Editorial Comment

Abstract

Renal access is the single most important step to completing a successful percutaneous nephrolithotomy (PCNL). Renal access obtained by a urologist is associated with increased stone-free rates, decreased complications, decreased length of stay and decreased hospital costs when compared to renal access obtained by a radiologist. 1e3 Data from U.S. insurance claims databases indicate that urologist-obtained access is on the rise, increasing from 13% in 2007 to 32% in 2017. 3 If urologistobtained access results in positive patient outcomes, why do the majority of urologists still rely on radiologists to obtain access for PCNL? A major barrier continues to be the learning curve. As the authors point out, techniques such as ultrasound guidance for access have decreased the learning curve compared to traditional fluoroscopy guidance, but even at less than 20 cases to learn ultrasound access, urologists experience variable training in obtaining access during residency/fellowship and thus do not uniformly finish their training feeling comfortable with obtaining their own access. Clearly there remains a clinical need to get us closer to 100% urologist-obtained access for PCNL.Robotic assistance may represent a solution for this clinical need. In this randomized, single-blind trial, the authors found a decreased number of needle punctures, decreased access time and increased success of trainees with robotic-assisted fluoroscopicguided vs ultrasound-guided renal access, with no difference in stone-free rates or complications between the groups. Pairing an artificial intelligence puncture trajectory finder with robotic-assisted needle access represents a novel advancement of technology. We often see new technologies with no clinical applicability. These results may represent an encouraging new potential avenue to increase urologist-obtained renal access with new technology matched to a clinical need.