Kompleks Üst Üriner Sistem Taş Tedavisinde Robotik Cerrahinin Rolü: Tek Merkez Deneyimi

Amaç: Bu çalışmanın amacı, farklı endikasyonlar ile da Vinci robotik sistem (Intuitive Surgical Incorporation, Sunnyvale, CA) kullanılarak yapılan üst üriner sistem taş hastalığı tedavilerinin klinik sonuçlarını paylaşmaktır. Gereç ve Yöntemler: Temmuz 2016 ve Temmuz 2023 tarihleri arasında merkezimizde robotik taş cerrahisi yapılan 12 hastanın verisi retrospektif olarak incelenmiştir. Daha önce geçirilmiş başarısız taş cerrahisi olan hastalarda büyük ve/ veya impakte üst üriner sistem taşı olması (n=7), eş zamanlı saptanan renal kitle için parsiyel nefrektomi gerekliliği (n=4) ve üreteropelvik bileşke (UPB) darlığına bağlı eş zamanlı pyeloplasti gerekliliği (n=1) sebebi ile robotik taş cerrahisi planlanmıştır. Bulgular: Çalışmaya dahil edilen 12 hastanın 7’si (%58) erkek, 5’i kadındı (%42) ve ortanca yaş 58 (IQR: 44–68) yıldı. Preoperatif BT değerlendirmesinde taşların ortanca boyutu 38 mm (IQR: 16–53) olarak bulundu. Hastaların 7’sinde (%58) çoklu taşlar var iken 5’inde (%42) soliter taş saptanmıştı. Hastaların 8’inde (%66,7) robotik pyelolitotomi ve/veya nefrolitotomi uygulanırken dört hastada ise robotik üreterolitotomi uygulandı. Cerrahi esnasında hastaların 7’sinde (%58) eş zamanlı fleksibl üreterorenoskopi ile endoskopik asistans gerekti. Ortanca ameliyat süresi ve tahmini kan kaybı sırası ile 190 dk (IQR: 126–148) ve 50 ml (min:0, maks: 300) olarak saptandı. Eş zamanlı parsiyel nefrektomi yapılan bir hastada hemoraji görülmesi üzerine transfüzyon ve ardından endoskopik psödoanevrizma embolizasyonu ihtiyacı oldu. Robotik pyelolitotomi yapılan bir hastada ise kendiliğinden azalan uzamış dren aktivitesi (6 gün) görüldü. Ameliyat sonrası yapılan tetkiklerde hastaların 11’inde (%92) tam taşsızlık sağlandığı görüldü. Rezidü taş görülen hastada ise JJ stent çekilmesi esnasında retrograd intrarenal cerrahi (RIRC) yapılarak 8 mm boyutundaki rezidü kalkül fragmante edilerek mutlak taşsızlık sağlandı. İlave girişim sonrası hastaların tamamında mutlak taşsızlık görüldü. Sonuçlar: Kompleks klinik senaryolarda robotik cerrahi, tek seansta yüksek mutlak taşsızlık ve düşük komplikasyon oranları yanında cerrahların artan robotik böbrek cerrahisi deneyimi de düşünüldüğünde büyük böbrek taşlarının tedavisinde de alternatif olarak hastalara sunulabilir.

Anahtar Kelimeler:

robotik cerrahi, flexible üreterorenoskopi, ürolitiyazis, komplikasyon

The Role of Robotic Surgery For Managing Complex Upper Urinary Tract Stone Disease: A Single Center Experience

Objective: The aim of this study is to present the outcomes of robotic surgery using a da Vinci robotic system (Intuitive Surgical Incorporation, Sunnyvale, CA) in different clinical indications in patients with upper urinary tract stone disease. Material And Methods: The data of 12 patients who underwent robotic stone surgery at our academic center between July 2016 and July 2023 were retrospectively evaluated. The reason to perform robotic stone surgery was large and/or impacted upper tract stone disease after a previous unsuccessful stone surgery (n=7), the need for a partial nephrectomy due to simultaneously detected renal solid lesion (n=4), and the need for pyeloplasty resulting from ureteropelvic junction obstruction (n=1). Results: Out of 12 patients included in the study, 7 patients (58%) were male, and 5 patients (42%) were female with a median age of 58 (IQR: 44 – 68) years. The median stone size was 38 mm (IQR: 16 – 53) as measured at a preoperative computerized tomography (CT) scan. 7 out of 12 patients (58%) had multiple urinary stones while 5 patients (42%) had a solitary stone. Assistance with flexible ureterorenoscopy was required in 7 out of 12 cases (58%). The median operation time and estimated blood loss were 190 minutes (IQR: 126 – 148) and 50 ml (min:0, max: 300), respectively. In a case who underwent concurrent partial nephrectomy, angioembolization was required due to postoperative bleeding. In another case, prolonged drain activity (6 days) was observed which resolved spontaneously during follow-up. Stonefree status was achieved in 11 out of 12 cases (92%). In the only case without stone-free status, the residual stone was fragmented during JJ stent removal by the technique of retrograde intrarenal surgery (RIRS). After this additional operation, stone-free status was achieved in all cases. Conclusion: Robotic stone surgery with its high stone-free rate and low complication rate represents an alternative approach in complex clinical scenarios considering the increasing experience of surgeons in robotic surgery.

Keywords:

robotic surgery, flexible ureterorenoscopy, urolithiasis, complication,

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