For medical applications, a key issue is whether robotic machines are better, or simply enhance human performance by lacking or reducing fatigability, allowing greater precision and efficiency over longer durations. This is particularly true for master/slave devices where expensive development costs can be offset by time saved, greater task performance precision, and increased productivity, and perhaps also consistency, particularly in repetitive or endurance‐based tasks. Ideally, a master/slave human–robot partnership should enhance the capability of each individual component part provided the master can maintain concentration throughout the task. In interventional urology, robotics has already made great inroads through the use of devices that are master‐independent, such as the PUMA560 [1] (1988; arm with six degrees of freedom used for brain biopsy and later for transurethral resection of prostate) and, more recently, the Cyberknife for precision radiotherapy. Zeus and Aesop (US Food and Drug Administration [FDA] approved in 1990; Computer Motion, Santa Barbara, CA, USA), were bought and quashed by Intuitive Surgical (Sunnyvale, CA, USA) in favor of their Da Vinci™, a next‐generation master/slave console‐controlled robotic device with endo‐wrist technology (FDA approved in 2000) [2, 3]. It and the Sensei‐Hansen device (Hansen Medical, Mountain View, CA, USA) [4, 5] were their urological successors, incorporating console‐based 3D optical visualization with magnification, motion control and scaling, tremor reduction, and a greater range of movement and ergonomics compared to traditional instruments. Although it is beyond the scope of this chapter to examine cost‐benefits, this aspect of all new technologies will be amplified in an era of economic austerity coupled to higher healthcare demands from chronic illness, fueled by obesity and ageing pandemics, and falling birth rates in the world’s developed nations.

Rupel and Brown’s endourological legacy of cystoscopic nephroscopy for renal stones at open surgery in 1941 [6] has been the evolution of a wide range of extracorporeal, ureteroscopic, percutaneous, and laparoscopic procedures, all embraced by urologists worldwide. The dominant large/branched renal stone treatment remains percutaneous nephrolithotomy (PCNL). Nevertheless, after two decades of evolution, classical retrograde intrarenal surgery (cRIRS) is now the most dominant endourological stone treatment modality overall. Expertise and allied technological growth has projected cRIRS to the mainstream of complex endourological stone and soft tissue treatment in the upper urinary tract. For the first time, cRIRS rightly challenges the dominant alternative of PCNL treatment of larger intrarenal calculi [7–12]. However, cRIRS for large stones remains a technically challenging procedure requiring specific expert endo‐skill sets, real‐time problem solving capabilities [13–15], and both physical and mental endurance. Even when ureteral access sheaths (UAS) are used (almost mandatory in this setting), and the stone(s) can be accessed and completely laser‐fragmented, the single‐sitting stone‐free rate is limited by the operator’s stamina during long dusting and “pop‐corning” procedures, and the size and number of stone fragments that can safely be removed down the ureter in a safe, timely manner (in turn dependent on stone composition and hardness, and collecting system anatomy). Additional limiting factors are current flexible ureterorenoscope (FUR) design, a moving target (renal respiratory excursion) during fragmentation, and awkward calyceal anatomy, particularly if several such cases are scheduled per day. This has resulted in ≥50% secondary procedure rates to render patients stone‐free. Furthermore, the surgeon depends on assistants for key task performance, to activate lasers (standby‐ready and energy‐rate settings adjustments), deploy nitinol baskets and capture fragments, maintain and enhance irrigant flow, aspirate, and to draw/inject contrast, while manipulating and targeting the ureterorenoscope tip. All operating room staff are exposed to radiation over a longer period (range of 1.7–56 μSv [16–18]). Meanwhile, less invasive evolutionary PCNL techniques (mini, ultra‐mini, super‐mini, and micro‐PCNL [19–24]) have also evolved to challenge cRIRS, to gain parity or ascendancy in the current larger renal stone treatment paradigm, particularly in Asia, so further technological and technique evolution is mandated.

During the last two decades, significant changes in both semirigid and FUR design, specifically tip and shaft size reduction along with configuration changes, have facilitated easier natural orifice access into the upper urinary tract for the majority of users (albeit at the cost of increased fragility and repair costs). Greater direction and range of tip deflection (both single and dual active flexion/extension motion range) has made navigation through the intrarenal collecting system easier, allowing more urologists to reach and inspect >95% of the entire collecting system (the most challenging part being the lower antero/medial calyx, especially in a dilated pelvicalyceal system which limits use of both active and secondary passive deflection).

In 2012, ELMED (Ankara, Turkey) started developing a procedure‐specific robot‐assisted RIRS (RA‐RIRS) device [25]. The IDEAL (idea, development, evaluation, assessment, long‐term study) framework for surgical innovation stages was embraced from prototype to the commercially available Avicenna Roboflex (IDEAL stage 1), and early clinical experience with treatments performed by different experienced endourologists (IDEAL stages 2–4) was reported as follows.