Commentary on Flexible robotic retrograde renoscopy: Description of novel robotic device and preliminary laboratory experience. Desai MM, Aron M, Gill IS, Pascal-Haber G, Ukimura O, Kaouk JH, Stahler G, Barbagli F, Carlson C, Moll F, Section of Laparoscopic and Robotic Surgery, Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, OH

To describe a novel flexible robotic system for performing retrograde intrarenal surgery. Remote robotic flexible ureterorenoscopy was performed bilaterally in 5 acute swine (10 kidneys). A novel 14F robotic catheter system, which manipulated a passive optical fiberscope mounted on a remote catheter manipulator was used. The technical feasibility, efficiency, and reproducibility of accessing all calices were assessed. Additionally, laser lithotripsy of calculi and laser ablation of renal papillae were performed. The robotic catheter system could be introduced de novo in 8 ureters; 2 ureters required balloon dilation. The ureteroscope could be successfully manipulated remotely into 83 (98%) of the 85 calices. The time required to inspect all calices within a given kidney decreased with experience from 15 minutes in the first kidney to 49 seconds in the last (mean 4.6 minutes). On a visual analog scale (1, worst to 10, best), the reproducibility of caliceal access was rated at 8, and instrument tip stability was rated at 10. A renal pelvic perforation constituted the solitary complication. Histologic examination of the ureter showed changes consistent with acute dilation without areas of necrosis. A novel robotic catheter system is described for performing retrograde ureterorenoscopy. The potential advantages compared with conventional manual flexible ureterorenoscopy include an increased range of motion, instrument stability, and improved ergonomics. Ongoing refinement is likely to expand the role of this technology in retrograde intrarenal surgery in the near future.