Open surgery was for a long time the standard of care for urinary stone disease. The first ureteroscopy procedure was described by Young in 1929,¹ and the first percutaneous access to remove a kidney stone in 1976 by Fernstrom and Johannson.² Subsequently, technology in minimally invasive urinary stone surgery has advanced tremendously. Flexible ureteroscopy coupled with advances in laser technology have allowed for retrograde access to stones in all locations of the ureter and kidney. Advances in percutaneous nephrolithotomy surgery and evolution to mini-percutaneous nephrolithotomy techniques have introduced smaller access tracts, allowing for same day surgery for larger stone disease. These procedures are performed expertly with both fluoroscopy and ultrasound guidance, yielding similar successful results.

To provide maximum efficacy for our patients, these surgeries require mastery of challenging techniques, including fine control of flexible scopes as well as precise percutaneous renal access. There exists a need to improve urologists’ acquisition of these skills or face decreased access to care for patients outside of specialty centers. The arrival of robotic platforms in ureteroscopy and percutaneous nephrolithotomy has set the stage for increased availability for these minimally invasive techniques for urologists and their patients. This is analogous to the introduction of robotic-assisted laparoscopic surgery platforms to expand the availability of laparoscopic radical prostatectomy to patients unable to travel to referral centers for laparoscopic care. The introduction of the robotic-assisted radical prostatectomy dramatically increased the number of urologists able to perform minimally invasive surgery for prostate cancer. Ultimately, this led to increased quality of patient care by increasing access to minimal invasive surgery.

Robotic ureteroscopy offers several potential advantages over traditional flexible ureteroscopy, including greater precision of scope control and ergonomic comfort for the surgeon. Through the use of a robotic control interface analogous to a video game controller, robotic ureteroscopy eliminates the need for wrist and hand contortion to manipulate the scope. Robotics provides automated scope stabilization, facilitating increased precision with which the urologist drives the ureteroscope. In addition, robotic control allows for the surgeon to be removed from radiation sources, controlling the surgery at a semi-remote location in the operating room. Coupled with new technology including pressure and irrigation sensors, robotic systems could also hypothetically reduce risk for collecting system injury and bacterial seeding into the bloodstream leading to sepsis.³

With robotic-assisted percutaneous renal access, one major potential draw is learning curve reduction for the most technically challenging aspect of the surgical procedure. While fluoroscopic and ultrasound imaging guidance are readily available approaches for renal access, a persistent clinical need includes more tools to bring easier renal access into a larger number or urologists’ hands. In addition, the potential to reduce radiation exposure risk in comparison to fluoroscopic guidance is a clear advantage. With the ANT-X: NDR Medical Technology, AI platform for fluoroscopy needle access targeting system, Taguchi et al showed a shorter puncture time relative to ultrasound guided access with less radiation exposure to enter the kidney.^4,5

These technologies together have dramatic potential to improve access to high-quality minimally invasive kidney stone surgery. By making it easier for urologists to obtain their own renal access for percutaneous nephrolithotomy and increase the precision by which ureteroscopy and endoscopic combined intrarenal surgery can be performed, more urologists will be able to offer these treatment modalities with greater accuracy to their patients. While here we present some anticipated benefits of this next generation of robotics, like many new technologies, we know that surgeons will often identify best case applications not currently apparent only after their widespread adoption. Ultimately, new innovations in stone surgery must be both clinically useful and cost effective, with the aspiration to make safer and more efficient surgical techniques accessible for all patient globally.