Review Article
Robotic renal transplantation: Current status Akshay Sood1, Prasun Ghosh2, Mani Menon1, Wooju Jeong1, Mahendra Bhandari1, Rajesh Ahlawat2 Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA, 2Medanta Institute of Kidney and Urology, Medanta-The Medicity, Gurgaon, India
1
Address for Correspondence: Dr. Akshay Sood, Vattikuti Urology Institute, Henry Ford Health System, 2799 W. Grand Boulevard , Detroit, Michigan, USA, 48202. E-mail: [email protected]
Abstract
Key words: Kidney transplantation, minimally invasive, robot assisted, robotic
INTRODUCTION: Kidney transplantation (KT) has traditionally been performed by open renal transplantation, but recently, a few groups including our own have described a minimally invasive approach to KT. We aim to discuss the current status of robotic kidney transplantation (RKT) and describe our technique of RKT with regional hypothermia. MATERIAL AND METHODS: We used the search terms “minimally invasive” OR “robotic” OR “robot assisted” AND “kidney transplantation.” Papers written in English and concerning technical and/or clinical outcomes following minimally invasive kidney transplantation were selected. Three hundred and eighteen unique articles were retrieved and nine were relevant. Comparative outcomes data following RKT with regional hypothermia versus open KT (OKT) from our own group were also included. FINDINGS: Nine papers, so far, have evaluated the role of robotic approach in KT and have conclusively established the feasibility, safety, and reproducibility of RKT, although these studies have been performed by experienced robotic surgeons/teams. The contemporary published series note that rejection rates were similar in RKT and OKT patients. Mean serum creatinine at 6 months in RKT and OKT patients was equivalent, across the three series. Most of the studies also note a dramatic reduction in the wound-related complication rates. CONCLUSION: RKT appears to be a safe surgical alternative to the standard open approach of KT. RKT is associated with reduced postoperative pain, analgesic requirement, and better cosmesis. RKT, although in its infancy, appears to be associated with lower complication rates. Access this article online Quick Response Code:
Website: www.journalofmas.com
DOI: 10.4103/0972-9941.147683
INTRODUCTION End-stage renal disease (ESRD), as the name suggests, represents the terminal stage in chronic kidney disease and is defined by a glomerular filtration rate (GFR) of less than 15 mL/min/1.73 m2.[1] ESRD is associated with high morbidity and mortality.[1] Chronic kidney disease and ESRD globally result in approximately 735,000 deaths annually. [2] The prevalence of ESRD varies in the developed versus the developing world; the situation being much graver in the developing nations. True estimates are seldom available in the developing nations, such as India, due to lack/prematurity of nationwide kidney disease registries. [3] Conservative estimates, however, state that the annual incidence of ESRD in India is approximately 229 persons per million with more than 100,000 new patients entering the renal replacement programs annually.[4] Different modalities exist for renal replacement therapy, such as hemodialysis, peritoneal dialysis, etc. however, kidney transplantation (KT) remains the treatment of choice for ESRD as it leads to longer survival and superior quality of life.[5] KT has traditionally been performed by open surgery, but recently, a few groups including our own have described a minimally invasive approach to KT. A pure laparoscopic approach has been described by Rosales et al.[6] and Modi et al.,[7-9] whereas more recently, a laparoscopic approach with robotic-assistance has been described by Giulianotti et al.[10,11] Boggi et al.,[12] our group,[13-16] and Tsai et al.[17] There is a strong rationale for utilizing minimally invasive surgery (MIS) in the ESRD patients. MIS (with robotic-assistance) leads to smaller incision, lesser surgical infections, technical complications, blood loss and postoperative pain, shorter hospital stay
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Sood, et al.: Robotic kidney transplantation
and convalescence period, and better cosmesis.[18,19] These outcomes are important in the general surgical population but attain even greater significance in the fragile ESRD patients, where preventing these adverse perioperative outcomes not only leads to better convalescence in the short-term but also leads to improved graft and patient survival in the long term.[20-22] Accordingly, in this review, we aim to discuss the current status of robotic kidney transplantation (RKT) and describe our technique of RKT with regional hypothermia.
EVIDENCE SYNTHESIS A literature search of Medline (PubMed) and EMBASE was performed on 21st September, 2014 to retrieve all published articles on robotic KT (between January 1990 and June 2014). We used the search terms “minimally invasive” OR “robotic” OR “robot assisted,” AND “kidney transplantation.” Papers written in English and concerning technical and/or clinical outcomes following minimally invasive kidney transplantation (MIKT) were selected. Three hundred and eighteen unique articles were retrieved and nine were relevant [Figure 1]. Reference lists of the selected papers were scrutinized for additional relevant articles but yielded no additional studies. Comparative outcomes data following RKT with regional hypothermia versus open KT (OKT) from our own group were also included (manuscript under review and published as an abstract). Table 1 summarizes the studies looking at outcomes following RKT in patients with end-ESRD. All studies, except one,[23] represent contemporary experience and were published between 2010 and 2014. Four studies were case reports and/ or technical papers,[10,12,13,23] three studies reported detailed outcomes following RKT,[11,15,17] and the remaining two studies dealt with the subject of patient safety and surgeon learning curve monitoring during adoption of a new technique, in the setting of RKT.[14,16] All contemporary RKT studies were from four groups/teams (see legend in Table 1].
SURGICAL TECHNIQUE We have previously described our surgical technique of RKT with regional hypothermia in detail in a step-by-step manner (with diagrammatic illustrations and a surgical video),[15] and have also compared it with other approaches of RKT in a tabulated fashion.[24] Here, we recapitulate the major steps of the procedure briefly. VIDEO: http://www.europeanurology.com/surgery-inmotion-video/1127/robotic-kidney-transplantation-withregional-hypothermia-a-step-by-step-description-of-thevattikuti-urology-institute-medanta-technique-idealphase-2a After induction of general anesthesia, the patient is placed in supine position and ports are placed as described before (in a manner similar to robotic radical prostatectomy). After the ports and the GelPOINT (hand-assist device) are placed, the patient is moved to Trendelenburg position. The operation starts with identification and
Figure 1: Flowchart representing the literature search results and inclusion of relevant studies
Table 1: Summary of the series looking at robotic kidney transplantation outcomes in patients with end-stage renal disease Study Hoznek et al. Giulianotti et al.b Boggi et al.c Oberholzer et al.b Menon et al.d Menon et al.d Abaza et al.d Sood et al.d Tsai et al.e
Publication year
Study period
MIKT approach
2002 2010 2011 2013 2013 2013 2013 2014 2014
2001 2009 2010 2009-2011 2012-2013 2012-2013 — 2012-2013 2012-2013
RKTa RKT RKT RKT RKT RKT RKT RKT RKT
Study design
Data collection
Cohort (n)
Level of evidence
Case report Case report Case report Case control Surgical safetyf Cohort studyf Technique paper Surgical safetyf Cohort study
Prospective Prospective Prospective Prospective Prospective Prospective Prospective Prospective Prospective
1 1 1 56 7 25 — 41 10
4 4 4 3 3 3 — 3 3
a In this study, the authors utilized robotic-assistance while performing the vascular dissection and anastomoses, but the access was established in a manner similar to open KT, Currently, only four groups/teams are actively performing RKT who have reported their experience, bTeam from Chicago, cTeam from Italy, d Team from Detroit-India, eTeam from China, fThese studies followed the IDEAL model of safe surgical innovation as proposed by the Balliol Collaboration at Oxford, UK, RKT: Robotic kidney transplantation, MIKT: Minimally invasive kidney transplantation
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skeletonization of the external-iliac vessels followed by bladder dropdown. Once optimal lengths of externaliliac vein and external-iliac artery are exposed and minor tributaries controlled, the bladder is filled with normal saline and is prepared from ureteroneocystostomy. Next, the pelvic bed is cooled with ice-slush and the graft kidney is introduced (both introduced via the GelPOINT). Following graft introduction, the graft renal vein and artery are anastomosed to the external-iliac vessels in an end-to-side continuous manner utilizing Gore-Tex suture. After completion of vascular anastomosis, the graft kidney is extraperitonealized using a peritoneal flap. After this, ureteroneocystostomy is performed robotically using the modified Lich-Gregoir technique. The patient is closed in a standard manner and an on-table ultrasound i obtained routinely to check for graft vascular flow.
RESULTS AND DISCUSSION Nine studies [Table 1], so far, have evaluated the role of robotic approach in KT and have conclusively established the feasibility, safety, and reproducibility of RKT, although these studies have been performed by surgeons/teams facile with robotic technology. Hoznek et al.[23] were the first to utilize robotic assistance during performance of a KT operation; in the single patient reported by Hoznek et al. the access to iliac fossa was established via open surgery and robotic assistance was only utilized to perform the dissection and the anastomoses. The first case report of a “truly” robotic KT operation, hence, came from Giulianotti et al.[10] from Chicago in 2009 (7 years after the study by Hoznek et al). The operation took 223 min to be completed with a warm ischemia time of 50 min. Boggi et al.[12] soon thereafter reported the first RKT case from Europe. Both these studies, although robotic, did employ hand assistance during at least one phase of the RKT operation. Boggi et al. performed ureterovesical anastomosis by open surgery via the Pfannenstiel incision, made earlier to introduce the kidney, whereas Giulianotti et al utilized hand assistance to manipulate the graft intracorporeally. On the other hand, the RKT technique described by Menon et al.[15] was
completely hand-assistance free. Furthermore, their technique also utilized intracorporeal graft cooling to maintain optimal graft temperature during vascular anastomoses, which the other studies did not utilize. Lastly, while all these three approaches have been transabdominal (though the final position of the graft is extraperitoneal in the approaches described by Giulianotti et al and Menon et al), the recent study of 10 patients reported by Tsai et al. represents the initial experience in robot-assisted retroperitoneal KT. Out of the nine studies, only three studies have reported detailed outcomes after RKT. Table 2 summarizes the perioperative outcomes from these studies. The study of RKT by Oberholzer et al.[11] and Tsai et al.[17] were both performed under warm ischemia. The mean warm ischemia times were 48 min and 67 min, respectively. On the other hand, the RKT study by Menon et al.[15] consistently employed the use of regional hypothermia (using ice-slush) during performance of vascular anastomosis. We routinely achieved graft surface temperatures of 18-20°C and our mean re-warming time (with ice-slush) was 47 min and warm ischemia time was 2.4 min. Accordingly, Oberholzer et al. noted a slower return of the graft function in patients undergoing RKT which we did not observe possibly due to the renoprotective effect of hypothermia[25] (Figure 2B; unpublished data). We and Modi et al. (in their study of laparoscopic KT) both noted a significant reduction in analgesic requirements in patients undergoing MIKT (other RKT studies did not evaluate this endpoint). On average, OKT patients required 3.2 mg of the analgesic medication (morphine equivalent), whereas laparoscopic KT patients required 1.4 mg in the study by Modi et al. (P = 0.005). In our study, patients undergoing RKT used on average lesser analgesic (unpublished data; 21.1 mg PCA-morphine vs. 29.5 mg; P = 0.003) while also reported lower pain scores (Figure 2A; P < 0.05). This might be related, at least in part, to the significant reduction is size of the incision. Modi et al. reported an average incision size of 5.5 cm in patients undergoing laparoscopic KT compared with an average incision size of 17.8 cm in OKT patients (P < 0.001). Similarly, in our study, RKT patients had an average incision length of 6.1 cm versus 15.6 cm in OKT patients (unpublished data; P < 0.001) and Tsai et al. reported an incision size of 7.7 cm in their cohort
Table 2: Summary of perioperative outcomes in the series looking at robotic kidney transplantation outcomes in patients with end-stage renal diseasea Study Oberholzer et al. Menon et al. Tsai et al.
RKT Donor (living: Operative time Warm ischemia time Estimated blood loss Conversion LOS (days) cohort (n) cadaveric) (min) [OKT vs. RKT] (min) [OKT vs. RKT] (mL) [OKT vs. RKT] to open (%) [OKT vs. RKT] 28b 25 10
26:2 25:0 6:4
— NA vs. 214 NA vs. 257
49.2 vs. 47.7 NA vs. 2.4c NA vs. 67.4c
121 vs. 110 NA vs. 151 —
0 0 0
8.1 vs. 8.2 NA vs. 8.4 NA vs. 13.6d
a
For detailed outcomes please refer to the individual studies, bIn this study, the total numbers of patients were 56 (all obese), cThe warm ischemia time was the time taken in harvesting the kidney in donor in this study—the re-warming time (with ice-slush hypothermia) was 47.7 min in this study, dBy protocol, all patients stayed in the hospital for 14 days, RKT: Robotic kidney transplantation; OKT: Open renal transplantation; NA: Not available
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Sood, et al.: Robotic kidney transplantation
of retroperitoneal RKT patients. In none of the studies there arose the need to convert the RKT to an open setting.
also reported a dramatic reduction in wound complications in patients undergoing RKT (3.6% vs. 28.6%; P = 0.02). We also noted 0% wound complications in our RKT cohort; there is substantial evidence to support that reduction in wound complications, especially, wound infections leads to improved graft and patient survival in the long term.[21] Furthermore, from a societal point of view, Oberholzer et al. pointed out an important issue that by decreasing complication rates (such as wound complications and DVT/embolism), RKT might lead to attenuation of disparities that currently exist with regard to transplant wait times and access to transplantation in morbidly obese patients, solely due to the fear of having higher postoperative complications in these patients.[26] There was no graft loss in patients undergoing RKT in all three studies evaluating RKT. One patient died of acute congestive heart failure (1.5 months post-KT), in our study, due to preexisting cardiac pathology.
Table 3 summarizes the functional outcomes and complication rates in patients undergoing RKT and OKT from the three series. Mean serum creatinine at 6 months in RKT and OKT patients was equivalent across the three series (Tsai et al did not report on outcomes in OKT patients and our data is presented in Figure 2B [unpublished data]). One patient undergoing RKT had delayed graft function (DGF) both in the studies by Oberholzer et al. (n=1; 3.6%) and Tsai et al. (n=1; 10%), whereas none of the patients in our cohort had DGF. In all three studies, there were no vascular complications (eg, vascular stenosis, vascular leak, or torsion). Rejection rates were similar in RKT and OKT patients as reported by Oberholzer et al. [Table 3]. Oberholzer et al.
Figure 2: Trends (a) postoperative pain; (b) postoperative creatinine fall
Table 3: Summary of functional outcomes in the series looking at robotic kidney transplantation outcomes in patients with endstage renal diseasea Study
Tsai et al. Oberholzer et al. Menon et al.
RKT Discharge Creatinine DGF (%) Complications (%) Re-explored (%) Rejection Graft Patient cohort (n) creatinine 6-mo episodes (%) loss (%) death (%) Vascular Wound 10 28b 25
1.3 2 1.3
1.2 1.5 1.1
1 (10) 1 (4) 0
0 0 0
— 1 (4) 0
0 0 2 (8)
2 (20) 3 (11) 1 (4)
0 0 0
0 0 1 (4)
a
For detailed outcomes please refer to the individual studies, bIn this study, the total numbers of patients were 56 (all obese), cThis is at a median follow up of 6.9 months
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In conclusion, RKT appears to be a safe surgical alternative to the standard open approach of KT. RKT is associated with reduced postoperative pain, analgesic requirement, and better cosmesis. RKT, although in its infancy, appears to be associated with lower complication rates when compared with both OKTs, and has graft function outcomes that are equivalent to OKT.
REFERENCES 1. 2.
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Thomas R, Kanso A, Sedor JR. Chronic kidney disease and its complications. Primary Care 2008;35:329-44. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2095-128. Rajapurkar MM, John GT, Kirpalani AL, Abraham G, Agarwal SK, Almeida AF, et al. What do we know about chronic kidney disease in India: First report of the Indian CKD registry. BMC Nephrol 2012;13:10. Singh AK, Farag YM, Mittal BV, Subramanian KK, Reddy SR, Acharya VN, et al. Epidemiology and risk factors of chronic kidney disease in India — Results from the SEEK (Screening and Early Evaluation of Kidney Disease) study. BMC Nephrol 2013;14:114. U.S. Renal Data System, USRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD. 2013. Rosales A, Salvador JT, Urdaneta G, Patiño D, Montlleó M, Esquena S, et al. Laparoscopic kidney transplantation. Eur Urol 2010;57:164-7. Modi P, Rizvi J, Pal B, Bharadwaj R, Trivedi P, Trivedi A et al. Laparoscopic kidney transplantation: An initial experience. Am J Transpl 2011;11:1320-4. Modi P, Thyagaraj K, Rizvi SJ, Vyas J, Padhi S, Shah K, et al. Laparoscopic en bloc kidney transplantation. Indian J Urol 2012;28:362-5. Modi P, Pal B, Modi J, Singla S, Patel C, Patel R, et al. Retroperitoneoscopic living-donor nephrectomy and laparoscopic kidney transplantation: Experience of initial 72 cases. Transplantation 2013;95:100-5. Giulianotti P, Gorodner V, Sbrana F, Tzvetanov I, Jeon H, Bianco F, et al. Robotic transabdominal kidney transplantation in a morbidly obese patient. Am J Transpl 2010;10:1478-82. Oberholzer J, Giulianotti P, Danielson KK, Spaggiari M, Bejarano-Pineda L, Bianco F, et al. Minimally invasive robotic kidney transplantation for obese patients previously denied access to transplantation. Am J Transpl 2013;13:721-8. Boggi U, Vistoli F, Signori S, D’Imporzano S, Amorese G, Consani G, et al. Robotic renal transplantation: First European case. Transpl Int 2011;24:213-8. Abaza R, Ghani KR, Sood A, Ahlawat R, Kumar RK, Jeong W, et al. Robotic
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25. 26.
kidney transplantation with intraoperative regional hypothermia. BJU Int 2014;113:679-81. Menon M, Abaza R, Sood A, Ahlawat R, Ghani KR, Jeong W, et al. Robotic Kidney Transplantation with Regional Hypothermia: Evolution of a Novel Procedure Utilizing the IDEAL Guidelines (IDEAL Phase 0 and 1). Eur Urol 2014;65:1001-9. Menon M, Sood A, Bhandari M, Kher V, Ghosh P, Abaza R, et al. Robotic Kidney Transplantation with Regional Hypothermia: A Step-by-step Description of the Vattikuti Urology Institute-Medanta Technique (IDEAL Phase 2a). Eur Urol 2014;65:991-1000. Sood A, Ghani KR, Ahlawat R, Modi P, Abaza R, Jeong W, et al. Application of the Statistical Process Control Method for Prospective Patient Safety Monitoring During the Learning Phase: Robotic Kidney Transplantation with Regional Hypothermia (IDEAL Phase 2a-b). Eur Urol 2014;66:371-8. Tsai MK, Lee CY, Yang CY, Yeh CC, Hu RH, Lai HS. Robot-assisted renal transplantation in the retroperitoneum. Transpl Int 2014;27:452-7. Trinh QD, Sammon J, Sun M, Ravi P, Ghani KR, Bianchi M, et al. Perioperative outcomes of robot-assisted radical prostatectomy compared with open radical prostatectomy: Results from the nationwide inpatient sample. Eur Urol 2012;61:679-85. Sood A, Jeong W, Peabody JO, Hemal AK, Menon M. Robot-Assisted Radical Prostatectomy: Inching Toward Gold Standard. Urol Clin North Am 2014;41:473-84. Giral-Classe M, Hourmant M, Cantarovich D, Dantal J, Blancho G, Daguin P, et al. Delayed graft function of more than six days strongly decreases longterm survival of transplanted kidneys. Kidney Int 1998;54:972-8. Lynch RJ, Ranney DN, Shijie C, Lee DS, Samala N, Englesbe MJ. Obesity, surgical site infection, and outcome following renal transplantation. Ann Surg 2009;250:1014-20. Matas AJ, Gillingham KJ, Payne WD, Najarian JS. The impact of an acute rejection episode on long-term renal allograft survival (t1/2). Transplantation 1994;57:857-9. Hoznek A, Zaki SK, Samadi DB, Salomon L, Lobontiu A, Lang P, et al. Robotic assisted kidney transplantation: An initial experience. J Urol 2002;167:1604-6. Sood A, Ghosh P, Jeong W, Khanna S, Das J, Bhandari M, et al. Minimally invasive kidney transplantation: Perioperative considerations and key 6-month outcomes. Transplantation 2014 [In press]. Wickham JE. Regional renal hypothermia. Ann R Coll Surg Engl 1971;48:99-113. Segev DL, Simpkins CE, Thompson RE, Locke JE, Warren DS, Montgomery RA. Obesity impacts access to kidney transplantation. J Am Soc Nephrol 2008;19:349-55.
Cite this article as: Sood A, Ghosh P, Menon M, Jeong W, Bhandari M, Ahlawat R. Robotic renal transplantation: Current status. J Min Access Surg 2015;11:35-9. Date of submission: 24/10/2014, Date of acceptance: 28/11/2014 Source of Support: Nil, Conflict of Interest: None declared.
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Robotic renal transplantation: Current status Akshay Sood1, Prasun Ghosh2, Mani Menon1, Wooju Jeong1, Mahendra Bhandari1, Rajesh Ahlawat2 Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA, 2Medanta Institute of Kidney and Urology, Medanta-The Medicity, Gurgaon, India
1
Address for Correspondence: Dr. Akshay Sood, Vattikuti Urology Institute, Henry Ford Health System, 2799 W. Grand Boulevard , Detroit, Michigan, USA, 48202. E-mail: [email protected]
Abstract
Key words: Kidney transplantation, minimally invasive, robot assisted, robotic
INTRODUCTION: Kidney transplantation (KT) has traditionally been performed by open renal transplantation, but recently, a few groups including our own have described a minimally invasive approach to KT. We aim to discuss the current status of robotic kidney transplantation (RKT) and describe our technique of RKT with regional hypothermia. MATERIAL AND METHODS: We used the search terms “minimally invasive” OR “robotic” OR “robot assisted” AND “kidney transplantation.” Papers written in English and concerning technical and/or clinical outcomes following minimally invasive kidney transplantation were selected. Three hundred and eighteen unique articles were retrieved and nine were relevant. Comparative outcomes data following RKT with regional hypothermia versus open KT (OKT) from our own group were also included. FINDINGS: Nine papers, so far, have evaluated the role of robotic approach in KT and have conclusively established the feasibility, safety, and reproducibility of RKT, although these studies have been performed by experienced robotic surgeons/teams. The contemporary published series note that rejection rates were similar in RKT and OKT patients. Mean serum creatinine at 6 months in RKT and OKT patients was equivalent, across the three series. Most of the studies also note a dramatic reduction in the wound-related complication rates. CONCLUSION: RKT appears to be a safe surgical alternative to the standard open approach of KT. RKT is associated with reduced postoperative pain, analgesic requirement, and better cosmesis. RKT, although in its infancy, appears to be associated with lower complication rates. Access this article online Quick Response Code:
Website: www.journalofmas.com
DOI: 10.4103/0972-9941.147683
INTRODUCTION End-stage renal disease (ESRD), as the name suggests, represents the terminal stage in chronic kidney disease and is defined by a glomerular filtration rate (GFR) of less than 15 mL/min/1.73 m2.[1] ESRD is associated with high morbidity and mortality.[1] Chronic kidney disease and ESRD globally result in approximately 735,000 deaths annually. [2] The prevalence of ESRD varies in the developed versus the developing world; the situation being much graver in the developing nations. True estimates are seldom available in the developing nations, such as India, due to lack/prematurity of nationwide kidney disease registries. [3] Conservative estimates, however, state that the annual incidence of ESRD in India is approximately 229 persons per million with more than 100,000 new patients entering the renal replacement programs annually.[4] Different modalities exist for renal replacement therapy, such as hemodialysis, peritoneal dialysis, etc. however, kidney transplantation (KT) remains the treatment of choice for ESRD as it leads to longer survival and superior quality of life.[5] KT has traditionally been performed by open surgery, but recently, a few groups including our own have described a minimally invasive approach to KT. A pure laparoscopic approach has been described by Rosales et al.[6] and Modi et al.,[7-9] whereas more recently, a laparoscopic approach with robotic-assistance has been described by Giulianotti et al.[10,11] Boggi et al.,[12] our group,[13-16] and Tsai et al.[17] There is a strong rationale for utilizing minimally invasive surgery (MIS) in the ESRD patients. MIS (with robotic-assistance) leads to smaller incision, lesser surgical infections, technical complications, blood loss and postoperative pain, shorter hospital stay
Journal of Minimal Access Surgery | January-March 2015 | Volume 11 | Issue 1
35
Sood, et al.: Robotic kidney transplantation
and convalescence period, and better cosmesis.[18,19] These outcomes are important in the general surgical population but attain even greater significance in the fragile ESRD patients, where preventing these adverse perioperative outcomes not only leads to better convalescence in the short-term but also leads to improved graft and patient survival in the long term.[20-22] Accordingly, in this review, we aim to discuss the current status of robotic kidney transplantation (RKT) and describe our technique of RKT with regional hypothermia.
EVIDENCE SYNTHESIS A literature search of Medline (PubMed) and EMBASE was performed on 21st September, 2014 to retrieve all published articles on robotic KT (between January 1990 and June 2014). We used the search terms “minimally invasive” OR “robotic” OR “robot assisted,” AND “kidney transplantation.” Papers written in English and concerning technical and/or clinical outcomes following minimally invasive kidney transplantation (MIKT) were selected. Three hundred and eighteen unique articles were retrieved and nine were relevant [Figure 1]. Reference lists of the selected papers were scrutinized for additional relevant articles but yielded no additional studies. Comparative outcomes data following RKT with regional hypothermia versus open KT (OKT) from our own group were also included (manuscript under review and published as an abstract). Table 1 summarizes the studies looking at outcomes following RKT in patients with end-ESRD. All studies, except one,[23] represent contemporary experience and were published between 2010 and 2014. Four studies were case reports and/ or technical papers,[10,12,13,23] three studies reported detailed outcomes following RKT,[11,15,17] and the remaining two studies dealt with the subject of patient safety and surgeon learning curve monitoring during adoption of a new technique, in the setting of RKT.[14,16] All contemporary RKT studies were from four groups/teams (see legend in Table 1].
SURGICAL TECHNIQUE We have previously described our surgical technique of RKT with regional hypothermia in detail in a step-by-step manner (with diagrammatic illustrations and a surgical video),[15] and have also compared it with other approaches of RKT in a tabulated fashion.[24] Here, we recapitulate the major steps of the procedure briefly. VIDEO: http://www.europeanurology.com/surgery-inmotion-video/1127/robotic-kidney-transplantation-withregional-hypothermia-a-step-by-step-description-of-thevattikuti-urology-institute-medanta-technique-idealphase-2a After induction of general anesthesia, the patient is placed in supine position and ports are placed as described before (in a manner similar to robotic radical prostatectomy). After the ports and the GelPOINT (hand-assist device) are placed, the patient is moved to Trendelenburg position. The operation starts with identification and
Figure 1: Flowchart representing the literature search results and inclusion of relevant studies
Table 1: Summary of the series looking at robotic kidney transplantation outcomes in patients with end-stage renal disease Study Hoznek et al. Giulianotti et al.b Boggi et al.c Oberholzer et al.b Menon et al.d Menon et al.d Abaza et al.d Sood et al.d Tsai et al.e
Publication year
Study period
MIKT approach
2002 2010 2011 2013 2013 2013 2013 2014 2014
2001 2009 2010 2009-2011 2012-2013 2012-2013 — 2012-2013 2012-2013
RKTa RKT RKT RKT RKT RKT RKT RKT RKT
Study design
Data collection
Cohort (n)
Level of evidence
Case report Case report Case report Case control Surgical safetyf Cohort studyf Technique paper Surgical safetyf Cohort study
Prospective Prospective Prospective Prospective Prospective Prospective Prospective Prospective Prospective
1 1 1 56 7 25 — 41 10
4 4 4 3 3 3 — 3 3
a In this study, the authors utilized robotic-assistance while performing the vascular dissection and anastomoses, but the access was established in a manner similar to open KT, Currently, only four groups/teams are actively performing RKT who have reported their experience, bTeam from Chicago, cTeam from Italy, d Team from Detroit-India, eTeam from China, fThese studies followed the IDEAL model of safe surgical innovation as proposed by the Balliol Collaboration at Oxford, UK, RKT: Robotic kidney transplantation, MIKT: Minimally invasive kidney transplantation
36
Journal of Minimal Access Surgery | January-March 2015 | Volume 11 | Issue 1
Sood, et al.: Robotic kidney transplantation
skeletonization of the external-iliac vessels followed by bladder dropdown. Once optimal lengths of externaliliac vein and external-iliac artery are exposed and minor tributaries controlled, the bladder is filled with normal saline and is prepared from ureteroneocystostomy. Next, the pelvic bed is cooled with ice-slush and the graft kidney is introduced (both introduced via the GelPOINT). Following graft introduction, the graft renal vein and artery are anastomosed to the external-iliac vessels in an end-to-side continuous manner utilizing Gore-Tex suture. After completion of vascular anastomosis, the graft kidney is extraperitonealized using a peritoneal flap. After this, ureteroneocystostomy is performed robotically using the modified Lich-Gregoir technique. The patient is closed in a standard manner and an on-table ultrasound i obtained routinely to check for graft vascular flow.
RESULTS AND DISCUSSION Nine studies [Table 1], so far, have evaluated the role of robotic approach in KT and have conclusively established the feasibility, safety, and reproducibility of RKT, although these studies have been performed by surgeons/teams facile with robotic technology. Hoznek et al.[23] were the first to utilize robotic assistance during performance of a KT operation; in the single patient reported by Hoznek et al. the access to iliac fossa was established via open surgery and robotic assistance was only utilized to perform the dissection and the anastomoses. The first case report of a “truly” robotic KT operation, hence, came from Giulianotti et al.[10] from Chicago in 2009 (7 years after the study by Hoznek et al). The operation took 223 min to be completed with a warm ischemia time of 50 min. Boggi et al.[12] soon thereafter reported the first RKT case from Europe. Both these studies, although robotic, did employ hand assistance during at least one phase of the RKT operation. Boggi et al. performed ureterovesical anastomosis by open surgery via the Pfannenstiel incision, made earlier to introduce the kidney, whereas Giulianotti et al utilized hand assistance to manipulate the graft intracorporeally. On the other hand, the RKT technique described by Menon et al.[15] was
completely hand-assistance free. Furthermore, their technique also utilized intracorporeal graft cooling to maintain optimal graft temperature during vascular anastomoses, which the other studies did not utilize. Lastly, while all these three approaches have been transabdominal (though the final position of the graft is extraperitoneal in the approaches described by Giulianotti et al and Menon et al), the recent study of 10 patients reported by Tsai et al. represents the initial experience in robot-assisted retroperitoneal KT. Out of the nine studies, only three studies have reported detailed outcomes after RKT. Table 2 summarizes the perioperative outcomes from these studies. The study of RKT by Oberholzer et al.[11] and Tsai et al.[17] were both performed under warm ischemia. The mean warm ischemia times were 48 min and 67 min, respectively. On the other hand, the RKT study by Menon et al.[15] consistently employed the use of regional hypothermia (using ice-slush) during performance of vascular anastomosis. We routinely achieved graft surface temperatures of 18-20°C and our mean re-warming time (with ice-slush) was 47 min and warm ischemia time was 2.4 min. Accordingly, Oberholzer et al. noted a slower return of the graft function in patients undergoing RKT which we did not observe possibly due to the renoprotective effect of hypothermia[25] (Figure 2B; unpublished data). We and Modi et al. (in their study of laparoscopic KT) both noted a significant reduction in analgesic requirements in patients undergoing MIKT (other RKT studies did not evaluate this endpoint). On average, OKT patients required 3.2 mg of the analgesic medication (morphine equivalent), whereas laparoscopic KT patients required 1.4 mg in the study by Modi et al. (P = 0.005). In our study, patients undergoing RKT used on average lesser analgesic (unpublished data; 21.1 mg PCA-morphine vs. 29.5 mg; P = 0.003) while also reported lower pain scores (Figure 2A; P < 0.05). This might be related, at least in part, to the significant reduction is size of the incision. Modi et al. reported an average incision size of 5.5 cm in patients undergoing laparoscopic KT compared with an average incision size of 17.8 cm in OKT patients (P < 0.001). Similarly, in our study, RKT patients had an average incision length of 6.1 cm versus 15.6 cm in OKT patients (unpublished data; P < 0.001) and Tsai et al. reported an incision size of 7.7 cm in their cohort
Table 2: Summary of perioperative outcomes in the series looking at robotic kidney transplantation outcomes in patients with end-stage renal diseasea Study Oberholzer et al. Menon et al. Tsai et al.
RKT Donor (living: Operative time Warm ischemia time Estimated blood loss Conversion LOS (days) cohort (n) cadaveric) (min) [OKT vs. RKT] (min) [OKT vs. RKT] (mL) [OKT vs. RKT] to open (%) [OKT vs. RKT] 28b 25 10
26:2 25:0 6:4
— NA vs. 214 NA vs. 257
49.2 vs. 47.7 NA vs. 2.4c NA vs. 67.4c
121 vs. 110 NA vs. 151 —
0 0 0
8.1 vs. 8.2 NA vs. 8.4 NA vs. 13.6d
a
For detailed outcomes please refer to the individual studies, bIn this study, the total numbers of patients were 56 (all obese), cThe warm ischemia time was the time taken in harvesting the kidney in donor in this study—the re-warming time (with ice-slush hypothermia) was 47.7 min in this study, dBy protocol, all patients stayed in the hospital for 14 days, RKT: Robotic kidney transplantation; OKT: Open renal transplantation; NA: Not available
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Sood, et al.: Robotic kidney transplantation
of retroperitoneal RKT patients. In none of the studies there arose the need to convert the RKT to an open setting.
also reported a dramatic reduction in wound complications in patients undergoing RKT (3.6% vs. 28.6%; P = 0.02). We also noted 0% wound complications in our RKT cohort; there is substantial evidence to support that reduction in wound complications, especially, wound infections leads to improved graft and patient survival in the long term.[21] Furthermore, from a societal point of view, Oberholzer et al. pointed out an important issue that by decreasing complication rates (such as wound complications and DVT/embolism), RKT might lead to attenuation of disparities that currently exist with regard to transplant wait times and access to transplantation in morbidly obese patients, solely due to the fear of having higher postoperative complications in these patients.[26] There was no graft loss in patients undergoing RKT in all three studies evaluating RKT. One patient died of acute congestive heart failure (1.5 months post-KT), in our study, due to preexisting cardiac pathology.
Table 3 summarizes the functional outcomes and complication rates in patients undergoing RKT and OKT from the three series. Mean serum creatinine at 6 months in RKT and OKT patients was equivalent across the three series (Tsai et al did not report on outcomes in OKT patients and our data is presented in Figure 2B [unpublished data]). One patient undergoing RKT had delayed graft function (DGF) both in the studies by Oberholzer et al. (n=1; 3.6%) and Tsai et al. (n=1; 10%), whereas none of the patients in our cohort had DGF. In all three studies, there were no vascular complications (eg, vascular stenosis, vascular leak, or torsion). Rejection rates were similar in RKT and OKT patients as reported by Oberholzer et al. [Table 3]. Oberholzer et al.
Figure 2: Trends (a) postoperative pain; (b) postoperative creatinine fall
Table 3: Summary of functional outcomes in the series looking at robotic kidney transplantation outcomes in patients with endstage renal diseasea Study
Tsai et al. Oberholzer et al. Menon et al.
RKT Discharge Creatinine DGF (%) Complications (%) Re-explored (%) Rejection Graft Patient cohort (n) creatinine 6-mo episodes (%) loss (%) death (%) Vascular Wound 10 28b 25
1.3 2 1.3
1.2 1.5 1.1
1 (10) 1 (4) 0
0 0 0
— 1 (4) 0
0 0 2 (8)
2 (20) 3 (11) 1 (4)
0 0 0
0 0 1 (4)
a
For detailed outcomes please refer to the individual studies, bIn this study, the total numbers of patients were 56 (all obese), cThis is at a median follow up of 6.9 months
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Sood, et al.: Robotic kidney transplantation
In conclusion, RKT appears to be a safe surgical alternative to the standard open approach of KT. RKT is associated with reduced postoperative pain, analgesic requirement, and better cosmesis. RKT, although in its infancy, appears to be associated with lower complication rates when compared with both OKTs, and has graft function outcomes that are equivalent to OKT.
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Cite this article as: Sood A, Ghosh P, Menon M, Jeong W, Bhandari M, Ahlawat R. Robotic renal transplantation: Current status. J Min Access Surg 2015;11:35-9. Date of submission: 24/10/2014, Date of acceptance: 28/11/2014 Source of Support: Nil, Conflict of Interest: None declared.
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