Robot-assisted laparoendoscopic single-site surgery for the simultaneous management of multiple urinary tract calculi: a case report and experience sharing

A 49-year-old male patient with the diagnosis of multiple urinary tract calculi at the right side was admitted to our hospital for regular operation. He had surgical histories of right ureterolithotomy in 1992 and laparoscopic cholecystectomy in 2005 and underwent extracorporeal shock wave lithotripsy (SWL) several times. No history of hypertension, heart disease, diabetes, or metabolic diseases was recorded. The body mass index (BMI) was 21.9 kg/m². No other positive sign was observed during the abdominal examination except mild percussion pain in the right renal area. Laboratory tests revealed elevated serum creatinine level of 111 μmol/L (normal range: 30–110 μmol/L) and elevated urea nitrogen level of 9.3 mmol/L (normal range: 1.8–7.5 mmol/L). The result of the urine sediment analysis was within the normal range. The isotope renogram result showed that the glomerular filtration rate (GFR) were 17.81 ml/min (right kidney) and 53.11 ml/min (left kidney). Computed tomography (CT) (Fig. 1) and three-dimensional reconstruction CT image (Fig. 2) showed that three calculi were located in the right kidney, one calculi was located in the right upper ureter, and three calculi were located in the bladder. The size and hounsfield unit for the renal calculi were 3.2 cm × 1.9 cm (1174 Hu), 2.0 cm × 1.3 cm (1036 Hu), and 1.4 cm × 1.1 cm (1052 Hu), respectively (Fig. 1a and d); for the ureter calculi were 2.1 cm × 1.7 cm (1098 Hu) (Fig. 1b and e); for the bladder calculi were 2.5 cm × 1.6 cm (529 Hu), 2.3 cm × 1.5 cm (558 Hu), and 2.1 cm × 1.3 cm (564 Hu), respectively (Fig. 1c and f).

The whole operation was performed through a transperitoneal approach by using the da Vinci Si system (INTUITIVE SURGICAL) and LAGIPORT™ single-site port (LAGIS ENTERPRISE CO.) (Fig. 3a). After endotracheal intubation under general anesthesia, the patient was first placed in a modified left lateral decubitus position with a 60°–70° bump (Fig. 3b). A 4 cm longitudinal incision was made around the umbilicus, and the single-site port was placed to establish the abdominal operative access. On the upper and lower symmetrical position of the port, two 12 mm trocars were placed for robot camera and assistant. On the left and right symmetrical position, two 8 mm robotic trocars were placed for the first and second robot arm (Fig. 3c). After taking out the calculi of the kidney and upper ureter, the patient was adjusted to a Trendelenburg position. The same port was used for docking robot to deal with bladder calculi. No additional incision was added during the whole procedure.

After entering the abdominal cavity, the hepatocolic ligament was incised, and the lateral peritoneum was incised along the paracolic sulcus. Next, the Gerota’s fascia was incised to expose the right renal pelvis. The right upper ureter was tortuous seriously due to the previous ureterolithotomy related tissue adhesion. The upper ureter, was firstly isolated from the adhesion tissue, and then was dissociated carefully to expose the calculi location. Next, the ureterolithotomy and pyelolithotomy were performed according to the standard procedures (Fig. 4a and Fig. 4b). After the ureter calculi and renal calculi were all removed, the double-J stent was indwelled into the ureter (Fig. 4c), and the incisions on the ureter and renal pelvis were closed with a 4–0 absorbable suture (Fig. 4d). The Trendelenburg position was adjusted, and a Foley catheter was inserted. Then, the robot was docked with the same single-site port to perform the cystolithotomy. After the bladder calculi were removed (Fig. 4e), the incision on the bladder was closed with a Quill™ self-retaining system (SRS) absorbable surgical suture (Fig. 4f). A drainage tube was placed, and the abdominal incision was sutured after no leakage of the bladder was confirmed. An additional video file shows the surgical procedure with more details (see Additional file 1: Video clip).