Robot-assisted Kidney Transplantation Research Articles

Robotic-assisted kidney transplant: a single center experience with median follow-up of 2.8years.

The main aim of the paper is to report a single-centre experience with RAKT, focusing on surgical, perioperative and functional outcomes at a median follow-up of 2.8years. Data of 26 RAKT patients was prospectively collected from December 2014 to February 2019 with follow-up of up to 55months. All donors were done laparoscopically. We followed Vattikuti-Medanta technique with modification of using pfannenstiel incision instead of Gelpoint and patient positioned in steep Trendelenburg position (30°) with leg split position. Hypothermia was maintained using a "modified graft hypothermia jacket". The engrafted kidney is oriented with the vessels being tagged with Prolene sutures. The mean BMI was 26.1 ± 4.7. The mean warm, cold and total ischemia times were 4.8 ± 1.1, 113.8 ± 20.9 and 118.7 ± 21.2min, respectively. Mean rewarming time was 62.5 ± 10min. The mean post-operative day (POD) 1, 3, 7, 30, 6months, 1 year and most recent creatinine was 3.4, 2.4, 1.8, 1.4,1.2, 1.2 and 1.69mg/dl. There was no case of delayed graft dysfunction (DGF) with graft survival of 1.8-55months. The mean GFR at POD 1, 1month and 1year was 24, 53.16 and 64.6. We had two intraoperative complications-one topsy turvy graft placement with anastomosis of donor ureter to native ureter and other had to be converted to open technique after anastomosis to control graft surface bleeding. Three postoperative complications-one patient has graft pyelonephritis which was managed conservatively with antibiotics. Two patients had lymphocele. One patient was managed with just aspiration while the other required laparoscopic de-roofing of the lymphocele. The mean hospital stay was 13.5 ± 3days. RAKT is feasible and safe only if performed by surgeons with appropriate background in robotic surgery and kidney transplantation after proper surgical training at experienced centres in the mid-term follow-up. Further studies need to confirm the long-term safety of RAKT.

PE79 - Prospective propensity matched non randomised comparison between open and robotic assisted kidney transplantation

PE79 - Prospective propensity matched non randomised comparison between open and robotic assisted kidney transplantation

Single-setting robot-assisted kidney transplantation consecutive to single-port laparoscopic nephrectomy in a child and robot-assisted living-related donor nephrectomy: initial Ghent experience

Kidney transplantation (KT) is the gold-standard treatment for end-stage renal disease (ESRD) in children. Robot-assisted kidney transplantation (RAKT) in adults is becoming increasingly common with potentially improved morbidity compared with open KT. The study objective was to evaluate feasibility and outcomes of RAKT in children. An 8-years-old boy with ESRD received a kidney transplant from his mother. Simultaneously in two operation theatres, the boy underwent single-port (GelPOINT®) right laparoscopic nephro-ureterectomy (LNU), and his mother underwent robot-assisted left donor nephrectomy (RADN).Two full surgical teams were operating at the same time. Subsequently, the boy underwent RAKT, introducing the graft through the GelPOINT®. Total operative time for LNU, RADN, and RAKT was 180, 140, and 195 min, respectively, with warm, cold, and rewarming ischemia times 1.5, 200, and 47 min, respectively. Blood loss was 300, 20, and 50 cc, respectively. No intraoperative complications were noted. Convalescence of both donor and recipient was uneventful, with good kidney function at 1-year follow-up. RAKT in children is technically feasible and safe, resulting in excellent graft function. Concomitant nephrectomy can be done laparoscopically through the single-site GelPOINT®. An experienced RAKT team with the full support of pediatric nephrologists is mandatory.

SUN-125 ROBOT ASSISTED KIDNEY TRANSPLANTATION - NEPHROLOGIST'S PERSPECTIVE

Robot assisted kidney transplantation , being a minimally invasive procedure, is said to offer certain advantages to the recipient : quicker recovery time, less blood loss, less wound infections, less post operative pain, and better cosmesis , when compared to open surgery. Aim of the study: To compare our experience of Robot assisted kidney transplantation (RAKT) with open kidney transplantation (OKT) surgery done by the same surgeon. Study of all robot assisted kidney transplantations (RAKT - group 1) done by a surgeon experienced in laparoscopic and robot assisted surgeries, from January 2015 to October 2018 in adult recipients (age above 18 years). Clinical data, outcomes and complications were analysed; this data was compared to recipients who underwent open kidney transplantation surgery (OKT -group 2) by the same surgeon during the same period. The donors were either first degree relatives (80%) or spouses (20%). The graft was positioned extraperitoneally. Both groups received identical immunosuppression according to our protocol - Tacrolimus ( initial dose of 0.1mg/kg/day) to maintain trough levels of 6 to 12 ng/ml in the first three months and subsequently 3 to 6ng/ml, Mycophenolate Mofetil ( 35mg/kg/day) and Prednisolone (0.5mg/kg/day initially , tapering to 0.125mg per day by 3 months). Total surgery time, cold ischemia time, blood loss, postoperative pain score by visual analogue scale, delayed graft function, reexploration rate, incidence of urinary tract & wound infections, length of hospital stay, length of surgical scar , and graft function in the two groups were studied. Statistical analysis was done using Students T test, Chi-Square test and Mann-whitney test. There were 54 recipients (38 males 16 females) in RAKT group and 104 (77 males 27 females ) in OKT group. The mean duration of follow up was 25 ± 10 months ( 1 month to 46 months). The two groups were comparable for recipient and donor age, gender, HLA match, diabetic status and number of graft arteries (Table I) . Body Mass Index was significantly higher in RAKT group (p < 0.001) . Table II shows the cold ischemia time, total surgery time, need for blood transfusions in the first 48 hours after surgery, pain score by Visual Analogue Scale for 48 hours, delayed graft function, reexploration rate, length of hospital stay, length of surgical scar . The need for blood transfusions , pain score, length of hospital stay and length of scar were less in RAKT group. Surgical site and urinary infectons and reexplorations were similar. There was no difference between the two groups in incidence of delayed graft function or graft function at 1, 6 and 12 months after surgery (Table III). The death censored graft survival was 99% in RAKT group and 98% in OKT group at the end of follow up for 3 years.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Robot Assisted Kidney transplantation is associated with less blood loss & postoperative pain, shorter hospital stay and better cosmesis , when compared to open surgery, especially in recipients with high BMI. Graft function is not affected by RAKT. As minimally invasive surgical procedures would be preferred in the days ahead, robot assisted kidney transplantation done by an experienced surgeon would offer certain distinct advantages to the recipeints.

Intra-abdominal Cooling System for the Transplanted Kidney.

Since its introduction, the minimally invasive, robot-assisted approach has become an important alternative in kidney transplantation surgery.1 However, there is a concern about possible increases in warm ischemia time of the transplanted kidney. Recently, Meier et al2 described a novel intra-abdominal cooling system to address the lengthened ischemia time. In robot-assisted kidney transplantation in porcine models, they succeeded in suppressing the temperature elevation of the donated kidney during anastomosis with their cooling device. Similarly, we developed simple thermo-barrier bags (TBBs) which aim to suppress the temperature of the transplanted kidney in the intra-abdominal cavity. In a porcine kidney transplantation model, the TBB, which was designed to look like a purse, was effective in suppressing the temperature. The temperature of the porcine model with a TBB was 20°C with an operative time of 30 minutes, whereas the temperature of a porcine model without a TBB rose as high as 30°C.3 Meier et al2 reported that their novel cooling device kept the temperature of the recovered kidney at 4°C to 6°C for 70 minutes during vascular anastomosis until reperfusion. On the other hand, the temperature of the porcine model without a cooling device elevated as high as 30°C at 30 minutes in the abdominal cavity, similar to our data. At present, the use of topical ice-cold solution to maintain the kidney temperature at 20°C during anastomosis in a robot-assisted surgery is thought to be effective.4 Therefore, we additionally tested the method of preserving the transplanted kidney with the ice-cold solution in a newly developed TBB when performing anastomosis (Figure 1). This modified method enabled us to keep the temperature of the transplanted kidney at 20°C for >60 minutes.FIGURE 1: TBB in place after anastomosis of the back wall of the renal artery. A new TBB was made of medical grade silicone. Topical ice-cold solution was also dripped on the surface of the transplanted kidney. TBB, thermo-barrier bag.The other issue is the safety of their device concerning the potential for ignition caused by the surgical knife. Energy devices, such as surgical knives, are commonly adopted in robot-assisted surgeries. As the Active Cooling System developed by Meier et al uses reperfusion by ethanol for cooling, potential ignition should always be taken into consideration. The safety features, as well as the cost-effectiveness of the device, should be of utmost importance. As reported by Meier, there are challenges with large animal experiments, such as kidney transplant in porcine models. It is usually difficult to conduct assessments of live pigs and to demonstrate their improved renal function because of the ethical issues. In contrast to rats and mice, in-bred pigs are limited in availability. Therefore, when conducting pig experiments that require duration of >4 days, researchers are often forced to administer immunosuppressive drugs to the pigs. Are there any alternative assessments to confirm the effectiveness of the temperature control of the intra-abdominal transplanted kidney in the acute phase other than evaluating the urine output?4 In this Letter to the Editor, we seek to exchange opinions with kidney transplantation experts, based on our experiments in this field, regarding the effectiveness and the safety features of Dr. Meier's medical device.

757 - Robotic assisted kidney transplantation: Update from the ERUS series

757 - Robotic assisted kidney transplantation: Update from the ERUS series

762 - Robot-assisted kidney transplantation in the obese: Result at 2 years of the first French series

762 - Robot-assisted kidney transplantation in the obese: Result at 2 years of the first French series

V44 - Robot-assisted kidney transplantation from deceased donors: Step-by-step technique

V44 - Robot-assisted kidney transplantation from deceased donors: Step-by-step technique

758 - Prospective propensity matched non-randomized comparison between open and robot-assisted kidney transplantation

758 - Prospective propensity matched non-randomized comparison between open and robot-assisted kidney transplantation

759 - Results of the 50 first cases of robotic assisted kidney transplantation compared to matched-pair open cases

759 - Results of the 50 first cases of robotic assisted kidney transplantation compared to matched-pair open cases

Robot-assisted kidney transplant in a child with Bardet–Biedl Syndrome

Robot-assisted kidney transplant in a child with Bardet–Biedl Syndrome

Intraoperative assessment of ureteral and graft reperfusion during robotic kidney transplantation with indocyanine green fluorescence videography.

The aim of this paper is to report the first preliminary experience with intraoperative indocyanine green (ICG) fluorescence videography (IFV) to assess graft and ureteral reperfusion during robot-assisted kidney transplantation (RAKT). We prospectively collected data from consecutive patients undergoing RAKT and IFV from living-donors at our Institution between January 2017 and April 2018. RAKT was performed following the principles of the Vattikuti-Medanta technique. ICG was injected intravenously after vascular anastomoses to quantitate graft and ureteral fluorescence signal. The signal intensity within selected intraoperative snapshots was evaluated for renal parenchyma, ureter and vascular anastomoses. A systematic review of the English-language literature about the topic was performed according to the PRISMA statement recommendations. Six patients were included. Neither conversions to open surgery nor major intra- or postoperative complications were recorded. At a median follow-up of 12 months (IQR 8-13), median estimated glomerular filtration rate was 64.2 mL/min/1.73 m2 (IQR 45.3-98.4). Intraoperative quantitative assessment of ICG fluorescence was successful in all patients. Of the five studies selected by our review, mostly prospective studies, all including open KT series. Yet, most studies were limited by lack of quantitative measures of IFV fluorescence. IFV during RAKT is feasible and safe and provides a reliable assessment of graft reperfusion. Larger studies are needed to standardize the technique and to evaluate the association between fluorescence signal, ultrasound parameters and postoperative kidney function.

Development of a robot-assisted kidney transplantation programme from deceased donors in a referral academic centre: technical nuances and preliminary results.

To report the development of the first robot-assisted kidney transplantation (RAKT) programme from deceased donors, examining technical feasibility and early perioperative and functional outcomes at a referral academic centre. A RAKT programme was developed in 2016 at our institution following structured modular training. Specific inclusion/exclusion criteria for both living and deceased donors were set. Data from patients undergoing RAKT from January 2017 to April 2018 were prospectively collected in an a priori developed web-based data set. RAKT followed the principles of the Vattikuti Urology Institute-Medanta technique, with specific technical modifications based on clinical recipient characteristics, as well as surgeon's skills and preference during the learning curve. Technical feasibility of RAKT from deceased donors and evaluation of perioperative and early functional outcomes were the main study endpoints. In all, 17 RAKTs were performed during the study period. Of these, six were from living donors and 11 were from deceased donors. All RAKTs were successfully completed without need of conversion. The median (interquartile range [IQR]) console time was 190 (160-220) min and the median (IQR) estimated blood loss was 120 (110-140) mL. The median times to complete venous, arterial and uretero-vesical anastomoses were 21, 22 and 21 min, respectively. The median (IQR) length of stay was 8 (6-12) days. At a median (IQR) follow-up of 8 (6-11) months, five (30%) complications were recorded. Of these, four (24%) were minor (Clavien-Dindo Grade I-II) and one major (Clavien-Dindo Grade IIIb, requiring graft nephrectomy). Overall, two patients were still on dialysis at last follow-up. A significant improvement in graft function was recorded progressively at all postoperative time points. Our preliminary experience outlines that: (i) the development of a RAKT programme is feasible in centres experienced in robotic surgery and open kidney transplantation; (ii) RAKT from deceased donors is feasible from both a technical and logistical perspective; and (iii) RAKT from deceased donors appears to achieve favourable early postoperative and functional outcomes. Larger studies with longer follow-up are needed to confirm these findings and compare the outcomes of RAKT from deceased donors with those from living donors.

The Evolution of Kidney Transplantation Surgery Into the Robotic Era and Its Prospects for Obese Recipients.

Robotic-assisted kidney transplantation (RAKT) represents the most recent innovation in the evolution of kidney transplantation surgery. Vascular techniques enabling kidney transplantation have existed since the early 20th century and contributed to the first successful open kidney transplant procedure in 1954. Technical advances have since facilitated minimally invasive laparoscopic and robotic techniques in live-donor surgery, and subsequently for the recipient procedure. This review follows the development of surgical techniques for kidney transplantation, with a special focus on the advent of robotic-assisted transplantation because of its potential to facilitate transplantation of those deemed previously too obese to transplant by standard means. The different techniques, indications, advantages, disadvantages, and future directions of this approach will be explored in detail. Robot-assisted kidney transplantation may become the preferred means of transplanting morbidly obese recipients, although its availability to such recipients remains extremely limited and strategies targeting weight loss pretransplantation should never be abandoned in favor of a "RAKT-first" approach.

P76 - Robot-Assisted kidney transplantation with regional hypothermia using grafts with multiple vessels: Results from the EAU Robotic Urology Section (ERUS) working group

P76 - Robot-Assisted kidney transplantation with regional hypothermia using grafts with multiple vessels: Results from the EAU Robotic Urology Section (ERUS) working group

V9 - Robot-Assisted kidney transplantation in a patient previously treated with robotic radical prostatectomy

V9 - Robot-Assisted kidney transplantation in a patient previously treated with robotic radical prostatectomy

VE51 - Robot-assisted kidney transplantation in a child. First successful minimal invasive pediatric transplantation in Europe

VE51 - Robot-assisted kidney transplantation in a child. First successful minimal invasive pediatric transplantation in Europe

P78 - Evaluation of inflammatory markers in open versus robotic assisted kidney transplantation from living donor

P78 - Evaluation of inflammatory markers in open versus robotic assisted kidney transplantation from living donor

PE83 - Safety and Efficacy of Robot-Assisted Kidney Transplantation

PE83 - Safety and Efficacy of Robot-Assisted Kidney Transplantation

Robotic pancreas transplantation: the state of the art.

Robotic pancreas transplantation is a novel procedure that aims to reduce surgical invasiveness, and thereby limit complications related to the surgical access. Given that few centers are providing robotic transplantation, this review serves as a state of the science article to outline early experiences and highlight areas for future research. Pancreas transplantation results in relatively high rates of wound and other surgical complications that are known to deleteriously impact outcomes. The minimally invasive, robotic-assisted approach decreases wound complications. Because of the obesity epidemic, overweight and obese status is encountered in an increasing number of transplant candidates. These candidates are subject to increased wound-related complications and most benefit from a robotic approach. The first clinical reports on laparoscopic, robotic-assisted kidney and pancreas transplantation indicate a significant decrease in wound complications and excellent outcomes in obese patients otherwise denied access to transplantation. With excellent results achieved in surgically challenging patients and further accumulation of experience, laparoscopic, robotic-assisted pancreas and kidney transplantation may evolve to a new standard approach.