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Objective To use meta-analysis to determine the accuracy of percutaneous core needle biopsy in the diagnosis of small renal masses (SMRs≤4.0 cm). Materials and Methods Studies were identified by searching PubMed, Embase, and the Cochrane Library database up to March 2013. Two of the authors independently assessed the study quality using QUADAS-2 tool and extracted data that met the inclusion criteria. The sensitivity, specificity, likelihood ratios, diagnostic odds ratio (DOR) and also summary receiver operating characteristic (SROC) curve were investigated and draw. Deek’s funnel plot was used to evaluate the publication bias. Result A total of 9 studies with 788 patients (803 biopsies) were included. Failed biopsies without repeated or aborted from follow-up/surgery result were excluded (232 patients and 353 biopsies). For all cases, the pooled sensitivity was 94.0% (95% CI: 91.0%, 95.0%), the pooled positive likelihood was 22.57 (95% CI: 9.20-55.34), the pooled negative likelihood was 0.09 (95% CI: 0.06-0.13), the pooled DOR was 296.52(95% CI: 99. 42-884.38). The area under the curve of SROC analysis was 0.959±0.0254. Conclusion Imaging-guided percutaneous core needle biopsy of small renal masses (SMRs≤4.0 cm) is highly accurate to malignant tumor diagnosis with unknown metastatic status and could be offered to some patients after clinic judgment prior to surgical intervention consideration.

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The Hippocratic Collection, including the most of ancient Greek medicine, remains still interesting, despite the recent advances that transformed definitely the urological healing methods. Considering the patient as a unique psycho-somatic entity and avoiding high risk surgical manipulations were the leading principles dictating the everyday practice. Contemporary physicians can still learn from the clinical observations in times of complete absence of laboratory or imaging aid, from the prognostic thoughts, the ethics, and the philosophical concepts, represented by the Hippocratic writings, tracing into them the roots of Rational Medicine in general and Urology in particular.

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Objective To stratify patients with bladder cancer into homogeneous risk groups according to statistically significant differences found in PFS (progression-free survival). To identify those patients at increased risk of progression and to provide oncological follow-up according to patient risk group. Materials and Methods A retrospective study of 563 patients treated with radical cystectomy (RC). In order to determine which factors might predict bladder tumour progression and death, uni- and multivariate analyses were performed. The risk groups were identified according to “inter-category” differences found in PFS and lack of differences, thus revealing intra-category homogeneity. Results Median follow up time was 37.8 months. Recurrence occurred in a total of 219 patients (38, 9%). In 63% of cases this was distant recurrence. Only two variables retained independent prognostic value in the multivariate analysis for PFS: pathological organ confinement and lymph node involvement. By combining these two variables, we created a new “risk group” variable. In this second model it was found that the new variable behaved as an independent predictor associated with PFS. Four risk groups were identified: very low, low, intermediate and high risk: • Very low risk: pT0 N0 • Low risk: pTa, pTis, pT1, pT2 and pN0 • Intermediate risk: pT3 and pN0 • High risk: pT4 N0 or pN1-3. Conclusions We retrospectively identified 4 risk groups with an independent prognostic value for progression-free survival following RC. Differences in recurrence patterns after RC between risk groups have led us to set different intervals in monitoring for cancer.

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Purpose There is little information in the literature on health-related quality of life (HRQOL) changes due to high-dose-rate (HDR) brachytherapy monotherapy for prostate cancer. Materials and Methods We conducted a prospective study of HRQOL changes due to HDR brachytherapy monotherapy for low risk or favorable intermediate risk prostate cancer. Sixty-four of 84 (76%) patients who were treated between February 2011 and April 2013 completed 50 questions comprising the Expanded Prostate Cancer Index Composite (EPIC) before treatment and 6 and/or 12 months after treatment. Results Six months after treatment, there was a significant decrease (p<0.05) in EPIC urinary, bowel, and sexual scores, including urinary overall, urinary function, urinary bother, urinary irritative, bowel overall, bowel bother, sexual overall, and sexual bother scores. By one year after treatment, EPIC urinary, bowel, and sexual scores had increased and only the bowel overall and bowel bother scores remained significantly below baseline values. Conclusions HDR brachytherapy monotherapy is well-tolerated in patients with low and favorable intermediate risk prostate cancer. EPIC urinary and sexual domain scores returned to close to baseline 12 months after HDR brachytherapy.

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Objective To evaluate the safety, efficacy and possible complications of 16-core transrectal prostate biopsies using two doses of ciprofloxacin for prophylaxis of infectious complications. Materials and Methods Sixteen-core prostate biopsies were performed on a number of patients with different signs of potential prostate cancer. Complications were assessed both during the procedure and one week later. After the procedure, urine samples were collected for culture. The rate of post-biopsy complications, hospital visits and hospitalizations were also analyzed. Ciprofloxacin (500 mg) was administered two hours before, and eight hours after the procedure. Results The overall rate of post-biopsy complications was 87.32%, being 5.4% of those considered major complications due to hemorrhage, or to urinary retention. Eight patients required hospital treatment post-biopsy. Fever occurred in just one patient (0.29%). There was no incidence of orchitis, epididymitis, prostatitis, septicemia, hospitalization, or death. The urine culture showed positive results in five patients (2.15%). Conclusion One-day prophylaxis with ciprofloxacin proved to be safe and effective in the prevention of infectious complications following 16-core prostate biopsies.

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Purpose To evaluate the relationship between unilateral or bilateral criptorchidism, patient age, primary location of the gonad and modality of treatment with testicular volume and hormonal status at 18 years in patients diagnosed and treated for cryptorchidism during childhood. Materials and Methods Testicular volume, LH, FSH, and testosterone were evaluated in 143 young men at 18 years treated in childhood for unilateral (n=103) or bilateral (n=40) cryptorchidism. Results Unilateral cryptorchidism: Location of testis was prescrotal in 36 patients, inguinal in 52 and non-palpable in 15. The mean volume was 9.7 mL compared to 16.2 mL. for the spontaneously descended testicle in unilateral cryptorchidism. However, 22 patients who received HCG had a significantly bigger testis (11.8 mL.) than those treated with primary surgery (9.2 mL). The results showed a significant positive correlation between testicular volume and patient age at treatment. Bilateral cryptorchidism Location of testis was prescrotal in 34 cases, inguinal in 40 and 6 patients with non-palpable testicles. Mean volume at 18 years was 12.9 mL, greater than unilateral cryptorchid testis (9.7 mL) but smaller than healthy contralateral in unilateral cases (16.2 mL). There were significant differences in the testicular growth for bilateral patients with testicular descent after being treated with HCG (14.4 mL) in respect with those untreated (11.1 mL) or those who underwent primary surgery (11.4 mL). There was a significant positive correlation between the testicular volume and palpable (12.4 mL) or non-palpable testis (10.4 mL). There was a correlation between unilateral or bilateral cryptorchidism and levels of FSH. Conclusions Testicular volume and hormonal function at 18 years for patients diagnosed and treated for cryptorchidism during childhood are strongly influenced by whether the undescended testis was unilateral or bilateral. Location of the testes at diagnosis or age of initial treatment exerts no definite effect on testicular volume improvement or hormonal levels at 18 years of age.

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Purpose The treatment of urinary tract infections (UTI) with antibiotics is commonly used, but recurrence and antibiotic resistance have been growing and concerning clinicians. We studied whether the rapid onset of a protective biofilm may be responsible for the lack of effectiveness of antibiotics against selected bacteria. Materials and Methods Two established uropathogenic Escherichia coli strains, UTI89 and CFT073, and two Pseudomonas aeruginosa strains, PA01 and Boston-41501, were studied to establish a reliable biofilm formation process. Bacterial growth (BG) was determined by optical density at 600 nm (OD 600) using a spectrophotometer, while biofilm formation (BF) using crystal violet staining was measured at OD 550. Next, these bacterial strains were treated with clinically relevant antibiotics, ciprofloxacin HCl (200 ng/mL and 2 μg/mL), nitrofurantoin (20 μg/mL and 40 μg/mL) and ampicillin (50 μg/mL) at time points of 0 (T0) or after 6 hours of culture (T6). All measurements, including controls (bacteria -1% DMSO), were done in triplicates and repeated three times for consistency. Results The tested antibiotics effectively inhibited both BG and BF when administered at T0 for UPEC strains, but not when the antibiotic administration started 6 hours later. For Pseudomonas strains, only Ciprofloxacin was able to significantly inhibit bacterial growth at T0 but only at the higher concentration of 2 μg/mL for T6. Conclusion When established UPEC and Pseudomonas bacteria were allowed to culture for 6 hours before initialization of treatment, the therapeutic effect of selected antibiotics was greatly suppressed when compared to immediate treatment, probably as a result of the protective nature of the biofilm.

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Objectives To evaluate post-orchiectomy utilization of radiation therapy (RT) versus other management approaches in stage IIA and IIB testicular seminoma patients. Materials and Methods Two hundred and forty-one patients with stage IIA and IIB testicular seminoma were identified between 1988 and 2003 using the Surveillance, Epidemiology, and End Results (SEER) database. Results Median follow-up was 10 years. Patients with stage IIA disease underwent RT more frequently than those with stage IIB disease (72% vs. 46%, respectively; P<0.001). There was no significant change in RT utilization for stage IIA or IIB disease between 1988 and 2003 (P = 0.89). Conclusions Between 1988 and 2003, stage IIA patients underwent RT more often than stage IIB patients in the United States. There was no significant change in RT utilization for stage IIA or IIB disease during this time period. Based on reports describing excellent progression-free survival with cisplatin-based chemotherapy, this approach has increased in popularity since 2003 and may eventually become the most popular treatment approach for both stage IIA and IIB testicular seminoma.

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Introduction Achieving stone free status (SFS) is the goal of stone surgery. In this study it is aimed to compare effectiveness of unenhanced helical computerized tomography (UHCT), KUB and ultrasonography (US) for detection of residual RFs and predicition of stone releated events following percutaneous nephrolitotomy (PNL). Materials and Methods Patients underwent PNL for radiopaque stones between November 2007 and February 2010 were followed. Patients were examined within 24-48 hours after the procedure by KUB, US and UHCT. For stone size 4 mm was accepted as cut off level of significance.Sensitivity and specificity of KUB and US for detection of RFs and value of them for prediction of stone related events were calculated. Results SFS was achieved in 95 patients (54.9%) and when cut off value of 4 mm for RFs was employed, SFS was achieved in 131 patients (75.7%). Sensitivity was 70.5% for KUB, and 52.5% for US. UHCT was shown to be significantly more efficient for detection of RFs compared to both KUB (p=0.01) and US (p=0.001). When cut off level of 4 mm employed, sensitivity of KUB and US increased to 85.7% and 57.1%. Statistical significant superiority of UHCT still remained (p value vs. KUB: 0.03 and p value vs. US: 0.008). Conclusion UHCT is the most sensitive diagnostic tool for detecting RFs after PNL. It has higher sensitivity regardless of stone size compared to KUB and US. Additionally UHCT has higher capability of predicting occurrence of stone related events.

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Objective To review the technique and outcome of perineal urethrostomy or urethral perineostomy and to identify factors related to the procedure failure. Material and methods We studied 17 patients who underwent perineal urethrostomy between 2009-2013 in a single hospital. Success was defined as no need for additional surgical treatment or urethral dilatation. We reviewed the clinical data related to age, weight, previous urethral surgery, diabetes, hypertension, ischemic cardiopathy, lichen sclerosus and other causes and studied their association with the procedure failure (univariate analysis). We completed the analysis with a multivariate test based on binary regression. Results The average follow-up was 39.41 months. From all the causes, we found Lichen Sclerosus in 35%, idiopathic etiology in 29% and prior hypospadia repair in 18%. Postoperative failure occurred in 3 patients, with a final success of 82.4%. The binary regression model showed as independent risk factors ischemic cardiopathy (OR: 2.34), and the presence of Lichen Sclerosis (OR: 3.21). Conclusions The success rate with the perineal urethrostomy technique shows it to be a valid option above all when we preserve the urethral blood supply and plate. Lichen sclerosus and ischemic vascular problems are risk factors to re-stenosis.

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Objectives To analyze the efficacy of intrarectal ice application as an anesthetic method prior to transrectal ultrasound (TRUS) guided prostate biopsy. Materials and Methods A total of 120 consecutive men were included into the study prospectively. Patients were equally randomized as group 1 and 2 with 60 patients each. Ice was applied as an anesthetic method 5 minutes before procedure to the patients in group 1. Patients in group 2 were applied 10 ml of 2% lidocaine gel 10 minutes before procedure. Twelve core biopsy procedure was performed for all patients. The pain level was evaluated using a visual analogue scale (VAS). Results Median pain score was 3.5 (1-8) in group 1 and 5 (1-8) in group 2. There is significantly difference between groups regarding the mean sense of pain level during the procedure. (p=0.007) There was also no difference in complications between two groups about presence and duration of macroscopic hematuria and rectal bleeding. Conclusions Intrarectal ice application prior to TRUS prostate biopsy has an effect on reducing pain. Development of new techniques about cold effect or ice can make this method more useful and decrease complication rates.

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Introduction Non-androgenic growth factors are involved in the growth regulation of prostate cancer (PCa). Objective This is the first Brazilian study to correlate, in a population of patients operated for PCa, PSA, total testosterone, insulin-like growth factor-I (IGF-I) and insulin-like growth factor-binding protein-3 (IGFBP-3) with Gleason score and to compare with a control group with benign prostate hyperplasia (BPH). Materials and Methods This retrospective single-center study included 49 men with previously diagnosed PCa and 45 with previously diagnosed BPH. PSA, testosterone, IGF-I, IGFBP-3 were determined in both groups. Results PSA and IGFBP-3 levels were significantly higher in the PCa group as compared to the BPH group (p<0.001 and p=0.004, respectively). There was a significant difference when we compared the PSA before surgery (p<0.001) and at the inclusion in the study (p<0.001) and IGFBP3 (0.016) among patients with Gleason <7, ≥7 and BPH. In the PCa group, PSA, testosterone, IGF-I and IGFBP-3 levels were comparable between Gleason <7 and ≥7. Conclusions Our data suggest that in localized PCa, the quantification of PSA and, not of IGF-1, may provide independent significant information in the aggressiveness. IGFBP-3 could be a biochemical marker of disease control in PCa patients.

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Purpose To determine the safety of continued administration of antithrombotic agents during transperineal (TP) prostate biopsy. Patients and Methods A total of 811 men who underwent transrectal ultrasound (TRUS)-guided TP biopsy from January 2008 to June 2012 at our two institutions were retrospectively analyzed. Among these 811 men, 672 received no antithrombotic agents (group I), 103 received and continued administration of antithrombotic agents (group II), and 36 interrupted administration of antithrombotic agents (group III). Overall complications were graded and hemorrhagic complications were compared (group I with group II) using propensity score matching (PSM) analysis. Results An overall complication rate of 4.6% was recorded. Hemorrhagic complications occurred in 1.8% and they were virtually identical in all the three groups, and no severe hemorrhagic complications occurred. One patient in group III required intensive care unit admission for cerebral infarction. PSM analysis revealed no statistical difference between groups I and II with regard to the incidence of gross hematuria, perineal hematoma, and rectal bleeding. Multiple regression analysis revealed that hemorrhagic complications were associated with lower body mass index (<21 kg/m2, P=0.0058), but not with administration of antithrombotic agents. Conclusions Continued administration of antithrombotic agents does not increase the risk of hemorrhagic complications; these agents are well tolerated during TP biopsy.

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Purpose The aim of the study was to analyse and compare the ability of multiparametric magnetic resonance imaging (mp–MRI) and prostate biopsy (PB) to correctly identify tumor foci in patients undergoing radical prostatectomy (RP) for prostate cancer (PCa). Materials and Methods 157 patients with clinically localised PCa with a PSA <10 ng/mL and a negative DRE diagnosed on the first (12 samples, Group A) or second (18 samples, Group B) PB were enrolled at our institution. All patients underwent mp-MRI with T2-weighted images, diffusion-weighted imaging, dynamic contrast enhanced-MRI prior to RP. A map of comparison describing each positive biopsy sample was created for each patient, with each tumor focus shown on the MRI and each lesion present on the definitive histological examination in order to compare tumor detection and location. The sensitivity of mp-MRI and PB for diagnosis was compared using Student’s t-test. The ability of the two exams to detect the prevalence of Gleason pattern 4 in the identified lesions was compared using a chi-square test. Results Overall sensitivity of PB and mp-MRI to identify tumor lesion was 59.4% and 78.9%, respectively (p<0.0001). PB missed 144/355 lesions, 59 of which (16.6%) were significant. mp-MRI missed 75/355 lesions, 12 of which (3.4%) were significant. No lesions with a GS≥8 were missed. Sensitivity of PB and mp-MRI to detect the prevalence of Gleason pattern 4 was 88.2% and 97.4%, respectively. Conclusions mp-MRI seems to identify more tumor lesions than PB and to provide more information concerning tumor characteristics.

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Objective To identify whether stabilization of larger bladder stones would improve the efficacy of combination (ultrasonic/pneumatic) lithotripsy in a phantom bladder stone model for percutaneous cystolithopaxy. Materials and Methods Using 1cm phantom Bego stones, a spherical model bladder was used to simulate percutaneous bladder access. A UroNet (US Endoscopy, USA) was placed alongside a Swiss Lithoclast probe through the working channel of a Storz 26Fr rigid nephroscope. Using a 30Fr working sheath, the stone was captured, and fragmented for 60seconds. Resulting fragments and irrigation were filtered through a 1mm strainer, and recorded. Five trials were performed with and without the UN. Durability was then assessed by measuring net defects, and residual grasp strength of each instrument. Descriptive statistics (mean, standard deviations) were used to summarize the data, and Student’s t-tests (alpha<0.05) were used to compare trials. Results The mean time to stone capture was 12s (8-45s). After fragmentation with UN stabilization, there were significant improvements in the amount of residual stone (22% dry weight reduction vs 8.1% without UN, p<0.001), number of fragments (17.5 vs 5.0 frag/stone, p=0.0029), and fragment size (3.6mm vs. 7.05 mm, p=0.035). Mesh defects were noted in all nets, ranging from 2-14 mm, though all but one net retained their original grip strength (36.8N). Conclusions Bladder stone stabilization improved fragmentation when used in conjunction with ultrasonic/pneumatic lithotripsy. However, due to limitations in maneuverability and durability of the UN, other tools need to identified for this indication.

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Objective The aim of this study was to evaluate the capability and the reliability of diffusion-weighted imaging (DWI) in the changes of kidneys occurring after extracorporeal shock wave lithotripsy (ESWL) treatment for renal stones. Materials and Methods A total of 32 patients who underwent ESWL treatment for renal stone disease between June and December 2011 were enrolled in this prospective study. Color Doppler ultrasonography (CDUS) and DWI were performed before and within 24 hours after ESWL. DWI was obtained with b factors of 0, 500 and 1000 s/mm2 at 1.5 T MRI. Each of Resistive index (RI) and ADC values were calculated from the three regions of renal upper, middle and lower zones for both of the affected and contralateral kidneys. Paired sample t test was used for statistical analyses. Results After ESWL, the treated kidneys had statistically significant lower ADC values in all different regions compared with previous renal images. The best discriminative parameter was signal intensity with a b value of 1000 s/mm2. The changes of DWI after ESWL were noteworthy in the middle of the treated kidney (p<0.01). There were no significant difference between RI values in all regions of treated and contralateral kidneys before and after treatment with ESWL (p>0.05). Conclusion DWI is a valuable technique enables the detection of changes in DWI after ESWL treatment that may provide useful information in prediction of renal damage by shock waves, even CDUS is normal.

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Purpose To assess the oncologic and functional outcomes of salvage renal surgery following failed primary intervention for RCC. Materials and Methods We performed a retrospective review of patients who underwent surgery for suspected RCC during 2004-2012. We identified 839 patients, 13 of whom required salvage renal surgery. Demographic data was collected for all patients. Intraoperative and postoperative data included ischemic duration, blood loss and perioperative complications. Preoperative and postoperative assessments included abdominal CT or magnetic resonance imaging, chest CT and routine laboratory work. Estimated glomerular filtration rate (eGFR) was calculated according to the Modification of Diet in Renal Disease equation. Results The majority (85%) of the patients were male, with an average age of 64 years. Ten patients underwent salvage partial nephrectomy while 3 underwent salvage radical nephrectomy. Cryotherapy was the predominant primary failed treatment modality, with 31% of patients undergoing primary open surgery. Pre-operatively, three patients were projected to require permanent post-operative dialysis. In the remaining 10 patients, mean pre- and postoperative serum creatinine and eGFR levels were 1.35 mg/dL and 53.8 mL/min/1.73 m2 compared to 1.43 mg/dL and 46.6 mL/min/1.73 m2, respectively. Mean warm ischemia time in 10 patients was 17.4 min and for all patients, the mean blood loss was 647 mL. The predominant pathological stage was pT1a (8/13; 62%). Negative surgical margins were achieved in all cases. The mean follow-up was 32.9 months (3.5-88 months). Conclusion While salvage renal surgery can be challenging, it is feasible and has adequate surgical, functional and oncological outcomes.

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Purpose To validate the Quality of Erection Questionnaire (QEQ) considering Brazilian social-cultural aspects. Materials and Methods To determine equivalence between the Portuguese and the English QEQ versions, the Portuguese version was back-translated by two professors who are native English speakers. After language equivalence had been determined, urologists considered the QEQ Portuguese version suitable. Men with self-reported erectile dysfunction (ED) and infertile men who had a stable sexual relationship for at least 6 months were invited to answer the QEQ, the International Index of Erectile Function (IIEF) and the RAND 36-Item Health Survey (RAND-36). The questionnaires were presented together and answered without help in a private room. Internal consistency (Cronbach’s α), test-retest reliability (Spearman), convergent validity (Spearman correlation) coefficients and known-groups validity (the ability of the QEQ Portuguese version to differentiate erectile dysfunction severity groups) were assessed. Results We recruited 197 men (167 ED patients and 30 non-ED patients), mean age of 53.3 and median of 55.5 years (23-82 years). The Portuguese version of the QEQ had high internal consistency (Cronbach α=0.93), high stability between test and retest (ICC 0.83, with IC 95%: 0.76-0.88, p<0.001) and Spearman correlation coefficient r=0.82 (p<0.001), which demonstrated the high correlation between the QEQ and IIEF results. The correlations between the QEQ and RAND-36 were significantly low in ED (r=0.20, p=0.01) and non-ED patients (r=0.37, p=0.04). Conclusion The QEQ Portuguese version presented good psychometric properties and high convergent validity in relation to IIEF. The low correlations between the QEQ and the RAND-36, as well as between the IIEF and the RAND-36 indicated IIEF and QEQ specificity, which may have resulted from the patients’ psychological adaptations that minimized the impact of ED on Quality of Life (QoL) and reestablished the well-being feeling.

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Objective To describe the surgical technique and initial experience with a single-port retroperitoneal renal biopsy (SPRRB). Materials and Methods Between January and April 2013, five children underwent SPRRB in our hospital. A single 1.5 cm incision was performed under the 12th rib at mid-axillary line, and an 11 mm trocar was inserted. A nephroscope was used to identify the kidney and dissect the perirenal fat. After lower pole exposure, a laparoscopic biopsy forceps was introduced through the nephroscope working channel to collect a renal tissue sample. Results SPRRB was successfully performed in five children. The mean operative time was 32 minutes, and mean estimated blood loss was less than 10 mL. The hospital stay of all patients was two days because they were discharged in the second postoperative day, after remaining at strict bed rest for 24 hours after the procedure. The average number of glomeruli present in the specimen was 31. Conclusion SPRRB is a simple, safe and reliable alternative to open and videolaparoscopic approaches to surgical renal biopsy.

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Main findings A 25-year-old hypertensive female patient was referred to our institution. Initial workup exams demonstrated a 2.8 cm cortical lower pole tumor in the right kidney. She underwent laparoscopic partial nephrectomy without complications. Histopathologic examination revealed a rare juxtaglomerular cell tumor known as reninoma. After surgery, she recovered uneventfully and all medications were withdrawn. Case hypothesis Secondary arterial hypertension is a matter of great interest to urologists and nephrologists. Renovascular hypertension, primary hyperadosteronism and pheocromocytoma are potential diagnosis that must not be forgotten and should be excluded. Although rare, chronic pyelonephritis and renal tumors as rennin-producing tumors, nephroblastoma, hypernephroma, and renal cell carcinoma might also induce hypertension and should be in the diagnostic list of clinicians. Promising future implications Approximately 5% of patients with high blood pressure have specific causes and medical investigation may usually identify such patients. Furthermore, these patients can be successfully treated and cured, most times by minimally invasive techniques. This interesting case might expand knowledge of physicians and aid better diagnostic care in future medical practice.

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Introduction The purpose of this video is to demonstrate the use of the robot to perform a transmesocolonic pyelolithotomy of a horseshoe kidney. Materials and Methods A 35-year old female presented with vague abdominal pain. CT scan imaging revealed the presence of a left horseshoe kidney with multiple pelvicalyceal stones. The patient was positioned in the supine position. A total of 4 ports were introduced. A 3-arm da Vinci robotic surgical system was docked, and the arms were connected. First, the dilated renal pelvis was identified behind the thin mesocolon. The mesocolon was entered and renal pelvis was dissected completely from the surrounding fat. Then, the renal pelvis was opened after adequate dissection and stones were visualized inside the calyces. By Prograsp forceps, stones were removed from all the calyces under vision and were extracted from the assistant trocar. Finally, the pylotomy incision was closed using 4 0 Maxon in a continuous fashion and the mesocolon was closed using 3 0 PDS interrupted sutures. A JP drain was placed. Result Operative time was forty-five minutes, blood loss was 100 ml. The patient was discharged after 48 hours with no immediate complications. Conclusion The utilization of minimal invasive surgery using the robot to extract multiple pelvicalyceal stones from a horseshoe kidney without reflecting the mesocolon proved to be a feasible and novel way in the management of complex stone disease improving the outcome with minimal morbidity.