Robot‐assisted retrograde intrarenal surgery: first clinical experience with the ILY® system

Abstract

The management of urinary stones has evolved considerably over the years, from open surgery to today's minimally invasive procedures, thanks to the advent of continuous technological advances, such as new lasers, tools miniaturisation, disposable endoscopes, suction sheaths, artificial intelligence, virtual reality, videoendoscopic technology and the introduction of robot-assisted surgery [1]. Thanks to these improvements, flexible ureteroscopy (fURS) has pushed its indications to treat almost all types of stones [2], due to its feasibility and safety, despite variable success rates. However, fURS is limited by ergonomic deficiencies and can be challenging, especially in complicated cases with multiple stones or a high stone burden. The main ergonomic problems of fURS are related to prolonged standing and static postures of the surgeon while wearing heavy protective lead aprons [3]. The surgeon must control the fluoroscopy and laser device by foot pedals while fixing the position of the endoscope with one hand and doing flexion, deflection, or rotation movements with the other hand, causing continuous tension of the wrist and finger muscles [3]. Also, an assistant is needed to manipulate the manual irrigation system, the laser fibre, or any accessory instruments. This makes the working space limited and uncomfortable. All these can undoubtedly cause musculoskeletal disorders that impair the capacity and quality of work performance [1, 3, 4]. Implementation of robotics in endourological interventions could offer potential benefits by improving ergonomics and potentially reducing radiation exposure and operation time due to the robot's memory function [4, 5]. Another advantage would be the stability and precision of the instrument and the fibre laser during lithotripsy [5, 6]. Consequently, robot-assisted retrograde intrarenal surgery (roboRIRS) has emerged to improve the operative outcomes, ergonomic conditions, and impact on surgeon health of conventional fURS. In 2011, Desai et al. [7] performed the first human trial of a robotic device for fURS. This device, originally developed for cardiovascular procedures, was based on a robotic flexible catheter system (Sensei™, Hansen Medical, Mountainview, CA, USA) consisting of an outer catheter sheath (14/12 F) and inner catheter guide (12/10 F) combined with a custom-built fibreoptic flexible ureteroscope, meaning that the ureteroscope is manipulated only passively, which proved to be insufficient for robot-assisted fURS [7]. In 2014, Saglam et al. [8] first reported data from a clinical trial with the Roboflex™ Avicenna (ELMED, Ankara, Turkey), a robot designed specifically for fURS, demonstrating it as a suitable, safe, and efficacious platform with a short learning curve, with ergonomic superiority and lower radiological exposure compared to conventional fURS. To date, few robotic platforms are available on the market to assist fURS procedures [5-8]. The ILY® robotic system (STERLAB, Vallauris, France) is a ureteroscope holder with multiple degrees of freedom, operated remotely by the surgeon with a wireless controller, keeping the surgeon away from sources of ionising radiation [6]. The ILY robot differs significantly from the Avicenna, which is a bulky platform including a master console with pedals and surgeon's seat, along with a manipulator for endoscope movements. Whereas, the ILY is a compact trolley mini-console operated remotely by a wireless controller, occupying minimal space in the operating room, and keeping the surgeon away from the radiation source. As no evidence for roboRIRS with the ILY robot in humans is available, the aim of this letter is to describe the surgical setting and present our case series to contribute to the existing literature. We present a descriptive analysis of six patients who underwent roboRIRS for urolithiasis at our centre in July 2023. All procedures were performed by experienced endourologists. The patients’ characteristics are detailed i