Journal of Surgical Oncology 2015;112:717–722
Minimally Invasive Renal Autotransplantation AKSHAY SOOD, MD,1* WOOJU JEONG, MD,1 RAJESH AHLAWAT, MD,2 FIRAS ABDOLLAH, MD,1 JESSE D. SAMMON, DO,1 MAHENDRA BHANDARI, MD,1 AND MANI MENON, MD1 1
Vattikuti Urology Institute, Henry Ford Health System, Detroit, Michigan Kidney and Urology Institute, Medanta—The Medicity, Gurgaon, India
2
Minimally invasive renal allotransplantation techniques have been recently described; reported benefits include reduced morbidity/complications. These benefits have been successfully adapted for minimally invasive renal autotransplantation, however, in a non-oncological setting. We, here, describe a novel alternative robot-assisted renal autotransplantation technique, utilizing GelPOINT, which by permitting ex vivo graft examination and surgery might allow further broadening of indications for minimally-invasive renal autotransplantation, to include complex oncological renal/ ureteral lesions. Future studies are needed to evaluate the utility of these techniques.
J. Surg. Oncol. 2015;112:717–722. © 2015 Wiley Periodicals, Inc.
KEY WORDS: minimally invasive; robotics; kidney; transplantation; autotransplantation
INTRODUCTION
LITERATURE REVIEW
Renal autotransplantation (ReATx), despite having been reported as an effective treatment modality for managing complex renal/ureteral lesions [1–4], has remained underutilized. Two reasons may be cited for it—first, the high morbidity associated with the procedure due to the requirement for two major interventions, open nephrectomy and open transplantation, in the same setting. The second reason may be the relative unfamiliarity of urologists with renal transplantation [5]. Minimally invasive approaches to renal transplantation (ReTx) have been recently described (in the setting of allotransplantation) [6–10]. These techniques, in particular the robot-assisted, have shown promise by being safe, reproducible and leading to lower complications and morbidity (when compared to open ReTx) even during the early experience [6–14]. We, therefore, hypothesized that by extending these benefits of minimally invasive ReTx to ReATx, coupled with the advantages of laparoscopic nephrectomy, the acceptance and indications for a “minimally invasive” ReATx might be expanded. In line with our hypothesis—recently, Gordon and Abaza et al. [15], building on their experience with robotic kidney transplantation with regional hypothermia [16], developed by our group [9,10], described a minimally invasive intracorporeal approach to ReATx in a patient with extensive ureteral loss (non-oncological setting). This case report represents the first account of a minimally invasive approach to ReATx. Against this background, in the current review, we explore the “potential” role of minimally invasive ReATx in the treatment of patients with neoplastic diseases of the upper urinary tract. Our aim was threefold: first, to provide a comprehensive review of the various indications for which ReATx has been utilized, with a focus on oncological indications. Next, to report on our technique of robotic kidney transplantation with regional hypothermia [10], discuss its applicability to ReATx, and contrast it with the robotic intracorporeal ReATx technique described by Gordon and Abaza et al. [15] highlighting important differences and merits of each approach. Lastly, we discuss the advantages-disadvantages and scope of these novel minimally invasive approaches in the context of ReATx.
A literature search of Medline (PubMed) and EMBASE was performed to retrieve all contemporary articles published on ReATx (January 1990 and December 2014). We used the search terms “[renal autotransplantation]” or “[kidney autotransplantation]” or “[kidney AND autotransplantation]” or “[renal AND autotransplantation].” The search was limited to the title and abstract fields while running the query and only papers written in English and concerning technical and/or clinical outcomes following renal autotransplantation were selected. The search was conducted on 28th of January 2015. Reference lists of the selected papers were scrutinized for additional relevant material but yielded no additional studies. Overall, 541 unique articles were retrieved and 127 were relevant (Fig. 1). Seventy-eight articles reported on utilization of ReATx for treatment of renal vascular lesions; these articles were not reviewed further as they discussed the role of ReATx in management of nononcological conditions. The remaining 49 articles reported on the role of ReATx in treatment of complex ureteral/renal lesions including proximal ureteral injury, ureteral stricture disease, intractable urolithiasis and neoplastic disease. Of the 49 articles, 21 described the use of ReATx in management of oncological disease (14 case reports; 7 case series). These were reviewed further and the reported outcomes were noted. Only one case report (out of the 127 articles; Abaza et al.), as previously mentioned, described the use ReATx in a minimally-invasive fashion, however, this was for a benign ureteral injury. Despite being a non-oncological report, due to the singular nature of the report it was reviewed and outcomes reported were noted.
ß 2015 Wiley Periodicals, Inc.
* Correspondence to: Akshay Sood, MD, Vattikuti Urology Institute, Henry Ford Health System, 2799 W. Grand Boulevard, Detroit, Michigan 48202. Fax: þ1.313.916.4352, E-mail: [email protected], [email protected] Received 31 March 2015; Accepted 30 April 2015 DOI 10.1002/jso.23939 Published online 20 May 2015 in Wiley Online Library (wileyonlinelibrary.com).
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Sood et al. kidney was also a common indication [4,23–26,]. In children, the major indication was synchronous Wilms tumor [27,28]. Lastly, a few groups reported on the use of ReATx as an effective treatment strategy for managing large ureteral defects secondary to encasement by abdominal malignancies including metastatic germ cell tumors and liposarcomas [29,30] and one case report demonstrated the use of ReATx for organ preservation against inadvertent radiation exposure (Fig. 2) [31]. All ReATx were performed via open surgery. Reported cold-ischemia times in these series varied from 118 to 162 min and operative times varied from 330 to 392 min. In all cases, a negative surgical margin could be achieved. Perioperative complications mainly included blood transfusions and dialysis. Length of stay varied from 7 to 19 days. These studies comprised level 4 evidence [32]. Tables I and II (part-b) summarize data from the only known study of minimally invasive ReATx (non-oncological setting) [15]; coldischemia time was 95.5 min, and the operation could be completed without needing to convert to open surgery and without any complications. The patient was discharged home on postoperative day 1. This study constitutes level 4 evidence [32].
Fig. 1. Flowchart depicting the literature search results and inclusion of relevant studies.
With respect to minimally invasive ReTx studies, outcome data from recent reviews on the subject were consulted [17–20]. Individuals studies cited in the reviews were consulted as and if the need arose.
ONCOLOGICAL INDICATIONS FOR RENAL AUTOTRANSPLANTATION Renal autotransplantation was first described by Hardy et al. in the year 1963 [1] for management of severe proximal ureteral injuries. Soon after, McLoughlin et al. [21] demonstrated its utility in management of complex renal lesions. Since then, ReATx has been utilized in the treatment of a variety of upper urinary tract pathologies. Here, we review the oncological conditions for which its use has been described. Tables I and II (part-a) summarize the key studies reporting the use of ReATx in oncological settings. The indications for ReATx included centrally located or multiple renal masses in the scenario of bilateral renal involvement or solitary functioning kidney [3,22]. Primary urothelial carcinoma (UC) of the renal pelvis or the ureter in the setting of bilateral neoplastic involvement or solitary functioning
ROBOTIC KIDNEY TRANSPLANTATION WITH REGIONAL HYPOTHERMIA AND ITS ADAPTATION FOR RENAL AUTOTRANSPLANTATION We have previously described our technique of robotic kidney transplantation with regional hypothermia in a detailed step-by-step manner (for allotransplantation), along with a surgical video [10]. Briefly, the patients were positioned and ports were placed in a manner typical for robot-assisted radical prostatectomy [33]. The operation started with skeletonization of the external-iliac vessels (EIVs), followed by dropping down of the bladder and ureteroneocystostomy site preparation. Subsequently, a transverse incision was made in the peritoneum, 2–3 cm distal to the cecum, and peritoneal flaps were raised to be utilized later for extraperitonealization of the allograft. This concluded the recipient bed preparation. Next, the iliac-fossa was cooled with ice-slush introduced through the GelPOINT. Then, the graft kidney wrapped in ice-gauze jacket was introduced. Graft vessels were anastomosed to the EIVs (venous anastomosis followed by arterial anastomosis) in an end-to-side fashion using 5-0 Gore-Tex suture. Following re-perfusion, the graft was extraperitonealized utilizing the
TABLE I. Summary of Selected Case Series/Reports Looking at Outcomes in Patients Undergoing Renal Autotransplantation (ReATx) Via Open or Minimally Invasive Techniques for an Oncological Indication* Study PART-A Desai et al. Kang et al.a Holm€ang et al.a Millar et al. Steffens et al.a Iida et al. B€olling et al. Bansal et al. Basiri et al. Cheng et al. Abraham et al. Nayak et al. PART-B Abaza et al.
Publication year
ReATx approach
1999 2004 2005 2005 2007 2009 2009 2013 2014 2014 2014 2014
Open Open Open Open Open Open Open Open Open Open Open Open
2014
Robotic
*
Nephrectomy approach
Study design
Open Open Open Open Open Laparoscopic Open Open Open Laparoscopic Laparoscopic Laparoscopic
Case Case Case Case Case Case Case Case Case Case Case Case
Robotic
series series series report series report report report report series series series
Case report
Cohort (n)
Level of Evidence
3 10 25 1 4 1 1 1 1 15 3 3
4 4 4 4 4 4 4 4 4 4 4 4
1
4
The case report by Abaza et al was a non-oncological report, however, due to the unique nature of the report it was included in the current review. For long-term outcomes following ReATx, please consult these studies.
a
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Renal Autotransplantation
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TABLE II. Summary of Perioperative Outcomes Reported in Selected Case Series/Reports Looking at Outcomes in Patients Undergoing Renal Autotransplantation (ReATx) Via Open or Minimally Invasive Techniques for an Oncological Indication* Study
Indication
PART-A Desai et al.
Bilateral Wilms tumor presenting synchronously Kang et al. Primary renal pelvis UC in the setting of bilateral disease Holm€ang et al.e Primary ureteral/renal pelvis UC in the setting of solitary kidney Millar et al. Bilateral Wilms tumor presenting synchronously Steffens et al.e Primary ureteral UC in the setting of solitary kidney Iida et al. Primary ureteral UC in the setting of bilateral disease B€olling et al. Renal transposition; to avoid exposure to highdose RT Bansal et al. Secondary encasement of the right ureter by liposarcoma Basiri et al. Secondary encasement of the left ureter by metastatic GCT Cheng et al. Primary ureteral UC þ/ in the setting of solitary kidney Abraham et al. Complex renal tumors þ/ in the setting of B/L renal tumors Nayak et al. Complex renal tumors þ/ in the setting of solitary kidney PART-B Abaza et al. Ureteral Injury (non-oncological indication) e
Operative Ischemia Timea (min) Timea,b (min)
Surgical Margins
EBLa (mL)
Complications
LOSa (day) NA NA
NA
164
Negative in all 3
NA
NA
NA
Negative
NA
Re-exploration in 2; BT in 1 patient None
NA
NA
Negative
NA
None
NA
NA
NA, C
Negative
NA
None
NA
NA
162, C/W
Negative in all 4
NA
BT in 1 patient
NA
NA
NA
Negative
NA
None
NA
NA
NA
NA
NA
None
NA
NA
NA
Negative
NA
None
NA
NA
NA
Negative
NA
None
NA
c
392
NA
Negative in 12
NA
360
118, C
Negative in all 3
d
330
NA; C
425
95.5; C
418
DGF in 1 patient; BT in 3 patients DGF in 1 patient
NA 7–12
Negative in all 3
267
Urinoma in 1 patient
8–19
—
50
None
1
BL, estimated blood loss; LOS, length of stay; UC, urothelial carcinoma; NA, not available; DGF, delayed graft function; BT, blood transfusion; RT, radiotherapy; GCT, germ cell tumor. a Operative time, Ischemia time, EBL and LOS are reported as mean values or range (as available) for the case series. b Ischemia: W, Warm, C, Cold. c In the report by Cheng et al, only 12 patients (out of the 15) underwent ReATx as 3 patients with evidence of advanced disease were treated by nephrectomy alone. d Nayak et al. reported the ischemia times only for the ex vivo excision part (mean 39 min) and did not comment on the ischemia times for autotransplantation. e For long-term outcomes following ReATx, please consult these studies. * The case report by Abaza et al was a non-oncological report, however, due to the unique nature of the report it was included in the current review.
peritoneal flaps prepared previously. Stented ureteroneocystostomy was performed following the modified Lich-Gregoir technique. Here, we describe a novel operative template—a modification of our aforementioned allotransplantation technique—which could be adapted for performing ReATx in a minimally-invasive manner:
Fig. 2. Oncological indications for renal autotransplantation reported in literature. Journal of Surgical Oncology
(1) GelPOINT: The GelPOINT device (Applied Medical, Rancho Santa Margarita, CA) is a hand-access platform. It consists of two parts—a GelSeal cap and an access port. It was initially devised for single-site surgery but we utilize it to deliver ice-slush (for regional pelvic hypothermia) and the graft kidney into the pelvic cavity [10,33,34]. For the proposed robot-assisted ReATx procedure, a 12-mm assistant port or a 12-mm camera port would be placed into the GelSeal cap ahead of time, for nephrectomy and autotransplantation steps, respectively (see below for details). (2) Patient position and port placement: (a) For the nephrectomy, the patient would be placed in supine position with legs in Allen stirrups. A gel roll will be placed behind the kidney and the bed would be rotated away from the operative side to elevate the flank, as is typical for nephroureterectomy [35]. Figure 3a shows the proposed patient position, port placement and robot docking for a left donor nephrectomy. The GelPOINT would be inserted through a 5–6 cm vertical paraumbilical incision. Four-ports would be utilized; a 12-mm camera port would be placed just lateral and above the umbilicus, two 8-mm robotic ports would be placed along the left mid-clavicular line just below the tip of the 12th rib and at the level of the umbilicus, respectively, and a 12-mm assistant port
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Fig. 3. Proposed patient position and port placement (utilizing six-ports) for robot-assisted renal autotransplantation, a customization of our technique of robotic kidney transplantation with regional hypothermia. would be placed through the GelPOINT. (b) For the autotransplantation, the bed would be made supine and the gel roll removed making the patient horizontal. Next, the patient would be transferred to steep Trendelenburg while remaining in lithotomy. The robot would be re-docked between the legs (Figure 3b). This would bring the patient into optimal position for a right iliac fossa transplant with minimal re-positioning of the patient (only the bed and the robot would need to be moved). Ports utilized for camera and left robotic arm during nephrectomy would be sutured closed (see ports labeled 1 and 2 in Figure 3a). Two additional ports would be inserted as shown (see ports labeled 5 and 6 in Figure 3b); a 12-mm assistant port in the right iliac fossa and an 8-mm robotic port along the right mid-clavicular line at the level of the umbilicus. The 12-mm camera port would be moved to the GelPOINT. (3) Nephrectomy: The nephrectomy would proceed transperitoneally in a manner typical for donor nephrectomy. Briefly, the colon would be reflected. The left renal vessels would be dissected carefully to the level of the aorta to maximize length. The lumbar, adrenal, and gonadal veins would be clipped and divided. Then, the kidney would be mobilized and the ureter would be dissected to obtain an optimal length. Next, the kidney would be brought out through the GelPOINT [9]. Similar steps would be applicable for a right sided donor kidney as well. (4) Bench surgery and iliac vessel bed preparation: The graft kidney, following extraction, would be bathed in ice-slush, flushed with heparinized saline and defatted. In case of multiple renal vessels, a “stump” preparation would be comfortably achieved to optimize vascular anastomosis during autotransplant. If the autografting is being performed for the treatment of a complex renal mass, meticulous enucleation would also be possible as has been described for open ReATx [3,22]. In case of a UC of the renal pelvis or ureter, careful inspection, examination and surgical resection may be done as needed [4,23–26]. Further, while these steps are being performed ex vivo, the console surgeon would prepare the iliac vessel bed for subsequent autotransplantation. Next, ice-slush would be instilled though the GelPOINT to cool the iliac fossa and then the graft, wrapped in ice-gauze jacket, would be introduced for anastomosis. (5) Autotransplantation: This part of the operation would essentially proceed in a manner similar to minimally invasive renal allotransplantation, as previously described by us [10]. In brief, the steps would consist of end to side venous and arterial anastomoses followed by graft extraperitonealization. Lastly, Journal of Surgical Oncology
stented ureterovesical anastomosis would be performed (utilizing modified Lich-Gregoir technique).
DISCUSSION The benefits of minimally invasive surgery are well established and have led to its widespread adoption [36–40]—including in the field of transplantation [17,41]—such that today laparoscopic approach represents the standard-of-care for living donor nephrectomy. The role of minimally invasive surgery for recipient grafting however had remained opaque, until recently. In the last few years, minimally-invasive approaches to renal transplantation have been described. These techniques have shown promise; Oberholzer et al. [11] demonstrated a striking reduction in wound infections in morbidly obese patients undergoing robotic ReTx versus a standard open ReTx (0% vs. 28.6%, P ¼ 0.004, respectively). Similarly, Modi et al. [12] observed a significant reduction in blood loss and analgesic requirements in patients undergoing minimally invasive ReTx. We also noted similar reductions in analgesic use, blood loss and complications in patients undergoing robot-assisted ReTx (compared to open ReTx; unpublished data). Recognizing these benefits and building on their experience with robotic kidney transplantation with regional hypothermia [16], Gordon and Abaza et al. [15] recently described a completely intracorporeal robot-assisted approach to ReATx. The indication for the procedure was a large ureteral defect secondary to trauma. The authors could safely and timely complete the procedure without needing to convert to an open setting, utilizing a five-port approach. While for patients with a benign lesion requiring ReATx, this approach might offer excellent outcomes; in the more complex and/or neoplastic cases the applicability of this approach might be limited. For example, in patients with multiple graft renal vessels, bench surgery would be mandatory and a completely intracorporeal approach may not be possible. Similarly, in patients with UC or complex central renal lesions who are candidates for ReATx, a completely intracorporeal approach might not lead to optimal oncological control. We believe that the minimally invasive ReATx technique that we describe here (utilizing the GelPOINT device) might be ideally suited for management of such cases, as it would allow for ontable vascular “stump” formation in cases with multiple renal vessels and frozen section surgical margin analysis during resection of UCs/ complex renal masses. Another benefit of our approach might be improved operating room (OR) time efficiency, as while the bench surgeon performs ex vivo graft examination, excision and preparation,
Renal Autotransplantation the console surgeon could cool and prepare the iliac vessel bed for transplantation. Finally, our six-port approach will not limit us to perform the autotransplantation on the ipsilateral side (i.e., the same as of the nephrectomy). On the other hand, the drawbacks of our technique would be the need for a 5–6 cm incision and six-ports, compared to the five-port approach of Abaza et al. without any major incisions. Both these approaches, although promising, should be considered experimental at present as these have been tested in a limited number of patients with benign indications (n ¼ 2; only one reported [the other case was performed by Ahlawat recently and has not been reported, based on personal communication]) and have been described by teams facile with robotic technology. Thus, these findings might not be generalizable. Further, although these approaches might lead to reduced incisional site morbidity and hospital stay, additional expense of robotic instrumentation should be taken into consideration. Hence, in patients who are candidates for ReATx, the decision to undergo a minimally invasive approach (vs. an open approach) should be patient preference driven after a full disclosure regarding the advantages and disadvantages, cost, and experimental nature of the minimally invasive technique has been made. Nonetheless, these minimally invasive ReATx techniques, by decreasing procedural morbidity, may lead to increased acceptance of ReATx “overall” as a treatment option for large/complex upper urinary tract lesions, relative to the other available options.
CONCLUSIONS Minimally invasive approaches to renal transplantation (for allografting) have been recently described; reported benefits include reduced morbidity and complications. These minimally invasive principles and the associated benefits have been successfully translated to ReATx (in a non-oncological setting; Abaza et al.). Our alternative novel robot-assisted ReATx technique—utilizing the GelPOINT device—by permitting ex vivo graft examination and surgery might allow further broadening of the indications for minimally invasive ReATx, to include complex neoplastic renal/ureteral lesions. Both of the described techniques have their merits and demerits and should be utilized on an individual-to-individual basis, given that the patient is a candidate for ReATx. Lastly, these approaches have been described by teams facile with robotic technology, and hence, might not be generalizable. Future prospective studies should be aimed to evaluate the utility and reproducibility of these laparoscopic techniques.
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Minimally Invasive Renal Autotransplantation AKSHAY SOOD, MD,1* WOOJU JEONG, MD,1 RAJESH AHLAWAT, MD,2 FIRAS ABDOLLAH, MD,1 JESSE D. SAMMON, DO,1 MAHENDRA BHANDARI, MD,1 AND MANI MENON, MD1 1
Vattikuti Urology Institute, Henry Ford Health System, Detroit, Michigan Kidney and Urology Institute, Medanta—The Medicity, Gurgaon, India
2
Minimally invasive renal allotransplantation techniques have been recently described; reported benefits include reduced morbidity/complications. These benefits have been successfully adapted for minimally invasive renal autotransplantation, however, in a non-oncological setting. We, here, describe a novel alternative robot-assisted renal autotransplantation technique, utilizing GelPOINT, which by permitting ex vivo graft examination and surgery might allow further broadening of indications for minimally-invasive renal autotransplantation, to include complex oncological renal/ ureteral lesions. Future studies are needed to evaluate the utility of these techniques.
J. Surg. Oncol. 2015;112:717–722. © 2015 Wiley Periodicals, Inc.
KEY WORDS: minimally invasive; robotics; kidney; transplantation; autotransplantation
INTRODUCTION
LITERATURE REVIEW
Renal autotransplantation (ReATx), despite having been reported as an effective treatment modality for managing complex renal/ureteral lesions [1–4], has remained underutilized. Two reasons may be cited for it—first, the high morbidity associated with the procedure due to the requirement for two major interventions, open nephrectomy and open transplantation, in the same setting. The second reason may be the relative unfamiliarity of urologists with renal transplantation [5]. Minimally invasive approaches to renal transplantation (ReTx) have been recently described (in the setting of allotransplantation) [6–10]. These techniques, in particular the robot-assisted, have shown promise by being safe, reproducible and leading to lower complications and morbidity (when compared to open ReTx) even during the early experience [6–14]. We, therefore, hypothesized that by extending these benefits of minimally invasive ReTx to ReATx, coupled with the advantages of laparoscopic nephrectomy, the acceptance and indications for a “minimally invasive” ReATx might be expanded. In line with our hypothesis—recently, Gordon and Abaza et al. [15], building on their experience with robotic kidney transplantation with regional hypothermia [16], developed by our group [9,10], described a minimally invasive intracorporeal approach to ReATx in a patient with extensive ureteral loss (non-oncological setting). This case report represents the first account of a minimally invasive approach to ReATx. Against this background, in the current review, we explore the “potential” role of minimally invasive ReATx in the treatment of patients with neoplastic diseases of the upper urinary tract. Our aim was threefold: first, to provide a comprehensive review of the various indications for which ReATx has been utilized, with a focus on oncological indications. Next, to report on our technique of robotic kidney transplantation with regional hypothermia [10], discuss its applicability to ReATx, and contrast it with the robotic intracorporeal ReATx technique described by Gordon and Abaza et al. [15] highlighting important differences and merits of each approach. Lastly, we discuss the advantages-disadvantages and scope of these novel minimally invasive approaches in the context of ReATx.
A literature search of Medline (PubMed) and EMBASE was performed to retrieve all contemporary articles published on ReATx (January 1990 and December 2014). We used the search terms “[renal autotransplantation]” or “[kidney autotransplantation]” or “[kidney AND autotransplantation]” or “[renal AND autotransplantation].” The search was limited to the title and abstract fields while running the query and only papers written in English and concerning technical and/or clinical outcomes following renal autotransplantation were selected. The search was conducted on 28th of January 2015. Reference lists of the selected papers were scrutinized for additional relevant material but yielded no additional studies. Overall, 541 unique articles were retrieved and 127 were relevant (Fig. 1). Seventy-eight articles reported on utilization of ReATx for treatment of renal vascular lesions; these articles were not reviewed further as they discussed the role of ReATx in management of nononcological conditions. The remaining 49 articles reported on the role of ReATx in treatment of complex ureteral/renal lesions including proximal ureteral injury, ureteral stricture disease, intractable urolithiasis and neoplastic disease. Of the 49 articles, 21 described the use of ReATx in management of oncological disease (14 case reports; 7 case series). These were reviewed further and the reported outcomes were noted. Only one case report (out of the 127 articles; Abaza et al.), as previously mentioned, described the use ReATx in a minimally-invasive fashion, however, this was for a benign ureteral injury. Despite being a non-oncological report, due to the singular nature of the report it was reviewed and outcomes reported were noted.
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* Correspondence to: Akshay Sood, MD, Vattikuti Urology Institute, Henry Ford Health System, 2799 W. Grand Boulevard, Detroit, Michigan 48202. Fax: þ1.313.916.4352, E-mail: [email protected], [email protected] Received 31 March 2015; Accepted 30 April 2015 DOI 10.1002/jso.23939 Published online 20 May 2015 in Wiley Online Library (wileyonlinelibrary.com).
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Sood et al. kidney was also a common indication [4,23–26,]. In children, the major indication was synchronous Wilms tumor [27,28]. Lastly, a few groups reported on the use of ReATx as an effective treatment strategy for managing large ureteral defects secondary to encasement by abdominal malignancies including metastatic germ cell tumors and liposarcomas [29,30] and one case report demonstrated the use of ReATx for organ preservation against inadvertent radiation exposure (Fig. 2) [31]. All ReATx were performed via open surgery. Reported cold-ischemia times in these series varied from 118 to 162 min and operative times varied from 330 to 392 min. In all cases, a negative surgical margin could be achieved. Perioperative complications mainly included blood transfusions and dialysis. Length of stay varied from 7 to 19 days. These studies comprised level 4 evidence [32]. Tables I and II (part-b) summarize data from the only known study of minimally invasive ReATx (non-oncological setting) [15]; coldischemia time was 95.5 min, and the operation could be completed without needing to convert to open surgery and without any complications. The patient was discharged home on postoperative day 1. This study constitutes level 4 evidence [32].
Fig. 1. Flowchart depicting the literature search results and inclusion of relevant studies.
With respect to minimally invasive ReTx studies, outcome data from recent reviews on the subject were consulted [17–20]. Individuals studies cited in the reviews were consulted as and if the need arose.
ONCOLOGICAL INDICATIONS FOR RENAL AUTOTRANSPLANTATION Renal autotransplantation was first described by Hardy et al. in the year 1963 [1] for management of severe proximal ureteral injuries. Soon after, McLoughlin et al. [21] demonstrated its utility in management of complex renal lesions. Since then, ReATx has been utilized in the treatment of a variety of upper urinary tract pathologies. Here, we review the oncological conditions for which its use has been described. Tables I and II (part-a) summarize the key studies reporting the use of ReATx in oncological settings. The indications for ReATx included centrally located or multiple renal masses in the scenario of bilateral renal involvement or solitary functioning kidney [3,22]. Primary urothelial carcinoma (UC) of the renal pelvis or the ureter in the setting of bilateral neoplastic involvement or solitary functioning
ROBOTIC KIDNEY TRANSPLANTATION WITH REGIONAL HYPOTHERMIA AND ITS ADAPTATION FOR RENAL AUTOTRANSPLANTATION We have previously described our technique of robotic kidney transplantation with regional hypothermia in a detailed step-by-step manner (for allotransplantation), along with a surgical video [10]. Briefly, the patients were positioned and ports were placed in a manner typical for robot-assisted radical prostatectomy [33]. The operation started with skeletonization of the external-iliac vessels (EIVs), followed by dropping down of the bladder and ureteroneocystostomy site preparation. Subsequently, a transverse incision was made in the peritoneum, 2–3 cm distal to the cecum, and peritoneal flaps were raised to be utilized later for extraperitonealization of the allograft. This concluded the recipient bed preparation. Next, the iliac-fossa was cooled with ice-slush introduced through the GelPOINT. Then, the graft kidney wrapped in ice-gauze jacket was introduced. Graft vessels were anastomosed to the EIVs (venous anastomosis followed by arterial anastomosis) in an end-to-side fashion using 5-0 Gore-Tex suture. Following re-perfusion, the graft was extraperitonealized utilizing the
TABLE I. Summary of Selected Case Series/Reports Looking at Outcomes in Patients Undergoing Renal Autotransplantation (ReATx) Via Open or Minimally Invasive Techniques for an Oncological Indication* Study PART-A Desai et al. Kang et al.a Holm€ang et al.a Millar et al. Steffens et al.a Iida et al. B€olling et al. Bansal et al. Basiri et al. Cheng et al. Abraham et al. Nayak et al. PART-B Abaza et al.
Publication year
ReATx approach
1999 2004 2005 2005 2007 2009 2009 2013 2014 2014 2014 2014
Open Open Open Open Open Open Open Open Open Open Open Open
2014
Robotic
*
Nephrectomy approach
Study design
Open Open Open Open Open Laparoscopic Open Open Open Laparoscopic Laparoscopic Laparoscopic
Case Case Case Case Case Case Case Case Case Case Case Case
Robotic
series series series report series report report report report series series series
Case report
Cohort (n)
Level of Evidence
3 10 25 1 4 1 1 1 1 15 3 3
4 4 4 4 4 4 4 4 4 4 4 4
1
4
The case report by Abaza et al was a non-oncological report, however, due to the unique nature of the report it was included in the current review. For long-term outcomes following ReATx, please consult these studies.
a
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Renal Autotransplantation
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TABLE II. Summary of Perioperative Outcomes Reported in Selected Case Series/Reports Looking at Outcomes in Patients Undergoing Renal Autotransplantation (ReATx) Via Open or Minimally Invasive Techniques for an Oncological Indication* Study
Indication
PART-A Desai et al.
Bilateral Wilms tumor presenting synchronously Kang et al. Primary renal pelvis UC in the setting of bilateral disease Holm€ang et al.e Primary ureteral/renal pelvis UC in the setting of solitary kidney Millar et al. Bilateral Wilms tumor presenting synchronously Steffens et al.e Primary ureteral UC in the setting of solitary kidney Iida et al. Primary ureteral UC in the setting of bilateral disease B€olling et al. Renal transposition; to avoid exposure to highdose RT Bansal et al. Secondary encasement of the right ureter by liposarcoma Basiri et al. Secondary encasement of the left ureter by metastatic GCT Cheng et al. Primary ureteral UC þ/ in the setting of solitary kidney Abraham et al. Complex renal tumors þ/ in the setting of B/L renal tumors Nayak et al. Complex renal tumors þ/ in the setting of solitary kidney PART-B Abaza et al. Ureteral Injury (non-oncological indication) e
Operative Ischemia Timea (min) Timea,b (min)
Surgical Margins
EBLa (mL)
Complications
LOSa (day) NA NA
NA
164
Negative in all 3
NA
NA
NA
Negative
NA
Re-exploration in 2; BT in 1 patient None
NA
NA
Negative
NA
None
NA
NA
NA, C
Negative
NA
None
NA
NA
162, C/W
Negative in all 4
NA
BT in 1 patient
NA
NA
NA
Negative
NA
None
NA
NA
NA
NA
NA
None
NA
NA
NA
Negative
NA
None
NA
NA
NA
Negative
NA
None
NA
c
392
NA
Negative in 12
NA
360
118, C
Negative in all 3
d
330
NA; C
425
95.5; C
418
DGF in 1 patient; BT in 3 patients DGF in 1 patient
NA 7–12
Negative in all 3
267
Urinoma in 1 patient
8–19
—
50
None
1
BL, estimated blood loss; LOS, length of stay; UC, urothelial carcinoma; NA, not available; DGF, delayed graft function; BT, blood transfusion; RT, radiotherapy; GCT, germ cell tumor. a Operative time, Ischemia time, EBL and LOS are reported as mean values or range (as available) for the case series. b Ischemia: W, Warm, C, Cold. c In the report by Cheng et al, only 12 patients (out of the 15) underwent ReATx as 3 patients with evidence of advanced disease were treated by nephrectomy alone. d Nayak et al. reported the ischemia times only for the ex vivo excision part (mean 39 min) and did not comment on the ischemia times for autotransplantation. e For long-term outcomes following ReATx, please consult these studies. * The case report by Abaza et al was a non-oncological report, however, due to the unique nature of the report it was included in the current review.
peritoneal flaps prepared previously. Stented ureteroneocystostomy was performed following the modified Lich-Gregoir technique. Here, we describe a novel operative template—a modification of our aforementioned allotransplantation technique—which could be adapted for performing ReATx in a minimally-invasive manner:
Fig. 2. Oncological indications for renal autotransplantation reported in literature. Journal of Surgical Oncology
(1) GelPOINT: The GelPOINT device (Applied Medical, Rancho Santa Margarita, CA) is a hand-access platform. It consists of two parts—a GelSeal cap and an access port. It was initially devised for single-site surgery but we utilize it to deliver ice-slush (for regional pelvic hypothermia) and the graft kidney into the pelvic cavity [10,33,34]. For the proposed robot-assisted ReATx procedure, a 12-mm assistant port or a 12-mm camera port would be placed into the GelSeal cap ahead of time, for nephrectomy and autotransplantation steps, respectively (see below for details). (2) Patient position and port placement: (a) For the nephrectomy, the patient would be placed in supine position with legs in Allen stirrups. A gel roll will be placed behind the kidney and the bed would be rotated away from the operative side to elevate the flank, as is typical for nephroureterectomy [35]. Figure 3a shows the proposed patient position, port placement and robot docking for a left donor nephrectomy. The GelPOINT would be inserted through a 5–6 cm vertical paraumbilical incision. Four-ports would be utilized; a 12-mm camera port would be placed just lateral and above the umbilicus, two 8-mm robotic ports would be placed along the left mid-clavicular line just below the tip of the 12th rib and at the level of the umbilicus, respectively, and a 12-mm assistant port
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Fig. 3. Proposed patient position and port placement (utilizing six-ports) for robot-assisted renal autotransplantation, a customization of our technique of robotic kidney transplantation with regional hypothermia. would be placed through the GelPOINT. (b) For the autotransplantation, the bed would be made supine and the gel roll removed making the patient horizontal. Next, the patient would be transferred to steep Trendelenburg while remaining in lithotomy. The robot would be re-docked between the legs (Figure 3b). This would bring the patient into optimal position for a right iliac fossa transplant with minimal re-positioning of the patient (only the bed and the robot would need to be moved). Ports utilized for camera and left robotic arm during nephrectomy would be sutured closed (see ports labeled 1 and 2 in Figure 3a). Two additional ports would be inserted as shown (see ports labeled 5 and 6 in Figure 3b); a 12-mm assistant port in the right iliac fossa and an 8-mm robotic port along the right mid-clavicular line at the level of the umbilicus. The 12-mm camera port would be moved to the GelPOINT. (3) Nephrectomy: The nephrectomy would proceed transperitoneally in a manner typical for donor nephrectomy. Briefly, the colon would be reflected. The left renal vessels would be dissected carefully to the level of the aorta to maximize length. The lumbar, adrenal, and gonadal veins would be clipped and divided. Then, the kidney would be mobilized and the ureter would be dissected to obtain an optimal length. Next, the kidney would be brought out through the GelPOINT [9]. Similar steps would be applicable for a right sided donor kidney as well. (4) Bench surgery and iliac vessel bed preparation: The graft kidney, following extraction, would be bathed in ice-slush, flushed with heparinized saline and defatted. In case of multiple renal vessels, a “stump” preparation would be comfortably achieved to optimize vascular anastomosis during autotransplant. If the autografting is being performed for the treatment of a complex renal mass, meticulous enucleation would also be possible as has been described for open ReATx [3,22]. In case of a UC of the renal pelvis or ureter, careful inspection, examination and surgical resection may be done as needed [4,23–26]. Further, while these steps are being performed ex vivo, the console surgeon would prepare the iliac vessel bed for subsequent autotransplantation. Next, ice-slush would be instilled though the GelPOINT to cool the iliac fossa and then the graft, wrapped in ice-gauze jacket, would be introduced for anastomosis. (5) Autotransplantation: This part of the operation would essentially proceed in a manner similar to minimally invasive renal allotransplantation, as previously described by us [10]. In brief, the steps would consist of end to side venous and arterial anastomoses followed by graft extraperitonealization. Lastly, Journal of Surgical Oncology
stented ureterovesical anastomosis would be performed (utilizing modified Lich-Gregoir technique).
DISCUSSION The benefits of minimally invasive surgery are well established and have led to its widespread adoption [36–40]—including in the field of transplantation [17,41]—such that today laparoscopic approach represents the standard-of-care for living donor nephrectomy. The role of minimally invasive surgery for recipient grafting however had remained opaque, until recently. In the last few years, minimally-invasive approaches to renal transplantation have been described. These techniques have shown promise; Oberholzer et al. [11] demonstrated a striking reduction in wound infections in morbidly obese patients undergoing robotic ReTx versus a standard open ReTx (0% vs. 28.6%, P ¼ 0.004, respectively). Similarly, Modi et al. [12] observed a significant reduction in blood loss and analgesic requirements in patients undergoing minimally invasive ReTx. We also noted similar reductions in analgesic use, blood loss and complications in patients undergoing robot-assisted ReTx (compared to open ReTx; unpublished data). Recognizing these benefits and building on their experience with robotic kidney transplantation with regional hypothermia [16], Gordon and Abaza et al. [15] recently described a completely intracorporeal robot-assisted approach to ReATx. The indication for the procedure was a large ureteral defect secondary to trauma. The authors could safely and timely complete the procedure without needing to convert to an open setting, utilizing a five-port approach. While for patients with a benign lesion requiring ReATx, this approach might offer excellent outcomes; in the more complex and/or neoplastic cases the applicability of this approach might be limited. For example, in patients with multiple graft renal vessels, bench surgery would be mandatory and a completely intracorporeal approach may not be possible. Similarly, in patients with UC or complex central renal lesions who are candidates for ReATx, a completely intracorporeal approach might not lead to optimal oncological control. We believe that the minimally invasive ReATx technique that we describe here (utilizing the GelPOINT device) might be ideally suited for management of such cases, as it would allow for ontable vascular “stump” formation in cases with multiple renal vessels and frozen section surgical margin analysis during resection of UCs/ complex renal masses. Another benefit of our approach might be improved operating room (OR) time efficiency, as while the bench surgeon performs ex vivo graft examination, excision and preparation,
Renal Autotransplantation the console surgeon could cool and prepare the iliac vessel bed for transplantation. Finally, our six-port approach will not limit us to perform the autotransplantation on the ipsilateral side (i.e., the same as of the nephrectomy). On the other hand, the drawbacks of our technique would be the need for a 5–6 cm incision and six-ports, compared to the five-port approach of Abaza et al. without any major incisions. Both these approaches, although promising, should be considered experimental at present as these have been tested in a limited number of patients with benign indications (n ¼ 2; only one reported [the other case was performed by Ahlawat recently and has not been reported, based on personal communication]) and have been described by teams facile with robotic technology. Thus, these findings might not be generalizable. Further, although these approaches might lead to reduced incisional site morbidity and hospital stay, additional expense of robotic instrumentation should be taken into consideration. Hence, in patients who are candidates for ReATx, the decision to undergo a minimally invasive approach (vs. an open approach) should be patient preference driven after a full disclosure regarding the advantages and disadvantages, cost, and experimental nature of the minimally invasive technique has been made. Nonetheless, these minimally invasive ReATx techniques, by decreasing procedural morbidity, may lead to increased acceptance of ReATx “overall” as a treatment option for large/complex upper urinary tract lesions, relative to the other available options.
CONCLUSIONS Minimally invasive approaches to renal transplantation (for allografting) have been recently described; reported benefits include reduced morbidity and complications. These minimally invasive principles and the associated benefits have been successfully translated to ReATx (in a non-oncological setting; Abaza et al.). Our alternative novel robot-assisted ReATx technique—utilizing the GelPOINT device—by permitting ex vivo graft examination and surgery might allow further broadening of the indications for minimally invasive ReATx, to include complex neoplastic renal/ureteral lesions. Both of the described techniques have their merits and demerits and should be utilized on an individual-to-individual basis, given that the patient is a candidate for ReATx. Lastly, these approaches have been described by teams facile with robotic technology, and hence, might not be generalizable. Future prospective studies should be aimed to evaluate the utility and reproducibility of these laparoscopic techniques.
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