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Robot-assisted kidney transplantation
Introduction
Open kidney transplantation (OKT) is considered the gold standard treatment for end-stage renal disease as it is able to achieve a greater survival rate and a better quality of life in comparison to hemodialysis. The introduction of this surgical technique, in the second half of the last century, is considered a milestone in the history of surgery. The first successful cadaveric kidney transplantation was performed in 1953 and earned the Nobel Prize for Medicine in 1990 for Dr. Joseph Murray.
Despite the open technique being the standard approach in KT, minimally invasive alternatives have been introduced and carried out in many centers around the world, with the aim to reduce postoperative morbidity and improve surgical performance. The first step toward a less invasive surgery was the introduction of laparoscopy in kidney transplantation in 2009. , In 2013, the first large series of laparoscopic renal transplantation was published, enrolling 72 surgeries from living donors with a mean operating time of 224 minutes. Rewarming time was around 60 minutes, which was significantly longer than 30 minutes in the open surgery group. Functional outcomes were also compared to the standard technique, reporting comparable results in terms of graft and patient survival, with a median follow-up of 22 months. This new technique provided advantages in terms of wound infection and the need for analgesia, due to less postoperative pain with a subsequent faster recovery. Moreover, as a minimally invasive approach, better aesthetical results were observed. On the other hand, the procedure appeared challenging and needed robust expertise in laparoscopy to avoid reaching an unacceptable operative time. The anastomotic time was particularly challenging, with possible consequences for patients’ outcomes and graft survival. In fact, patients with end-stage renal disease have a higher risk of respiratory acidosis and hypertension due to carbon dioxide inflation of the peritoneum during long-time laparoscopic surgery. The obvious limitations of laparoscopic suturing techniques did not allow a widespread adoption of laparoscopic surgery for renal transplantation.
To overcome these limitations, robot-assisted kidney transplantation (RAKT) has shown promising results as a less invasive alternative to the open approach, with a minimal learning curve for surgeons experienced in robotic surgery.
Since the first RAKT performed in 2010, the surgical technique has been refined and standardized in highly experienced robotic centers around the world. Few authors have compared surgical and functional results with the open approach, showing possible advantages in selected cases, such as obese patients and multiple vessel grafts. , Furthermore, a structured program was developed in order to expand RAKT’s indication to deceased donors.
Robot-assisted kidney transplantation: Living donor
Background
Living donor nephrectomy
Around 20% of all kidney transplantations in Europe are performed using living donor grafts, while in the United States the percentage is up to 40%. A living donor’s kidney generally comes from familial or “emotionally related” donors. Compared to a deceased donor kidney, the use of a living donor graft has been shown to have advantages in terms of earlier graft function, longer graft survival, reducing waiting list. Furthermore, in the case of donation from a familiar ABO compatible, the receiver may take advantage of less aggressive immunosuppressive regimen. The left kidney is generally preferred for donation because of a longer renal vein, but in case of differing functions between the two kidneys, the kidney with the lower function is used. Until 1995, the standard surgical technique to extract the graft from the living donor was the open approach. This has been replaced by laparoscopic living donor nephrectomy. This newer procedure showed better results in terms of pain control, blood loss, hospital stay, and better aesthetic results, compared to the open technique.
Pushed by the minimal invasive revolution, in 2001 the Group of the University of Illinois (Chicago) reported the first series of robot-assisted laparoscopic donor nephrectomies, using the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA). This new approach, despite its high costs, demonstrated to be feasible, reproducible, and safe. The vessels are usually divided with a da Vinci vascular stapler although an assistant-controlled stapler can also be used.
Living donor kidney transplantation
The first pure RAKT was performed in the United States in 2010. This technique was reproduced and refined by several authors. In 2014, Menon et al. described a standardized technique using a transperitoneal approach and guaranteeing regional hypothermia with the Vattikuti-Medanta technique. , In Europe, the first two RAKTs were performed in July 2015. In 2016, the European Association of Urology (EAU) Robotic Urology Session (ERUS-RAKT) formed a working group in order to follow RAKT’s outcomes. , To date in Europe, 11 centers joined the group with more than 300 procedures conducted with 1 year of follow-up, showing comparable outcomes with OKT.
Operative technique
See the box that follows for special equipment required.
SPECIAL EQUIPMENT REQUIRED
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Robotic instruments
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Fenestrated bipolar forceps
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Monopolar scissors
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Potts scissors
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ProGrasp forceps
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Needle driver (×2)
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Black diamond micro forceps
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Scalpel
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Arterial punch
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Sutures
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PDS 5/0
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Gore-Tex 6/0 (CV-6 TTc-9 or THc-12 needle)
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Robotic or laparoscopic bulldog clamps (×4)
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Laparoscopic scissors, suction device, graspers, Hem-o-lok clip appliers
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GelPOINTToomey syringes
Living donor nephrectomy
The most common technique used to perform living donor nephrectomy is the transperitoneal laparoscopic approach. Considering its functional results are comparable to the open and robot-assisted approach, this technique shows a better cost-benefit ratio.
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