THE INTERNATIONAL JOURNAL OF MEDICAL ROBOTICS AND COMPUTER ASSISTED SURGERY ORIGINAL Int J Med Robotics Comput Assist Surg 2014; 10: 286–293. Published online 6 March 2014 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/rcs.1576
ARTICLE
Evolution of robotic nephrectomy for living donation: from hand-assisted to totally robotic technique
Alessandro Giacomoni1* Stefano Di Sandro1,2 Andrea Lauterio1 Giacomo Concone1,2 Iacopo Mangoni1 Plamen Mihaylov1 Matteo Tripepi1 Luciano De Carlis1 1
Department of General Surgery and Transplantation, Niguarda Ca’ Granda Hospital, Milan, Italy
Abstract Background The application of robotic-assisted surgery offers EndoWrist instruments and 3-D visualization of the operative field, which are improvements over traditional laparoscopy. The results of the few studies published so far have shown that living donor nephrectomy using the robot-assisted technique is safe, feasible, and offers advantages to patients. Materials and methods Since November 2009, 16 patients have undergone robotic-assisted living donor nephrectomy at our Institute. Patients were divided into two groups according to the surgical technique adopted for the procedure: Group A, hand-assisted robotic nephrectomy (eight patients); Group B, totally robotic nephrectomy (eight patients).
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Department of Surgical Sciences, University of Pavia, Italy *Correspondence to: Alessandro Giacomoni MD, Department of General Surgery and Transplantation, Niguarda Hospital – Milan, Piazza Ospedale Maggiore, 3, Italy. E-mail: [email protected]
Results Intra-operative bleeding was similar in the two groups (90 vs 100 mL for Group A and B, respectively). Median warm ischemia time was significantly shorter in Group A (2.3 vs 5.1 min for Group A and B, respectively, P-value = 0.05). Switching to the open procedure was never required. Median operative time was not significantly longer in Group A than Group B (275 min vs 250 min, respectively). Conclusion Robotic assisted living kidney recovery is a safe and effective procedure. Considering the overall technical, clinical, and feasibility aspects of living kidney donation, we believe that the robotic assisted technique is the method of choice for surgeon’s comfort and donors’ safety. Copyright © 2014 John Wiley & Sons, Ltd. Keywords
robotic-assisted nephrectomy; living donation; kidney transplantation
Introduction
Accepted: 2 January 2014
Copyright © 2014 John Wiley & Sons, Ltd.
Living donor kidney transplantation (LDKT) is a valid alternative for patients with end-stage renal disease (ESRD) (1). Many studies indicate that the results of LDKT are significantly better than the ones obtained with deceased kidney transplantation in terms of long-term patient and graft survival (1). Moreover, LDKT offers several advantages over deceased kidney donations: the recipient experiences better quality of life, better graft and immediate graft function, to which the possibility of transplanting patients either pre-emptively or after a shorter dialysis period is to be added (1–9). Concerns remain related to donor
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risk. Most donors monitored after donation had preserved glomerular filtration rate (GFR), normal albumin excretion, and excellent quality of life (1). The risk of ESRD in carefully screened kidney donors appears to be similar to the risk in the general population (1). Over the last decade the United Network for Organ Sharing (UNOS) has reported that LDKT is performed more and more frequently. The number of LDKTs has now exceeded the number of transplantations with deceased donors in 2001 (10,11). LDKTs have been fostered not only because they have proved to offer advantages over deceased donor transplantations, but also because of the extensive introduction of minimally invasive surgical procedures for kidney recovery (11). Minimally invasive techniques appear to be more acceptable to donors, most likely because of the significant reduction in post-operative pain, decreased length of hospital stay, rapid patient re-habilitation and better cosmetic results (10–13). Consequently, the laparoscopic approach to living donation nephrectomy, first reported by Ratner LE and co-workers in 1995 (14), has been adopted in an increasing number of cases, both for hand-assisted and for totally laparoscopic procedures. It appears to be the technique of choice for living kidney recovery so far. However, the laparoscopic approach has several technical limitations: 2-D imaging, restricted instrument motion that can make knotting and suturing more difficult, and surgeon discomfort (15–20). Robotic-assisted surgery (da Vinci robotic system, Intuitive Surgical Inc., Sunnyvale, CA) is used more and more often because it offers the clear advantages of EndoWrist instruments and Stable 3-D visualization of the operative field. This technique for kidney recovery from living donors has been introduced recently and only a few papers have been published on this subject so far. They all consistently point out the safety and feasibility of the technique, as well as the benefits of living donor nephrectomy performed using the robot-assisted technique (15–20). Herein, we describe our experience of robotic nephrectomy for LDKT and we point out surgical details related to the evolution from the hand-assisted techniques to totally robotic nephrectomy. The aim of this study is to assess the safety and feasibility of this surgical procedure.
Materials and methods Out of 1955 kidney transplantations performed at our Institute since 1972, 186 (10.5%) were LDKT. Sixteen were robotic-assisted living donor nephrectomies performed between November 2009 and November 2011. We compared patients according to the surgical technique adopted for the procedure: Group A, hand-assisted robotic nephrectomy (eight patients); Group B, totally robotic nephrectomy (eight patients).
Demographic and baseline patient data Table 1 compares donor demographic data between the two groups. Donors did not differ in terms of median age, male/female distribution and median body mass index (BMI). All the patients in the two groups were Caucasian. Two patients in Group A and one patient in Group B had a history of abdominal surgery. Distribution of patient co-morbidity was similar in the two groups. All the patients underwent left nephrectomy. Two patients in Group A and three patients in Group B had more than one renal artery. In particular, patients in Group A with more than one artery had one superior polar accessory artery or one inferior polar accessory artery, whereas in Group B the three patients with more than one renal artery had one superior polar artery, one inferior polar artery or one accessory hilar artery from the aorta. No patients had accessory renal veins. Only two patients, one in Group A and one in Group B, had early bifurcations. In each case we were able to obtain a common patch used for single anastomosis.
Donor selection Each patient suitable for living donation was proposed for minimally invasive nephrectomy. Relative contra-indication to minimally invasive donor nephrectomy was a history of more than one abdominal surgical procedure. Until November 2009, at our Institute laparoscopic nephrectomy
Table 1. Demographic and baseline patient features Variables Median age Sex M/F Body Mass Index (BMI) Caucasian race Previous abdominal surgery Patients with co-morbidity Patients with > 1 renal artery Patients with > 1 renal vein
Copyright © 2014 John Wiley & Sons, Ltd.
Group A (8 patients)
Group B (8 patients)
Sig. P-value
47 (32–59) 3/5 23 (19–32) 8/8 1/8 1/8 2/8 0/8
54 (46–65) 4/4 23 (19–26) 8/8 1/8 2/8 3/8 0/8
NS NS NS NS NS NS NS NS
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Table 2. Intra-operative (I.O.) and post-operative (P.O.) patient data. Complications were classified as follow: a, post-operative bleeding; b, re-operations; c, acute pyelonephritis; d, acute renal failure; e, chronic renal failure; f, deep vein thrombosis; g, pulmonary embolism; h, urinary infections; i, wound infections; k, lymphatic fistula; l, bowel sub-occlusion Variables Median I.O. bleeding (mL) Median Nr. of blood cells unit I.O. accidental hemorrhage Warm ischemia time (min) Nr of case of 2nd accessory trocar Nr of conversion Median overall operation time (min) Median console time (min) Length of hospital stay (days) P.O. day of re-alimentation P.O. day of drainage remove P.O. day of canalization P.O. case who developed complications (Type)
Group A (8 patients)
Group B (8 patients)
Sig. P-value
90 (10–400) 0 1/8 2.3 (0.30–3.8) 0/8 0/8 275 (85–450) 185 (55–360) 5 (5–9) 2 (1–3) 3 (1–7) 3 (2–6) 2 (d,k)
100 (10–750) 0 0/8 5.1 (4.2–6.5) 2/8 0/8 250 (120–500) 150 (85–390) 5 (4–6) 1 (0–2) 2 (1–2) 3 (2–4) 1 (l)
NS NS NS 0.05 NS NS NS NS NS NS NS NS NS
was considered to be the technique of choice for living kidney recovery. In November 2009 we agreed that the first choice was the robotic technique and all kidney donations performed at our unit since then have been performed with robotic assistance. Donor candidates were at least 18 years old and were living relatives or spouses of the recipients. After the donation statement, candidates underwent psychological and legal evaluation in order to unveil coercion to donation, if any. Renal vascular anatomy was studied with spiral computed tomography (CT-scan) with 3-D vessel reconstruction for patients 50 years or older, and with MRI for the others. The left kidney was routinely the first choice. Right kidney was considered as a second option in cases of more favorable renal vascular anatomy. The presence of accessory kidney arteries was not a reason to deny recovery or for selecting the right kidney per se. All candidates were well informed about the risk of technical switching to the open approach and the procedure was planned only after the donor had signed the informed consent form.
midline incision of around 8 cm for the assistant hand. After that, one 12 mm trocar for 30° camera was placed in the peri-umbilical region, in front of renal hilum identified by the assistant hand, approximately 3 cm above the umbilicus and left lateral trans-rectal line. Two 8 mm robotic trocars were placed on the left lateral abdominal wall along the mid-clavicular line. Another 12 mm trocar was placed in the left inguinal region for the assistant (Figure 1). At this time, the robotic cart was docked to the trocars on the left side of the patient. Basic access and first connected robotic instruments were a bipolar Maryland forceps controlled by the left robotic arm and monopolar hook on the right robotic arm. The first step of the surgical procedure was dissection of the left colon from the wall peritoneum and exposure of the renal region. After that, the ureter was located and marked by elastic tape. Following the gonadal vessel tract, we identified the left renal vein. Left renal vein and left renal
Surgical technique and evolution of the surgical strategy Eight consecutive robot hand-assisted nephrectomies were performed (group A). Subsequently we introduced a few modifications to facilitate the surgical technique, performing eight consecutive totally robotic nephrectomies (group B). Group A (first eight cases) Between November 2009 and December 2010, we performed eight hand-assisted robotic nephrectomies following the protocols of the pioneering experience of the surgical team of the University of Illinois at Chicago (20). After general anesthesia, patients were placed in right 60-degree lateral decubitus position. First surgical time was to prepare a mini-laparotomy by sub-umbilical Copyright © 2014 John Wiley & Sons, Ltd.
Figure 1. Trocar placement strategy in the first technique adopted. No. 1 indicates the midclavicular line Int J Med Robotics Comput Assist Surg 2014; 10: 286–293. DOI: 10.1002/rcs
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artery were isolated from their origin to approximately 4 cm above the renal pelvis and separated from the adrenal, gonadal, and lumbar vessels. These vessels were cut after distal and proximal placement of hem-o-lock clips (Weck, Germany). The upper renal pole was dissected from the adrenal gland, and the anterior and posterior kidney surface was completely dissected from the perirenal fat tissue. Once the whole kidney was dissected and liberated from all surrounding tissues, the ureter was cut approximately at the iliac vessel crossing level; the distal ureter was closed by hem-o-lock and the proximal ureter was left open. At this stage, intravenous (IV) heparin was administered at a dose of 80 U/kg. After that, the renal artery was stapled by endo-TA stapler (ENDO TA 30stapler; US Surgical, Norwalk, CT, USA) exactly at its origin from the aorta. Before cutting the renal artery, a hem-o-lock was placed on the already stapled line and the artery was cut. Subsequently, the renal vein was stapled and cut by Endopath Stapler (Echelon 60; Ethicon Endosurgery, LLC, Guaynabo, PR, USA) and the kidney was removed through the lower midline incision and taken to the back table. Check-out: the last check of the renal bed and trocar access holes was performed laparoscopically, after extraction of the specimen, closing the mini-laparotomy, and re-induction of pneumoperitoneum. One tubular 21 fr drain was placed in the renal bed. Hemostasis was mainly achieved by bipolar electrocauterization and monopolar hook. Bipolar forceps was applied continuously and simultaneously, by placing it mainly on the left robotic arm. For vessels of median diameter (3–5 mm), hemostasis was achieved by the application of robotic hem-o-lock clips or metallic clip placement by the assistant. For major vessels (>10 mm), we used the Endopath Stapler. When that mechanic instrument could not be applied, hemostasis was achieved by monofilament Prolene® 4/0 or 5/0 stiches.
nephrectomy, adopting a modified technique leading to the evolution from a hand-assisted robotic technique to a totally robotic technique. The patient decubitus was modified from right 60-degree lateral decubitus to completely right lateral 90-degree decubitus. The first surgical step was to perform a Kustner preparatory incision of around 8–10 cm, opening the fascia but not the peritoneum. After that, pneumoperitoneum was inducted by Veress needle, introduced into the left hypochondrium. Camera trocar (12 mm) was moved along the midclavicular line and the two 8 mm robotic trocars were moved from the left midclavicular line to the left anterior axillary line. Another 12 mm trocar was placed on the left extreme side of the prepared Kustner incision (Figure 2). At this time, robotic cart was docked to the trocars on the left side of the patient. Concerning the surgical console time, leading modifications were introduction of the Ultracision during kidney dissection; reduced application of the hem-o-lock clips and increased use of metallic clips; kidney isolation with the whole peri-renal fat tissue. After renal vessel suturing and cutting, specimen extraction occurred by completing the fascia and peritoneum incision on the sub-umbilical midline fascia incision. All the other technical notes were identical to the ones related to the first technique.
Group B (second eight cases) Between January 2011 and December 2011, we performed another eight cases of robotic assisted-
χ 2 analysis was used to compare categorical data between groups, and the independent-samples t test to analyze continuous variables. P ≤ 0.050 was considered
Data analysis To better understand the advantages or disadvantages of the modified technique, we compared the two patient cohorts in terms of demographic and baseline patient features (Table 1), intra-operative data, post-operative outcome and complications (Table 2).
Statistical analysis
Figure 2. Image A and B show the modified technique for patient and trocar placement; line 1 indicates the anterior axillary line. Image C reports one case of Kustner incision for kidney extraction Copyright © 2014 John Wiley & Sons, Ltd.
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statistically significant. All analyses were performed with the statistical program SPSS® version 13.0 (SPSS, Chicago, Illinois, USA).
Results Intra-operative data The comparison of intra-operative features showed that intra-operative bleeding was not significantly different between the two groups (90 mL vs 100 mL for Group A vs B, respectively). No patients were intra-operatively transfused with blood cell units. However, one Group A patient had an accidental intra-operative hemorrhage due to vascular lesion of the adrenal branch at the origin from the left renal vein. This patient lost about 400 mL of blood. Hemorrhage was arrested by clamping the vein with bipolar forceps. The lesion was eventually sutured robotically by Prolene 4/0 tie and the procedure was not converted to open access. No case of accidental intra-operative hemorrhage occurred in Group B. One patient in group B had continuous moderate bleeding from the adrenal gland and renal bed during the operation. This patient had an overall blood loss of 750 mL, but did not required blood transfusion. As a matter of fact, no patient in either group was transfused intra-operatively. The median warm ischemia time was significantly shorter in Group A (2.3 vs 5.1 min for Group A vs B, respectively, P-value = 0.05). In one Group B patient (case #1) we had to introduce one extra accessory 5 mm trocar to hold the kidney up and better expose the kidney vessels at the time of vessel stapler. Switching to open procedure never occurred. Median operation time was slightly longer in Group A than in Group B (275 min vs 250 min, respectively); however, the difference was not statistically significant. As of today, right kidneys were never robotically recovered at our Institute.
Post-operative patient outcome and complications The duration of post-surgery hospital stay was identical in the two groups (5 days). All the patients in the two groups resumed oral nutrition between the first and second postoperative day (median 2 vs 1 for Group A vs B, respectively). The abdominal drain was usually removed on the third post-operative day (median 3 vs 2 for Group A vs B, respectively). Bowel recovery occurred usually on the third post-operative day (median 3 days in both groups). Central venous catheters (CVC) were removed mostly on the third post-operative day (median 3 days vs 2 days for Group A vs B, respectively). Nasogastric tube Copyright © 2014 John Wiley & Sons, Ltd.
was removed intra-operatively, before patients awakened in both groups. It is important to point out that the last three patients resumed oral nutrition on the same day as the operation and that CVC was not required. Overall, no patients developed severe (> grade II Clavien score) post-operative complications. Only one patient had a grade II complication. He developed a post-discharge sub-occlusion syndrome. The patient was re-admitted from the emergency room and treated by conservative therapy due to the absence of organic reasons for sub-occlusion at imaging and endoscopy. After three days of total parenteral nutrition, the patient experienced complete spontaneous regression of the clinical picture and was discharged on day 4. The very last patient developed post-operative complications because of a lymphatic fistula. This patient had continuous drainage of lymphatic liquid from the abdominal drainage (around 500–700 mL per day) and received a hypo-lipid diet. On the seventh post-operative day drainage was removed due to significant reduction (>50%) in the abdominal drainage. The patient was discharged on the ninth postoperative day with clinical regression of the fistula.
Donor and recipient renal function Renal function tests normalized in all donors before discharge. At discharge, the overall median serum creatinine level was 0.9 mg/dl (1.25 vs 1.02 for Group A vs B, respectively) and the overall median measured glomerular filtration rate was 96 mL min (range, 79 to 132 mL min-1). Only one patient had transient mild acute renal failure. Median serum creatinine was 1.5 mg/dl (range: 1.35–1.64 mg/dl). Nine days after the procedure, the patient experienced complete regression of renal insufficiency and normalization of serum creatinine (1.23 mg/dl). No cases of graft loss occurred among the recipients. 15 out of 16 transplanted kidneys had an immediate function; resumption of renal function was delayed only in one patient. The overall median serum creatinine level of this patient was 1.39 mg/dl (0.49 vs 2.59 mg/dl, respectively) and the overall median measured glomerular filtration rate was 81 mL min-1 (range, 43 to 132 mL min-1) on the 10th post-operative day.
Discussion Our experience confirms the evidence reported in the small number of papers published so far about the feasibility and safety of robotic nephrectomy for living kidney transplantation (15–20). This paper extends the results of the paper by Hubert et al. (15), who reported the feasibility and the effectiveness of recovering living kidney Int J Med Robotics Comput Assist Surg 2014; 10: 286–293. DOI: 10.1002/rcs
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using a completely robotic-assisted technique, i.e. without any hand-assistance. In 2007 Hubert and co-workers published their experience of 38 procedures of entirely robot-assisted laparoscopic live donor nephrectomies and concluded that this procedure can be safely carried out, insofar as robotics enhances the laparoscopist’s skills, enables the surgeon to dissect meticulously and reduces the risk of problematic bleeding. Donor morbidity and hospitalization are reduced by the laparoscopic approach and the use of robotics allows the surgeon to work under better ergonomic conditions (15). Horgan and co-workers reported the largest series of hand-assisted robotic kidney recoveries for living transplantation (17). As of today, this series remains the largest one reported worldwide. Our experience took inspiration from their proposed leading technique (20). Therefore, at our Institute we attempted a meticulous reproduction of the technique proposed by University of Illinois at Chicago. At our Institute laparoscopic nephrectomy was considered to be the technique of choice for living kidney recovery until November 2009. We then agreed that the first choice was the robotic technique and since then all kidney donations have been performed at our unit with robotic assistance. This technique (17–20) was adopted for eight consecutive cases performed by our team between 2009 and 2010. The advantages of using robotic hand-assisted nephrectomy over standard laparoscopic tools, were immediately evident, mainly the first surgeon’s comfort and the major advantages offered by the robotic EndoWrist instruments and 3-D visualization of the operative field. The surgeon’s comfort is essential for reproducibility of the outcome of a surgical intervention. In long lasting procedures, it can even play a role in the wellbeing and safety of the patient. It is difficult to achieve a quantitative assessment of the surgeon’s comfort, because there is no single parameter for its assessment. However, when fatigue and ease of the procedure are taken into consideration one can easily appreciate the advantages offered by robotic assistance. Post-operative donor outcome appeared to be the same as in standard laparoscopic cohorts. After the first eight cases, it appeared that it was possible to skip the hand-assistance, which, in some instances, fails to offer valid support. Because of that, we introduced some modifications to the UIC technique, in order to facilitate the procedure. This is why we compared the results of the first series of eight consecutive cases with the results of the second series of eight consecutive totally robotic kidney recoveries to investigate the benefits of our modified surgical technique in-depth. Skipping the hand assistance allowed us to perform the procedure with only two surgeons (instead of three): the first one at the robot console and the second one scrubbed in the operating field for laparoscopic assistance. The Copyright © 2014 John Wiley & Sons, Ltd.
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absence of hand-assistance might increase the risk of higher blood loss in case of major vessel injury, whereas the Kustner preparatory incision, with only the peritoneum left closed, allows one to rapidly switch to the open procedure. The risk of higher blood loss in case of major vessel injury with the totally robotic technique, albeit extremely rare, has to be taken into account. On the other hand, minor vascular lesions may be arrested and repaired more easily without hand assistance, because the procedure might be actually hindered by robot instruments and the assistant hand. In the totally robotic procedure, major kidney vessels may be well exposed through complete kidney suspension by robotic arms at the time stapling. Despite that, placing one extra assistant 5 mm trocar should always be taken into consideration to provide more effective support for the first procedures of the surgeon. Adding one extra trocar does not jeopardize the success or the effectiveness of the procedure. We resorted to one additional assistant trocar in one case to achieve better exposure of the kidney vessels at the time of staplering. Hand assistance may play a significant role in structure exposure during kidney dissection. However, in our experience, three leading modifications have contributed to avoid hindrance due to the presence of the bowels or other structures in the operative field, even without hand assistance:
-
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patient decubitus changed from right 60-degree lateral decubitus to completely right lateral 90-degree decubitus; camera and right and left robotic trocars moved more to the left laterally as described in the methods section; assistant support for structure exposure by laparoscopic instruments.
Kustner incision appears to be more acceptable to the donors, particularly to female donors because esthetic results are significantly better. Other minor changes introduced by our modified procedure improved the overall technical aspects of the robotic technique of UIC surgical team. The modified side of the camera placement allows better visualization of the overall operative field, particularly for the approach to the posterior kidney hilum. In our first series, the kidney was completely dissected and separated from the surrounding fatty tissue. It appears to be easier and safer to achieve kidney isolation with the whole surrounding fatty tissue. It is easier particularly as far as the dissection of the posterior renal face is concerned, because of the feasibility of a complete blind dissection from the renal bed. It is safer because of the distance between the cleavage plan and kidney capsule, hilum, and ureter. After the first cases, we significantly reduced the frequency of the Int J Med Robotics Comput Assist Surg 2014; 10: 286–293. DOI: 10.1002/rcs
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placement of hem-o-lock around the renal vein, because of the impediment that hem-o-locks may become at staplering time. Moreover, the use of metallic laparoscopic clips, when indicated, makes the procedure faster and less expensive. The dissection of the adrenal gland with a harmonic scalpel starting from the upper renal pole appears to be safer, faster, and less hemorrhagic when Ultracision is applied instead of monopolar hook. The last technical note resulting from our experience is the option to staple the renal artery posteriorly to the renal vein; it appears easier to keep a transection line very close to the aorta and obtain a graft artery that is as long as possible. Intra-operative and post-operative patient outcome was similar in the hand assisted and in the totally robotic nephrectomy groups. It was generally favorable, showing that this procedure is just as safe and effective as the hand-assisted technique. Our findings are consistent with previously published experience (15–20). One of the more relevant concerns about totally robotic living donor nephrectomy is the warm ischemia time. Although in our experience the median warm ischemia time was significantly longer in Group B than in Group A (2.3 vs 5.1 min for Group A vs B, respectively P-value = 0.05), it did not impair graft function. Similar results were reported by Hubert and co-workers (15). Moreover, a retroperitoneoendoscopic technique seems to have the same range of warm ischemia time (21). Comparing the post-operative donor outcome in our experience with the outcome in the experience of the University of Illinois at Chicago, a significant difference can be found in median post-operative hospital stay (5 days vs 2 days in Milan and Chicago, respectively) and operative time. Indeed, although minimally invasive living kidney recovery has significantly reduced patient hospital stay at our Institute to worldwide figures, the difference versus UIC results is still important. It may be due to the lower volume of these procedures performed at our Institute. Another explanation may be the absence of highly restricting economic criteria for patient postoperative hospital stay in our country. However, we think that we will be able shorten donor hospital stay as the number of procedures increases. As far as operative time is concerned, our longer operative time reflects the learning curve and it has decreased after the first cases. An indication of this is the duration of the interventions we report here, which was reduced from the 4 hours of the first intervention to the average 2½ hours of the subsequent ones. Robotic assisted kidney recovery is a more expensive procedure than traditional laparoscopy. This may be the only disadvantage of this procedure. However, robotic cost may be reduced by daily use of the robot itself, as may occur in a high volume institute if the ‘Da Vinci’ is made available to multidisciplinary surgical teams. Copyright © 2014 John Wiley & Sons, Ltd.
This study is not devoid of limitations: its small sample size and its retrospective design are to be taken into consideration. In conclusion, robotic assisted living kidney recovery is a safe and effective procedure that offers a better chance than traditional laparoscopy of reproducing the safety achieved with open surgery. The cost of this procedure remains the only significant disadvantage. In the future efforts should focus on reducing the costs of the procedure. As discussed in this paper, totally robotic kidney recovery is a technique in evolution and the prospects of robotic staplers, EndoWrist ligature, and robotic single port may further increase robotic advantages. In our experience, robotic assisted kidney living donation appears to be the technique of choice for donors. Hand assisted techniques may always be taken into consideration for selected cases or at Institutions where in-depth training programs are implemented.
Conflict of interest The authors have stated explicitly that there are no conflicts of interest in connection with this article.
Funding No specific funding.
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Int J Med Robotics Comput Assist Surg 2014; 10: 286–293. DOI: 10.1002/rcs
ARTICLE
Evolution of robotic nephrectomy for living donation: from hand-assisted to totally robotic technique
Alessandro Giacomoni1* Stefano Di Sandro1,2 Andrea Lauterio1 Giacomo Concone1,2 Iacopo Mangoni1 Plamen Mihaylov1 Matteo Tripepi1 Luciano De Carlis1 1
Department of General Surgery and Transplantation, Niguarda Ca’ Granda Hospital, Milan, Italy
Abstract Background The application of robotic-assisted surgery offers EndoWrist instruments and 3-D visualization of the operative field, which are improvements over traditional laparoscopy. The results of the few studies published so far have shown that living donor nephrectomy using the robot-assisted technique is safe, feasible, and offers advantages to patients. Materials and methods Since November 2009, 16 patients have undergone robotic-assisted living donor nephrectomy at our Institute. Patients were divided into two groups according to the surgical technique adopted for the procedure: Group A, hand-assisted robotic nephrectomy (eight patients); Group B, totally robotic nephrectomy (eight patients).
2
Department of Surgical Sciences, University of Pavia, Italy *Correspondence to: Alessandro Giacomoni MD, Department of General Surgery and Transplantation, Niguarda Hospital – Milan, Piazza Ospedale Maggiore, 3, Italy. E-mail: [email protected]
Results Intra-operative bleeding was similar in the two groups (90 vs 100 mL for Group A and B, respectively). Median warm ischemia time was significantly shorter in Group A (2.3 vs 5.1 min for Group A and B, respectively, P-value = 0.05). Switching to the open procedure was never required. Median operative time was not significantly longer in Group A than Group B (275 min vs 250 min, respectively). Conclusion Robotic assisted living kidney recovery is a safe and effective procedure. Considering the overall technical, clinical, and feasibility aspects of living kidney donation, we believe that the robotic assisted technique is the method of choice for surgeon’s comfort and donors’ safety. Copyright © 2014 John Wiley & Sons, Ltd. Keywords
robotic-assisted nephrectomy; living donation; kidney transplantation
Introduction
Accepted: 2 January 2014
Copyright © 2014 John Wiley & Sons, Ltd.
Living donor kidney transplantation (LDKT) is a valid alternative for patients with end-stage renal disease (ESRD) (1). Many studies indicate that the results of LDKT are significantly better than the ones obtained with deceased kidney transplantation in terms of long-term patient and graft survival (1). Moreover, LDKT offers several advantages over deceased kidney donations: the recipient experiences better quality of life, better graft and immediate graft function, to which the possibility of transplanting patients either pre-emptively or after a shorter dialysis period is to be added (1–9). Concerns remain related to donor
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risk. Most donors monitored after donation had preserved glomerular filtration rate (GFR), normal albumin excretion, and excellent quality of life (1). The risk of ESRD in carefully screened kidney donors appears to be similar to the risk in the general population (1). Over the last decade the United Network for Organ Sharing (UNOS) has reported that LDKT is performed more and more frequently. The number of LDKTs has now exceeded the number of transplantations with deceased donors in 2001 (10,11). LDKTs have been fostered not only because they have proved to offer advantages over deceased donor transplantations, but also because of the extensive introduction of minimally invasive surgical procedures for kidney recovery (11). Minimally invasive techniques appear to be more acceptable to donors, most likely because of the significant reduction in post-operative pain, decreased length of hospital stay, rapid patient re-habilitation and better cosmetic results (10–13). Consequently, the laparoscopic approach to living donation nephrectomy, first reported by Ratner LE and co-workers in 1995 (14), has been adopted in an increasing number of cases, both for hand-assisted and for totally laparoscopic procedures. It appears to be the technique of choice for living kidney recovery so far. However, the laparoscopic approach has several technical limitations: 2-D imaging, restricted instrument motion that can make knotting and suturing more difficult, and surgeon discomfort (15–20). Robotic-assisted surgery (da Vinci robotic system, Intuitive Surgical Inc., Sunnyvale, CA) is used more and more often because it offers the clear advantages of EndoWrist instruments and Stable 3-D visualization of the operative field. This technique for kidney recovery from living donors has been introduced recently and only a few papers have been published on this subject so far. They all consistently point out the safety and feasibility of the technique, as well as the benefits of living donor nephrectomy performed using the robot-assisted technique (15–20). Herein, we describe our experience of robotic nephrectomy for LDKT and we point out surgical details related to the evolution from the hand-assisted techniques to totally robotic nephrectomy. The aim of this study is to assess the safety and feasibility of this surgical procedure.
Materials and methods Out of 1955 kidney transplantations performed at our Institute since 1972, 186 (10.5%) were LDKT. Sixteen were robotic-assisted living donor nephrectomies performed between November 2009 and November 2011. We compared patients according to the surgical technique adopted for the procedure: Group A, hand-assisted robotic nephrectomy (eight patients); Group B, totally robotic nephrectomy (eight patients).
Demographic and baseline patient data Table 1 compares donor demographic data between the two groups. Donors did not differ in terms of median age, male/female distribution and median body mass index (BMI). All the patients in the two groups were Caucasian. Two patients in Group A and one patient in Group B had a history of abdominal surgery. Distribution of patient co-morbidity was similar in the two groups. All the patients underwent left nephrectomy. Two patients in Group A and three patients in Group B had more than one renal artery. In particular, patients in Group A with more than one artery had one superior polar accessory artery or one inferior polar accessory artery, whereas in Group B the three patients with more than one renal artery had one superior polar artery, one inferior polar artery or one accessory hilar artery from the aorta. No patients had accessory renal veins. Only two patients, one in Group A and one in Group B, had early bifurcations. In each case we were able to obtain a common patch used for single anastomosis.
Donor selection Each patient suitable for living donation was proposed for minimally invasive nephrectomy. Relative contra-indication to minimally invasive donor nephrectomy was a history of more than one abdominal surgical procedure. Until November 2009, at our Institute laparoscopic nephrectomy
Table 1. Demographic and baseline patient features Variables Median age Sex M/F Body Mass Index (BMI) Caucasian race Previous abdominal surgery Patients with co-morbidity Patients with > 1 renal artery Patients with > 1 renal vein
Copyright © 2014 John Wiley & Sons, Ltd.
Group A (8 patients)
Group B (8 patients)
Sig. P-value
47 (32–59) 3/5 23 (19–32) 8/8 1/8 1/8 2/8 0/8
54 (46–65) 4/4 23 (19–26) 8/8 1/8 2/8 3/8 0/8
NS NS NS NS NS NS NS NS
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Table 2. Intra-operative (I.O.) and post-operative (P.O.) patient data. Complications were classified as follow: a, post-operative bleeding; b, re-operations; c, acute pyelonephritis; d, acute renal failure; e, chronic renal failure; f, deep vein thrombosis; g, pulmonary embolism; h, urinary infections; i, wound infections; k, lymphatic fistula; l, bowel sub-occlusion Variables Median I.O. bleeding (mL) Median Nr. of blood cells unit I.O. accidental hemorrhage Warm ischemia time (min) Nr of case of 2nd accessory trocar Nr of conversion Median overall operation time (min) Median console time (min) Length of hospital stay (days) P.O. day of re-alimentation P.O. day of drainage remove P.O. day of canalization P.O. case who developed complications (Type)
Group A (8 patients)
Group B (8 patients)
Sig. P-value
90 (10–400) 0 1/8 2.3 (0.30–3.8) 0/8 0/8 275 (85–450) 185 (55–360) 5 (5–9) 2 (1–3) 3 (1–7) 3 (2–6) 2 (d,k)
100 (10–750) 0 0/8 5.1 (4.2–6.5) 2/8 0/8 250 (120–500) 150 (85–390) 5 (4–6) 1 (0–2) 2 (1–2) 3 (2–4) 1 (l)
NS NS NS 0.05 NS NS NS NS NS NS NS NS NS
was considered to be the technique of choice for living kidney recovery. In November 2009 we agreed that the first choice was the robotic technique and all kidney donations performed at our unit since then have been performed with robotic assistance. Donor candidates were at least 18 years old and were living relatives or spouses of the recipients. After the donation statement, candidates underwent psychological and legal evaluation in order to unveil coercion to donation, if any. Renal vascular anatomy was studied with spiral computed tomography (CT-scan) with 3-D vessel reconstruction for patients 50 years or older, and with MRI for the others. The left kidney was routinely the first choice. Right kidney was considered as a second option in cases of more favorable renal vascular anatomy. The presence of accessory kidney arteries was not a reason to deny recovery or for selecting the right kidney per se. All candidates were well informed about the risk of technical switching to the open approach and the procedure was planned only after the donor had signed the informed consent form.
midline incision of around 8 cm for the assistant hand. After that, one 12 mm trocar for 30° camera was placed in the peri-umbilical region, in front of renal hilum identified by the assistant hand, approximately 3 cm above the umbilicus and left lateral trans-rectal line. Two 8 mm robotic trocars were placed on the left lateral abdominal wall along the mid-clavicular line. Another 12 mm trocar was placed in the left inguinal region for the assistant (Figure 1). At this time, the robotic cart was docked to the trocars on the left side of the patient. Basic access and first connected robotic instruments were a bipolar Maryland forceps controlled by the left robotic arm and monopolar hook on the right robotic arm. The first step of the surgical procedure was dissection of the left colon from the wall peritoneum and exposure of the renal region. After that, the ureter was located and marked by elastic tape. Following the gonadal vessel tract, we identified the left renal vein. Left renal vein and left renal
Surgical technique and evolution of the surgical strategy Eight consecutive robot hand-assisted nephrectomies were performed (group A). Subsequently we introduced a few modifications to facilitate the surgical technique, performing eight consecutive totally robotic nephrectomies (group B). Group A (first eight cases) Between November 2009 and December 2010, we performed eight hand-assisted robotic nephrectomies following the protocols of the pioneering experience of the surgical team of the University of Illinois at Chicago (20). After general anesthesia, patients were placed in right 60-degree lateral decubitus position. First surgical time was to prepare a mini-laparotomy by sub-umbilical Copyright © 2014 John Wiley & Sons, Ltd.
Figure 1. Trocar placement strategy in the first technique adopted. No. 1 indicates the midclavicular line Int J Med Robotics Comput Assist Surg 2014; 10: 286–293. DOI: 10.1002/rcs
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artery were isolated from their origin to approximately 4 cm above the renal pelvis and separated from the adrenal, gonadal, and lumbar vessels. These vessels were cut after distal and proximal placement of hem-o-lock clips (Weck, Germany). The upper renal pole was dissected from the adrenal gland, and the anterior and posterior kidney surface was completely dissected from the perirenal fat tissue. Once the whole kidney was dissected and liberated from all surrounding tissues, the ureter was cut approximately at the iliac vessel crossing level; the distal ureter was closed by hem-o-lock and the proximal ureter was left open. At this stage, intravenous (IV) heparin was administered at a dose of 80 U/kg. After that, the renal artery was stapled by endo-TA stapler (ENDO TA 30stapler; US Surgical, Norwalk, CT, USA) exactly at its origin from the aorta. Before cutting the renal artery, a hem-o-lock was placed on the already stapled line and the artery was cut. Subsequently, the renal vein was stapled and cut by Endopath Stapler (Echelon 60; Ethicon Endosurgery, LLC, Guaynabo, PR, USA) and the kidney was removed through the lower midline incision and taken to the back table. Check-out: the last check of the renal bed and trocar access holes was performed laparoscopically, after extraction of the specimen, closing the mini-laparotomy, and re-induction of pneumoperitoneum. One tubular 21 fr drain was placed in the renal bed. Hemostasis was mainly achieved by bipolar electrocauterization and monopolar hook. Bipolar forceps was applied continuously and simultaneously, by placing it mainly on the left robotic arm. For vessels of median diameter (3–5 mm), hemostasis was achieved by the application of robotic hem-o-lock clips or metallic clip placement by the assistant. For major vessels (>10 mm), we used the Endopath Stapler. When that mechanic instrument could not be applied, hemostasis was achieved by monofilament Prolene® 4/0 or 5/0 stiches.
nephrectomy, adopting a modified technique leading to the evolution from a hand-assisted robotic technique to a totally robotic technique. The patient decubitus was modified from right 60-degree lateral decubitus to completely right lateral 90-degree decubitus. The first surgical step was to perform a Kustner preparatory incision of around 8–10 cm, opening the fascia but not the peritoneum. After that, pneumoperitoneum was inducted by Veress needle, introduced into the left hypochondrium. Camera trocar (12 mm) was moved along the midclavicular line and the two 8 mm robotic trocars were moved from the left midclavicular line to the left anterior axillary line. Another 12 mm trocar was placed on the left extreme side of the prepared Kustner incision (Figure 2). At this time, robotic cart was docked to the trocars on the left side of the patient. Concerning the surgical console time, leading modifications were introduction of the Ultracision during kidney dissection; reduced application of the hem-o-lock clips and increased use of metallic clips; kidney isolation with the whole peri-renal fat tissue. After renal vessel suturing and cutting, specimen extraction occurred by completing the fascia and peritoneum incision on the sub-umbilical midline fascia incision. All the other technical notes were identical to the ones related to the first technique.
Group B (second eight cases) Between January 2011 and December 2011, we performed another eight cases of robotic assisted-
χ 2 analysis was used to compare categorical data between groups, and the independent-samples t test to analyze continuous variables. P ≤ 0.050 was considered
Data analysis To better understand the advantages or disadvantages of the modified technique, we compared the two patient cohorts in terms of demographic and baseline patient features (Table 1), intra-operative data, post-operative outcome and complications (Table 2).
Statistical analysis
Figure 2. Image A and B show the modified technique for patient and trocar placement; line 1 indicates the anterior axillary line. Image C reports one case of Kustner incision for kidney extraction Copyright © 2014 John Wiley & Sons, Ltd.
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statistically significant. All analyses were performed with the statistical program SPSS® version 13.0 (SPSS, Chicago, Illinois, USA).
Results Intra-operative data The comparison of intra-operative features showed that intra-operative bleeding was not significantly different between the two groups (90 mL vs 100 mL for Group A vs B, respectively). No patients were intra-operatively transfused with blood cell units. However, one Group A patient had an accidental intra-operative hemorrhage due to vascular lesion of the adrenal branch at the origin from the left renal vein. This patient lost about 400 mL of blood. Hemorrhage was arrested by clamping the vein with bipolar forceps. The lesion was eventually sutured robotically by Prolene 4/0 tie and the procedure was not converted to open access. No case of accidental intra-operative hemorrhage occurred in Group B. One patient in group B had continuous moderate bleeding from the adrenal gland and renal bed during the operation. This patient had an overall blood loss of 750 mL, but did not required blood transfusion. As a matter of fact, no patient in either group was transfused intra-operatively. The median warm ischemia time was significantly shorter in Group A (2.3 vs 5.1 min for Group A vs B, respectively, P-value = 0.05). In one Group B patient (case #1) we had to introduce one extra accessory 5 mm trocar to hold the kidney up and better expose the kidney vessels at the time of vessel stapler. Switching to open procedure never occurred. Median operation time was slightly longer in Group A than in Group B (275 min vs 250 min, respectively); however, the difference was not statistically significant. As of today, right kidneys were never robotically recovered at our Institute.
Post-operative patient outcome and complications The duration of post-surgery hospital stay was identical in the two groups (5 days). All the patients in the two groups resumed oral nutrition between the first and second postoperative day (median 2 vs 1 for Group A vs B, respectively). The abdominal drain was usually removed on the third post-operative day (median 3 vs 2 for Group A vs B, respectively). Bowel recovery occurred usually on the third post-operative day (median 3 days in both groups). Central venous catheters (CVC) were removed mostly on the third post-operative day (median 3 days vs 2 days for Group A vs B, respectively). Nasogastric tube Copyright © 2014 John Wiley & Sons, Ltd.
was removed intra-operatively, before patients awakened in both groups. It is important to point out that the last three patients resumed oral nutrition on the same day as the operation and that CVC was not required. Overall, no patients developed severe (> grade II Clavien score) post-operative complications. Only one patient had a grade II complication. He developed a post-discharge sub-occlusion syndrome. The patient was re-admitted from the emergency room and treated by conservative therapy due to the absence of organic reasons for sub-occlusion at imaging and endoscopy. After three days of total parenteral nutrition, the patient experienced complete spontaneous regression of the clinical picture and was discharged on day 4. The very last patient developed post-operative complications because of a lymphatic fistula. This patient had continuous drainage of lymphatic liquid from the abdominal drainage (around 500–700 mL per day) and received a hypo-lipid diet. On the seventh post-operative day drainage was removed due to significant reduction (>50%) in the abdominal drainage. The patient was discharged on the ninth postoperative day with clinical regression of the fistula.
Donor and recipient renal function Renal function tests normalized in all donors before discharge. At discharge, the overall median serum creatinine level was 0.9 mg/dl (1.25 vs 1.02 for Group A vs B, respectively) and the overall median measured glomerular filtration rate was 96 mL min (range, 79 to 132 mL min-1). Only one patient had transient mild acute renal failure. Median serum creatinine was 1.5 mg/dl (range: 1.35–1.64 mg/dl). Nine days after the procedure, the patient experienced complete regression of renal insufficiency and normalization of serum creatinine (1.23 mg/dl). No cases of graft loss occurred among the recipients. 15 out of 16 transplanted kidneys had an immediate function; resumption of renal function was delayed only in one patient. The overall median serum creatinine level of this patient was 1.39 mg/dl (0.49 vs 2.59 mg/dl, respectively) and the overall median measured glomerular filtration rate was 81 mL min-1 (range, 43 to 132 mL min-1) on the 10th post-operative day.
Discussion Our experience confirms the evidence reported in the small number of papers published so far about the feasibility and safety of robotic nephrectomy for living kidney transplantation (15–20). This paper extends the results of the paper by Hubert et al. (15), who reported the feasibility and the effectiveness of recovering living kidney Int J Med Robotics Comput Assist Surg 2014; 10: 286–293. DOI: 10.1002/rcs
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using a completely robotic-assisted technique, i.e. without any hand-assistance. In 2007 Hubert and co-workers published their experience of 38 procedures of entirely robot-assisted laparoscopic live donor nephrectomies and concluded that this procedure can be safely carried out, insofar as robotics enhances the laparoscopist’s skills, enables the surgeon to dissect meticulously and reduces the risk of problematic bleeding. Donor morbidity and hospitalization are reduced by the laparoscopic approach and the use of robotics allows the surgeon to work under better ergonomic conditions (15). Horgan and co-workers reported the largest series of hand-assisted robotic kidney recoveries for living transplantation (17). As of today, this series remains the largest one reported worldwide. Our experience took inspiration from their proposed leading technique (20). Therefore, at our Institute we attempted a meticulous reproduction of the technique proposed by University of Illinois at Chicago. At our Institute laparoscopic nephrectomy was considered to be the technique of choice for living kidney recovery until November 2009. We then agreed that the first choice was the robotic technique and since then all kidney donations have been performed at our unit with robotic assistance. This technique (17–20) was adopted for eight consecutive cases performed by our team between 2009 and 2010. The advantages of using robotic hand-assisted nephrectomy over standard laparoscopic tools, were immediately evident, mainly the first surgeon’s comfort and the major advantages offered by the robotic EndoWrist instruments and 3-D visualization of the operative field. The surgeon’s comfort is essential for reproducibility of the outcome of a surgical intervention. In long lasting procedures, it can even play a role in the wellbeing and safety of the patient. It is difficult to achieve a quantitative assessment of the surgeon’s comfort, because there is no single parameter for its assessment. However, when fatigue and ease of the procedure are taken into consideration one can easily appreciate the advantages offered by robotic assistance. Post-operative donor outcome appeared to be the same as in standard laparoscopic cohorts. After the first eight cases, it appeared that it was possible to skip the hand-assistance, which, in some instances, fails to offer valid support. Because of that, we introduced some modifications to the UIC technique, in order to facilitate the procedure. This is why we compared the results of the first series of eight consecutive cases with the results of the second series of eight consecutive totally robotic kidney recoveries to investigate the benefits of our modified surgical technique in-depth. Skipping the hand assistance allowed us to perform the procedure with only two surgeons (instead of three): the first one at the robot console and the second one scrubbed in the operating field for laparoscopic assistance. The Copyright © 2014 John Wiley & Sons, Ltd.
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absence of hand-assistance might increase the risk of higher blood loss in case of major vessel injury, whereas the Kustner preparatory incision, with only the peritoneum left closed, allows one to rapidly switch to the open procedure. The risk of higher blood loss in case of major vessel injury with the totally robotic technique, albeit extremely rare, has to be taken into account. On the other hand, minor vascular lesions may be arrested and repaired more easily without hand assistance, because the procedure might be actually hindered by robot instruments and the assistant hand. In the totally robotic procedure, major kidney vessels may be well exposed through complete kidney suspension by robotic arms at the time stapling. Despite that, placing one extra assistant 5 mm trocar should always be taken into consideration to provide more effective support for the first procedures of the surgeon. Adding one extra trocar does not jeopardize the success or the effectiveness of the procedure. We resorted to one additional assistant trocar in one case to achieve better exposure of the kidney vessels at the time of staplering. Hand assistance may play a significant role in structure exposure during kidney dissection. However, in our experience, three leading modifications have contributed to avoid hindrance due to the presence of the bowels or other structures in the operative field, even without hand assistance:
-
-
patient decubitus changed from right 60-degree lateral decubitus to completely right lateral 90-degree decubitus; camera and right and left robotic trocars moved more to the left laterally as described in the methods section; assistant support for structure exposure by laparoscopic instruments.
Kustner incision appears to be more acceptable to the donors, particularly to female donors because esthetic results are significantly better. Other minor changes introduced by our modified procedure improved the overall technical aspects of the robotic technique of UIC surgical team. The modified side of the camera placement allows better visualization of the overall operative field, particularly for the approach to the posterior kidney hilum. In our first series, the kidney was completely dissected and separated from the surrounding fatty tissue. It appears to be easier and safer to achieve kidney isolation with the whole surrounding fatty tissue. It is easier particularly as far as the dissection of the posterior renal face is concerned, because of the feasibility of a complete blind dissection from the renal bed. It is safer because of the distance between the cleavage plan and kidney capsule, hilum, and ureter. After the first cases, we significantly reduced the frequency of the Int J Med Robotics Comput Assist Surg 2014; 10: 286–293. DOI: 10.1002/rcs
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placement of hem-o-lock around the renal vein, because of the impediment that hem-o-locks may become at staplering time. Moreover, the use of metallic laparoscopic clips, when indicated, makes the procedure faster and less expensive. The dissection of the adrenal gland with a harmonic scalpel starting from the upper renal pole appears to be safer, faster, and less hemorrhagic when Ultracision is applied instead of monopolar hook. The last technical note resulting from our experience is the option to staple the renal artery posteriorly to the renal vein; it appears easier to keep a transection line very close to the aorta and obtain a graft artery that is as long as possible. Intra-operative and post-operative patient outcome was similar in the hand assisted and in the totally robotic nephrectomy groups. It was generally favorable, showing that this procedure is just as safe and effective as the hand-assisted technique. Our findings are consistent with previously published experience (15–20). One of the more relevant concerns about totally robotic living donor nephrectomy is the warm ischemia time. Although in our experience the median warm ischemia time was significantly longer in Group B than in Group A (2.3 vs 5.1 min for Group A vs B, respectively P-value = 0.05), it did not impair graft function. Similar results were reported by Hubert and co-workers (15). Moreover, a retroperitoneoendoscopic technique seems to have the same range of warm ischemia time (21). Comparing the post-operative donor outcome in our experience with the outcome in the experience of the University of Illinois at Chicago, a significant difference can be found in median post-operative hospital stay (5 days vs 2 days in Milan and Chicago, respectively) and operative time. Indeed, although minimally invasive living kidney recovery has significantly reduced patient hospital stay at our Institute to worldwide figures, the difference versus UIC results is still important. It may be due to the lower volume of these procedures performed at our Institute. Another explanation may be the absence of highly restricting economic criteria for patient postoperative hospital stay in our country. However, we think that we will be able shorten donor hospital stay as the number of procedures increases. As far as operative time is concerned, our longer operative time reflects the learning curve and it has decreased after the first cases. An indication of this is the duration of the interventions we report here, which was reduced from the 4 hours of the first intervention to the average 2½ hours of the subsequent ones. Robotic assisted kidney recovery is a more expensive procedure than traditional laparoscopy. This may be the only disadvantage of this procedure. However, robotic cost may be reduced by daily use of the robot itself, as may occur in a high volume institute if the ‘Da Vinci’ is made available to multidisciplinary surgical teams. Copyright © 2014 John Wiley & Sons, Ltd.
This study is not devoid of limitations: its small sample size and its retrospective design are to be taken into consideration. In conclusion, robotic assisted living kidney recovery is a safe and effective procedure that offers a better chance than traditional laparoscopy of reproducing the safety achieved with open surgery. The cost of this procedure remains the only significant disadvantage. In the future efforts should focus on reducing the costs of the procedure. As discussed in this paper, totally robotic kidney recovery is a technique in evolution and the prospects of robotic staplers, EndoWrist ligature, and robotic single port may further increase robotic advantages. In our experience, robotic assisted kidney living donation appears to be the technique of choice for donors. Hand assisted techniques may always be taken into consideration for selected cases or at Institutions where in-depth training programs are implemented.
Conflict of interest The authors have stated explicitly that there are no conflicts of interest in connection with this article.
Funding No specific funding.
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