Abstract
Objective: To report the University of Florence technique for robot-assisted kidney transplantation (RAKT) from living donor (LD) and deceased donor (DD), highlighting the evolution of surgical indications and technical nuances in light of a single surgeon's learning curve.Materials and Methods: A dedicated program for RAKT from LDs was developed at our Institution in 2017 and implemented later with a specific framework for DDs. All RAKTs were performed by a single highly experienced surgeon. Data from patients undergoing RAKT between January 2017 and December 2019 were prospectively collected in a dedicated web-based data platform. In this report we provide a comprehensive step-by-step overview of our technique for RAKT, focusing on the potential differences in peri-operative and mid-term functional outcomes between LDs vs. DDs.Results: Overall, 160 KTs were performed in our center during the study period. Of these, 39 (24%) were performed with a robot-assisted laparoscopic technique, both from LDs (n = 18/39 [46%]) and from DDs (n = 21/39 [54%]). Eleven (11/39 [18%]), 13(13/39 [26%]), and 15 (15/39 [30%]) RAKTs were performed in 2017, 2018, and 2019, respectively, highlighting an increasing adoption of robotics for KT over time at our Institution. Median time for arterial (19 min for LD and 18 min for DD groups), venous (21 min for LD, 20 min for DD) and uretero–vesical (18 min for LD and 15 for DD) anastomosis were comparable between the two groups (all p > 0.05), as the median rewarming time (59 min vs. 56 min, p = 0.4). The rate of postoperative surgical complications according to Clavien–Dindo classification did not differ between the two study groups, except for Clavien–Dindo grade II complications (higher among patients undergoing RAKT from DDs, 76 vs. 44%, p = 0.042). Overall, 7/39 (18%) patients (all recipients from DDs) experienced DGF; two of them were on dialysis at last FU.Conclusions: Our experience confirms the feasibility, safety, and favorable mid-term outcomes of RAKT from both LDs and DDs in appropriately selected recipients, highlighting the opportunity to tailor the technique to specific recipient- and/or graft-characteristics. Further research is needed to refine the technique for RAKT and to evaluate the benefits and harms of robotics for kidney transplantation from DDs.
Highlights
While still being considered an experimental procedure (1), robot-assisted kidney transplantation (RAKT) from living donors (LDs) has been recently introduced at selected referral Centers worldwide, reproducing the principles of open kidney transplantation (KT) and achieving favorable perioperative outcomes with the advantages of minimally invasive surgery (2–5).To date, most groups performing RAKT replicated the Vattikuti-Medanta technique (1)
In this report we describe the University of Florence technique for RAKT from both LD and deceased donors (DDs), highlighting the evolution of both indications and technical nuances over a 3-year period, as well as the intraoperative, perioperative and mid-term functional outcomes
The graft is gently introduced into the abdomen through the Alexis R device, with the hilum oriented toward the site of the iliac fossa, adding 250 mL of ice into the abdominal cavity to achieve regional hypothermia
Summary
While still being considered an experimental procedure (1), robot-assisted kidney transplantation (RAKT) from living donors (LDs) has been recently introduced at selected referral Centers worldwide, reproducing the principles of open kidney transplantation (KT) and achieving favorable perioperative outcomes with the advantages of minimally invasive surgery (2–5).To date, most groups performing RAKT replicated the Vattikuti-Medanta technique (1). After this step, the robotic instruments are temporarily removed, the robot is undocked, and the Pfannenstiel incision is performed to allow placement of the Alexis R retractor or the GelPOINT device (Figures 3A,B). The robotic instruments are temporarily removed, the robot is undocked, and the Pfannenstiel incision is performed to allow placement of the Alexis R retractor or the GelPOINT device (Figures 3A,B) This surgical step is performed after the development of the Retzius space and bladder preparation to reduce the risk of any potential bladder injury. The venotomy was performed by using cold scissors, that allowed an easy modeling of the venotomy as well as a reduction in terms of costs for surgical instrumentation
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