next for the benefit of our patients.