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The Orthotropic Neobladder; How to Make It Easy?-JuniperPublishers

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The Orthotropic Neobladder; How to Make It Easy?

Ahmed M Moeen* and Diaa A Hameed

Assiut urology and nephrology Hospital, Assiut University, Egypt

Submission: February 14, 2017; Published: March 03, 2017

*Corresponding author: Ahmed M Moeen, Assiut urology and nephrology Hospital, Assiut University, Egypt, Email: moeen3@yahoo.com

How to cite this article: Ahmed M M, Diaa A H. The Orthotropic Neobladder; How to Make It Easy?. JOJ uro & nephron. 2017; 2(1): 555580.10.19080/JOJUN.2017.2.555580

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Abstract

Radical cystectomy and urinary diversion is the standard treatment for patients with muscle invasive bladder cancer. Urinary diversion after radical cystectomy requires skill and expertise. Multiple techniques of urinary diversion are present. However, the orthotropic neobladder (OBS) may be better in terms of quality of life. For the sake of simplicity, neobladder reconstruction is better divided into the following stages;

Stage I: Patient selection and preparation

Stage II: Radical cystectomy and lymphadenectomy

Stage III: Neobladder reconstruction

Stage IV: Uretero- and Urethro-enteric anastomosis

Stage V : Postoperative management

Stage VI: Management of complications

Keywords: Orthotopic neobladder; Reconstruction; Stages; Complications

Abbreviations: RCX: Radical Cystectomy; OBS: Orthotopic Neobladder; ERAS: Enhanced Recovery after Surgery; LND: Lymphadenectomy

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Introduction

Radical cystectomy (RCX) and urinary diversion is the standard treatment for patients with muscle invasive bladder cancer and some patients with non-muscle invasive disease who failed the intra-vesical treatment [1]. Multiple techniques of urinary diversion are present. However, the orthotopic neobladder (OBS) may be better in terms of quality of life, as it is the closest to the normal bladder in location and function. However, it is measured as one of the most difficult urologic procedure [2]. In this short review, we try to simplify the basic principles of neobladder reconstruction for the beginners to make their practice easier. For the sake of simplicity, neobladder reconstruction is better divided into stages; the higher stages need higher experience. We divide it into the following stages;

Stage I: Patient selection and preparation

Stage II: Radical cystectomy and lymphadenectomy

Stage III: Neobladder reconstruction

Stage IV: Uretero- and Urethro-enteric anastomosis

Stage V: Postoperative management

Stage VI: Management of complications

Stage I: Patient selection and preparation

To start with, successful neobladder reconstruction starts with appropriate patient selection and preparation. The main pillars of this stage that should be well recognized are; the indications, contraindications, how to counsel the patients and the peri-operative preparations.

In general, two important criteria must be maintained in patients indicated for RCX to be eligible for OBS: an intact rhabdosphincter to preserve the urinary continence and the radicality of surgery should not be compromised by the retained membranous urethra to which the neobladder will be anastomosed.

On the contrary, the contraindications are multiple and diverse. This implies that the selection criteria are strict and the patient should be an "A1" patient medically and mentally. It includes, patients indicated for urethrectomy as those with bladder neck tumors and extensive infiltrations of the prostate, urethral sphincteric or stricture diseases, those with permanently compromised renal function or severely impaired liver functions, increased risk of metabolic complications as those with previous bowel resection or sever diverticulosis mental or physical Impairments that precludes the ability to self-catheterize when this is necessary, incompliant patients for postoperative regular follow-up, impossibility of nerve- sparing surgery at least on one side, high dose of peri operative radiotherapy and Age > 80 years [3]. The age is not an absolute contraindications and the differentiation between the biological and chronological age is the most important. However, the age of 80 may be the stimulus not to do OBS, as it may be associated with a higher incidence of postoperative morbidity but without increased mortality even in high volume centers [4].

Counseling is very critical. The patient should know all the risks and benefits of this surgery. He/she should know that the possibility of conversion to other diversion forms is an option due to any intra-operative oncological, anatomic or anesthetic reasons [3]. Also, the expectation should be realistic, he/she should know that his neobladder is not a new bladder and there is no urinary diversion technique that could replace all the functions of the natural bladder.

RCX needs an extensive preoperative preparation, careful intra-operative and postoperative manipulations to optimize the functional outcomes. In 2014, published in the European urology a 22 items designed for enhanced recovery after Surgery (ERAS). These include; preoperative medical optimization, bowel preparations can be safely omitted, avoidance of long-term sedative, thrombosis prophylaxis, antimicrobial prophylaxis 1 hr before skin incision, skin preparation with Chlorhexidine- alcohol to decrease surgical site infection, epidural analgesia should continue for 72 hrs to relieve pain without opioids, careful peri-operative fluid management and avoidance of intraoperative hypothermia, early removal or no nasogastric tube use, prevention of postoperative ileus and nausea and vomiting, early mobilization and early oral diet. They concluded that these ERAS items improve the patient care, decrease the postoperative morbidity and the length of hospital stay [5].

Stage II: Radical cystectomy and lymphadenectomy

When discussing the stage of RCX, we will not discuss the surgery on details, but we will stress on three important issues; timing of surgery, how quality of RCX and lymphadenectomy will affect the outcome and lastly certain surgical steps should be done carefully and others should be avoided.

First, timing is very critical as it was shown that there is window of opportunity of about 3 months, after which delaying cystectomy may be associated with increase in the risk of progression and cancer specific mortality [6].

Second, how quality of surgery affecting the outcome is evident from the following; positive surgical margin occurs in 4% with high volume urologists and 14% in low volume ones. Local recurrence will develop in 6% of margin negative patients if compared to 68% of margin positive counterparts. The Mortality rate is about 0.7% in high volume hospitals and 3.1% in low volume ones [7,8].

Certain surgical steps during RCX will affect the reconstructive functional outcome greatly. Ureteric dissection should be done carefully to preserve its vascularity and preserve the lower most part of the ureters which is very important factor in reflux prevention. The pressure in the lower part of the ureter is about 20-30 cm of water and the bladder end filling pressure is 20cm for an optimal cystometric capacity of 450 cm. So, this pressure difference is a safety margin [9].

Multiple techniques of dorsal vein ligation are present; it should be done carefully to avoid bleeding. If done so, it will help so much in preparation of the urethral stump in a traumatic way with preservation of a well-functioning urethral length and performing nerve sparing RCX in a visually clear field which not only improve the sexual function but also affect continence status [10,11].

On the contrary, prostatic capsule and seminal sparing RCX should be avoided. It may improve the postoperative erectile function but does not really improve the continence status. In the meantime, 10-15% higher oncologic failure rate makes it preferably should be avoided [12,13].

Regarding lymphadenectomy (PLND), extended PLND should be considered the standard in patients undergoing RCX as it will clear up to 90% of the lymph nodes if compared to 50% nodal yield when a limited PLND is only performed [14]. When an extended PLND was compared to limited one in patients with ≤pT3P N0.2 disease, the 5 years recurrence-free survival was significantly better (49 vs. 19%, respectively) [15]. Surprisingly, with expanding the template to the inferior mesenteric artery, similar survival and recurrence rates in pT2-3cN0 cM0 patients were found as extended PLND [16]. This may be due to the lymph node metastases higher than the common iliac bifurcation is a characteristic of systematic disease which cannot be controlled by extensive surgery [17].

Stage III: Neobladder reconstruction

Certain goals should be achieved to obtain a good reservoir which are; large capacity, low intra-luminal pressure, no reflux, continence preservation and minimal absorption of urinary solutes.

All intestinal segments were extensively studied for reservoir reconstruction. However, the intestinal segment which stood the test of time is the ileum due to the following reasons; it is more distensible if compared to other segments [18], has favorable urodynamic parameters in the form of large capacity, better compliance and lower filling pressure [19], better continence rates if compared with colonic neobladder [20], its mucosal atrophy with less reabsorption of urinary solutes is more reliable than the large bowel [21] and finally the ease with which the small bowel can be surgically manipulated.

Originally, neobladders were reconstructed from larger intestinal segments as the original Studer (56-60cm) and Hautmann (70cm) ileal neobladders to Improve the nighttime Incontinence [22,23]. However, for more than two decades, 40-45cm of the ileum, 25cm apart from the ileo-cecal valve proved to be quit sufficient [24 ,25 ]. The functional capacity will increase within weeks or months from 150 to 500 ml. This will decrease the incidence of chronic retention with low intra-luminal pressure [26].The postoperative electrolyte disturbance or metabolic acidosis will be minimized [27]. Also, preservation of the terminal part of the ileum and the ileo-cecal valve will decrease the postoperative diarrhea and vitamin B12 deficiency [28]. The risk of spontaneous rupture will decrease as the tension on the large reservoir when filled with urine is significantly higher than in small reservoir with the same intraluminal pressure [27].

Configuration of the reservoir will affects the functional outcome to a great extent. Detubularization and cross folding will minimize the development of high pressure peaks. A spherical reservoir has multiple advantages, the maximum radius according to Laplace's law will be obtained, so the maximum volume to surface area ratio with lower end filling pressure will results. Also, higher wall tension (tension=pressure × radius) in response to the urethral closure pressure will make the sensation of fullness is more likely [3]. Also, there is metabolic advantage as the length of the bowel resection and the area available for reabsorption from the reservoir are minimized [29].

Stage IV: Uretero- and Urethro-enteric anastomosis

The uretero-enteric and urethro-enteric anastomosis are two risky steps during neobladder reconstruction. Improper reconstruction will endanger the upper urinary tract or the whole urinary tract respectively. Good anastomosis should be tension free, water tight, mucosa to mucosa and stunted. Regarding ureteric reimplantation, to do or not to do anti- refluxing technique is a matter of debate [30]. However, the stricture rate is generally higher with anti-refluxing techniques. Regarding the urethro-enteric anastomosis, there are 2 types of neourethra; hole and non-hole techniques. In order to perform safe urethro-enteric anastomosis, we should preserve well- functioning urethral length and prepare the urethral Stump carefully, the neourethra should be wide button hole, most dependent, mucosa to mucosa, tension free with no leakage or tube anastomosis. If the urethro-enteric anastomosis is under tension, certain sequential steps should be performed; careful selection of bowel loops, opening of the peritoneum covering the mesentery, releasing the mesenteric fat, removing the sigmoid colon out of the pelvis, reducing the steep of trendelnburg positioning angle, perineal pressure and freeing the right colonic junction and moving the ileum and the right colon downwards.

Stage V: Post-operative management

Meticulous postoperative care and life-long follow up are very critical for good long-term results [23]. In the immediate postoperative setting, thrombosis prophylaxis by subcutaneous heparin should be administered preferably in the arm instead of the thigh to prevent lymphocyte. The neobladder should be irrigated gently and frequently to avoid mucous accumulation. Bowel stimulation with para sympathomimetics should be instituted from day 2 or 3. Serial body weight and blood gas analysis should be measured [3].

Regarding the catheters and stents, the time of their removal is debated. Originally, the ureteric catheters, supra-pubic tube and the urethral catheters were removed at about 10, 12 and 21 days respectively. However, in updated experience of some experts, they stated that they could be removed at days 5-7, 8-10 (after cystogram) and at 10-12 respectively [3].

Following catheter removal, patients are carefully instructed how to void. Initially, in a sitting position every 2 h during the day by slight increase the intra-abdominal pressure. Thereafter every 3 h; later every 4 h until approaching a capacity of 400-500 ml. use of alarm clock at night to avoid nocturnal enuresis.

Serial check of the residual urine, urine analysis, venous blood gas analysis and supplement of bicarbonate (2-6g) and salt whenever indicated should be performed. Long-term follow- up is very important to early detect and manage the following events; metabolic complications (vitamin B12, electrolytes, base excess), voiding complains (incontinence, difficulty and increased mucous production due to infection), occurrence of delayed complications (neobladder outlet obstruction or uretero-enteric strictures) and oncological failure [3].

Stage VI: Management of complications

RCX is the most difficult urologic procedure with a wide range of peri-operative complications even with most experienced surgeons with a post operative complications rate of 25-57%. However, the rate of severe and lethal complications is acceptably low with in-hospital mortality of 3% and re-operative rates of 2.3-17%. The complications should be classified by the five- grade modification of the original Clavien system [3].

Management of neobladder complications requires patience and expertise. It could be managed either by endoscopic, laparoscopic or open surgery routes. But, the minimally invasive endoscopic management should be tried first, whenever possible. As it saves a lot of hazards that may occur with laparoscopic or open surgery due to marked intra-abdominal adhesions and allows the patient to return faster to normal daily activity. Uretero-enteric stricture, pouch stones, recurrent neobladder tumors, urethral recurrence and urethro-enteric stenosis all could be managed endoscopically [28].

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Conclusion

In conclusion, RCX and OBS is an advanced multi-steps urologic procedure. To make it easy, certain precautions should be followed. We should carefully select our patients. Standard RCX and extended PLND should be performed. Dorsal vein ligation and urethral stump preparation should be done cautiously as they are risky key steps. Familiarity with other urinary diversion techniques is important for the urologistas intra-operative findings may change the plane. Regular life-long follow up for delayed complications is important. For best results, a regular skilled operative team and a high volume well- equipped hospital with high case load are mandatory.

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Multi-Center Phase II Study of the Clinical Use of the Avicenna Roboflex-JuniperPublishers

Abstract

Objectives: To present the results of a multicentric phase-II study, representing the next step according to the IDEAL-criteria in the evualuation process of robot-assisted flexible ureterorenocopy.

Material and methods: The Avicenna Roboflex consists of a console and the manipulator. Peri-operative data from 266 patients who underwent robotic retrograde intra-renal stone surgery (robRIRS) between January 2015 and March 2016 at two centres (Heilbronn, Ankara) were recorded prospectively. Six surgeons were involved in the study. We treated 90 females and 176 male patients with a mean age of 55 (2576) years. 118 stones were located on the right and 148 on the left side. Mean number of stones was 1.8 with a mean stone burden of 1620 (98-10600)mm3; 43% of the patients were pre-stented. A 12/14F access sheath was used in all cases; laser fragmentation was accomplished by a high-energy laser device applying actual concepts of laser lithotripsy.

Results: Preparation of the robot required 4:30min (range 3-8min); docking time was 4 min (range 1-29min). Console time to identify the stone amounted 4min (range 1-12min.); total operating time was 96 min (range 58-193min) including a console time of 65(16-174) min. Laser lithotripsy was performed in 245 patients (92%), 112(42%) patients required extraction of larger fragments using N-gage-basket. The stone clearance rate amounted 25(9-101)mmA3/min. Total fluoroscopy time was time 2:30min with a radiation dosis of 297 cGy*cm2. 117(44%) of our patients were stented post-operatively of which 75(28%) had the stent on a string removed on day 1 together with the Foley catheter. In 2(0.7%) cases we had to convert to classical FURS due to technical failure of the robot. Median post-operative hospital stay was 1(1-30) day. We encountered one case of urosepsis (Clavien 3a) requiring treatment on an intensive care unit.

Conclusion: In this setting, Avicenna Roboflex proved to be robust with only two cases of technical failure requiring conversion to classical FURS. The radiation exposure for the surgeon can be significantly reduced. In conclusion, we were able to integrate the device easily in our daily routine.

Keywords: Avicenna roboflex; Intra-renal stone; Ureteroscopy

Abbreviations: robRIRS: robotic Retrograde Intra-Renal Stone Surgery; SD: Standard Deviation; NIRF: Near-Infrared Fluorescent

Introduction

Management of urolithiasis changed dramatically during the last decades. Whereas in the eighties and nineties of last century extracorporeal shock wave lithotripsy dominated the spectrum of endourological techniques, recently percutaneous surgery and especially retrograde intra-renal surgery has gained significant importance [1]. This was possible because of the continuous improvements of endourological armamentarium and miniaturization of the instruments [2-8]. Nevertheless, flexible ureteroscopy respectively retrograde intra-renal surgery is limited by ergonomic deficiencies including stone manipulation, laser disintegration or extraction of fragments particularly when treating multiple stones or larger renal calculi [9,10]. Thus, the next level of stone management may represent robot-assisted retrograde intra-renal surgery overcoming most of these technological obstacles.

Similar to robot-assisted laparoscopic surgery, such devices represent master-slave systems (Figure 1) [11-15]. First trials modifying a system designed for cardiology (Hansen, United States) were not very successful due to size limitations and limited mobility in the renal collecting system [11-13]. Since 2010 we were involved in experimental and clinical introduction of the Avicenna Roboflex (Elmed, Ankara, Turkey), which was specifically designed for flexible ureteroscopy [14,15]. Beside proof of safe and efficient applicability, the device underwent constant improvements by the manufacturer. In this article we (idea, development, evaluation, assessment, long-term study)- want to present the results of the multi-centric phase-II study, criteria [15,16].

Material and Methods

Specification of the robotic device

The Avicenna Roboflex consists of a console and the manipulator(Figure 2). The basic functions of the device have been described previously.The main include:

o Control of deflection using a wheel for the right hand (Figure 3).

o Control of rotation and horizontal movements via refined joy-stick (Figure 4).

o Integrated HD-monitor displaying the endoscopic view and major data defining the position of the tip of the flexible ureteroscope (Figure 5).

Exchangeable handle for three different digital flexible ureterorenoscopes (Karl Storz Flex X2; Olympus URF-V2; Wolf Cobra digital)

o Air driven control unit to activate foot pedals of laser and fluoroscopy

Following the introduction of the robot in 2 European stone centres (2013 Ankara TR; 2014 Heilbronn, Germany) we collected prospectively peri-operative data from all patients (n=266) who underwent robotic retrograde intra-renal stone surgery (robRIRS) between January 2015 and March 2016. Six different surgeons were involved in the study. We treated 90 females and 176 male patients with a mean age of 55(25-76) years. The body mass index was 29.1(20.6-43.3) and ASA-score was 2.3. 118 stones were located on the right and 148 on the left side. Mean number of stones was 1.8 with a mean stone burden of 1620(98-10600)mm3. 43% of the patients were presented.

Treatment protocol

All stones of this study were treated with the Flex X2- ureteroscope (Karl Storz, Tuttlingen, Germany). In all cases we used a 12/14F access sheath, laser fragmentation was accomplished by use of a high-energy laser device (Lumenis Pulse 100W, United States) applying actual concepts of laser lithotripsy [17] including dusting (low energy (0.2-0.5 J), high frequency (20-40 Hz)), fragmentation (high energy (1.0-1.5 J), low frequency (10-15 Hz)), and the pop-corn/jacuzzi-effect (mid energy (0.5-1.0 J), mid frequency (20-30 Hz)). Larger fragments (2-4 mm) were extracted by use of the NGage-device (Cook, Ireland). Recorded performance parameter included set-up time of the robot, docking time of the robot, console time to stone contact, overall console time, treatment time, stone clearance rate, x-ray parameters (fluoroscopy time, radiation exposure and desimetry).

Statistics

Numerical data were expressed as mean with standard deviation (SD) including range; categorical data as number. SPSS program version 15 was used for data analysis. Categorical variables were analysed using Chi-squared test (or Fisher's exact test). Mann-Whitney test was used for numeric variables. P-values less than 0.05 were considered statistically significant.

Results

Preparation of the robot required 4:30min (range 3-8min); docking time was 4min (range 1-29min).Console time to visible identification of the stone amounted 4min (range 1-12min.), which included inspection of the entire collecting system.

The total operating time was 96min (range 58-193min) including a console time of65(16-174) min. Laser lithotripsy was performed in 245 patients (92%), 112(42%) patients required extraction of larger fragments using N-gage-basket. The stone clearance rate amounted 25(9-101)mm3/min. Total fluoroscopy time was time 2:30min with a radiation dosis of 297 cGy*cm2. In 117(44%) of our patients were stented postoperatively of which 75(28%) had the stent on a string removed on day 1 together with the Foley catheter. In 2(0.7%) cases we had to convert to classical FURS due to technical failure of the robot.

Post-operative data

Median postoperative hospital stay was 1(1-30) day. We encountered one case of urosepsis (Clavien 3a) requiring treatment on an intensive care unit.

Discussion

During the last 15 years robot-assisted surgery has gained an established and irreversible role in urologic laparoscopic surgery [18,19]. In 2016, installations of da Vinci-systems increased by 21% to more than 2,500 units worldwide, and robotic procedures leaped by 25% to more than 450,000, mainly performed in urology, gynaecology and visceral surgery [19]. The main advantages of robot-assisted surgery concern significant improvement of ergonomics, which enabled widespread application of laparoscopic techniques with acceptable learning curves. Additionally, the use of the robot resulted in better results mainly concerning reconstructive parts of the procedure: e. g. postoperative stenosis of the urethro-vesical anastomosis could be basically eliminated.

However, the use of robotic master-slave-systems is not limited to laparoscopic surgery. Already, in 2008 Desai et al. accomplished to use the Sensei-Magelan-system (Hansen Medical, Mountain View, USA) designed for cardio-vascular interventions by Fred Moll, the inventor of the da Vinci-system to perform robot-assisted flexible ureterorenoscopy [12,13]. In this system, the surgeon sits also in front of a console manipulating a steerable flexible tube (Figure 1) usually used for trans-vascular intra-cardiac interventions. The robotic flexible catheter system consists of an outer catheter sheath (14/12F) and inner catheter guide (12/10F). A 7.5F fibre-optic flexible ureteroscope was inserted through the inner catheter guide. Remote manipulation of the catheter system manoeuvres the ureteroscope tip, which was glued in place to the inner guide. The tip of the outer sheath was positioned at uretero pelvic junction to stabilize navigation of inner guide inside the collecting system. This means that the ureteroscope is manipulated only passively [13]. However, this project has been discontinued because it was difficult to manipulate the ureteroscope passively by use of the steerable tube.

Since 2012, ELMED (Ankara, Turkey) is working on of a robot specifically designed for FURS [14]. Roboflex Avicenna was continuously developed to perform flexible ureteroscopy providing all necessary functions for FURS. It enables the use of different kind of ureteroscopes and holmium-YAG-lasers. The surgeon sits at a console using both hands and feet to control all movements of the endoscope. Compared to manual FURS several functions could be integrated: it enables fine-tuning of the movements, motorized insertion and retraction of the laser fibre, automatic repositioning for introduction of the fibre. This means, that robotic FURS has superior performance qualities compared to the classic procedure. In the first clinical study the positive impact of the system on ergonomics could be verified using a validated questionnaire [15]. However, in this study one urologist (R.S.) being involved in development and clinical introduction of the device proctored all seven surgeons during their cases.

The present study was conducted to assess the real-live scenario when using the device on a daily base in two urologic departments involving six different surgeons. Furthermore, new technical improvements of Avicenna Roboflex were evaluated. Comparing our results with the initial study docking time of the robot was longer (4 vs. 1min), time to visualize the stone was similar (4 vs. 3.7min) and the console time was longer (96 vs. 53min). However, the stone volume was larger (1620 vs. 1300mm3). Moreover, we were able to demonstrate that we could safely and successfully apply all modern techniques and protocols of flexible URS, such as laser dusting, using pop-corn/ Jacuzzi-effect, and extraction of larger fragments [17].

In this setting, Avicenna Roboflex proved to be robust with only two cases of technical failure requiring conversion to classical FURS. The radiation exposure for the surgeon can be significantly reduced. In conclusion, we were able to integrate the device easily in our daily routine.

The first two clinical studies of Avicenna Roboflex were able to demonstrate safety and efficacy of the system providing significant ergonomic advantages with a very short learning curve for an FURS-experienced surgeon (max 5 cases). Of course, retrograde intra-renal surgery is less complicated compared to laparoscopic radical prostatectomy, particularly in case of small stones, which can be extracted by use of a Nitinol-basket [20]. On the other side, the introduction of the device provides a safe and non-exhausting environment for the surgeon. Based on this we were able to extent the indication of FURS/RIRS to larger intrarenal calculi resulting to decrease of extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy [21,22].

Further studies should now focus to evaluate further the impact of these advantages on the results compared to classical FURS/RIRS. This has to include the analysis of lifetime of the ureteroscopes, requirement of secondary treatment, postoperative complications and radiation exposure to the surgeon [23-26]. The outcomes of these studies are relevant when discussing the costs of the device. In contrast to radiology, where new imaging devices are introduced without proving any cost- effectiveness, in surgery the introduction of robotic systems is always associated by cost-discussions.

However, development of robotic systems will never stop. Beyond surgical robots as master-slave devices, the role of robotics might be even extended: Shademan et al. described in-vivo supervised autonomous soft tissue surgery in an open surgical setting, enabled by a plenoptic three-dimensional and near-infrared fluorescent (NIRF) imaging system supporting an autonomous suturing algorithm to complete complex surgical tasks on deformable soft tissue, such as suturing an intestinal anastomosis [27]. Similarly, robot-assisted water-jet-ablation (Procept, Redwood Shores, United States) showed significantly better ablation efficacy compared to standard transurethral resection [28]. Next years will be fascinating to evaluate the impact of robot-assistance for laparoscopy, but also for robot- assisted flexible ureterorenoscopy.