A Better Mousetrap: Minimally-Invasive Management of Symptomatic Caliceal Diverticular Stones in the Era of Robotic Surgery
Richard E. Link, MD, PhD, Professor of Urology and the Carlton-Smith Endowed Chair in Urologic Education at the Baylor College of Medicine, discusses the pros and cons of different techniques for managing caliceal diverticular stones, a simple problem requiring a complex solution. The presentation aims to provide a framework for the identification and management of this condition since there are not enough high-quality studies to have a definitive strategy. Dr. Link discusses caliceal diverticulum incidence, etiology, and presentation, as well as the specific qualities of stones in caliceal diverticula, noting that stone formation is not caused by the presence of a caliceal diverticulum, but rather by the same metabolic anomalies experienced by other stone formers. He then dissects the different surgical options for treatment, including: extracorporeal shockwave lithotripsy (ESWL), which results in stone-free rates of ≤25% and should only be used in patients who cannot tolerate more effective therapy; ureteroscopic management, which is superior to ESWL but still has low success rates; and percutaneous management, which was the gold standard treatment before the era of robotic surgery, and results in a stone-free rate between 70 and 100%, although it can be a challenging surgery. Dr. Link also discusses laparoscopic diverticulectomy and robotic true partial nephrectomy, more aggressive approaches that may be needed if percutaneous management fails. He concludes with several case studies, emphasizing that treatments should be tailored to individual patients.
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