Robotic Kidney Transplantation

Fig. 20.1

Incision at 1 month after robotic kidney transplantation

Unpublished results from the IDEAL stage 2b/3 prospective nonrandomized trial comparing RKT with OKT reveal lower postoperative pain scores after RKT, and a corresponding decrease in analgesic requirements.

Blood Loss

Minimally invasive surgery has been associated with decreased blood loss as compared to open surgery. This is both due to shorter length of incision, pneumoperitoneum reducing venous blood loss, and decreased vascular complications. Our experience showed an average 151.7 ml blood loss in RKT as compared to 296.8 ml in OKT (P ≤ 0.001). Methods to decrease vascular complications and blood loss during surgery are discussed later in the chapter.

Renal Function and Outcome Measures

Results of open kidney transplant have improved with improvements in perioperative care and better immunosuppression. Our recent comparison of 125 RKT and 543 OKT in eligible patients performed over 3 years showed no difference in fall of serum creatinine postoperatively, at discharge, as well as at 3 and 6 months after surgery. Delayed graft function was seen in 1.6% (2/125) patients in RKT group, compared to 3.13% (17/543) in OKT group (p > 0.05). The data comparing RKT vs. OKT has found no significant difference in graft survival as well as patient survival.

Preventing Blood Loss and Vascular Complications During RKT

Blood loss and vascular complications are important causes of morbidity and graft failure following kidney transplantation. 3-D magnified vision and dexterity of instruments provide an opportunity for a foolproof vascular anastomosis using a robot. Vascular complications have been reported in 2.6% patients after open surgery. Prevention of vascular complications during RKT starts with a careful preoperative assessment. Vascular anatomy of the donor is equally important. In general, all parameters being equal, left donor nephrectomy is preferred over a right due to its longer renal vein. The vascular anatomy is reassessed on the bench to look for atheromas, intimal flaps, or accessory renal arteries which may have been missed. Any reconstruction to minimize the recipient arterial anastomoses is also done at this stage. Any small hilar vessels or vein tributaries are ligated. A careful bench preparation is an essential investment to prevent bleeding on removal of clamps after anastomoses in the recipient surgery robotically. We recommend following a defined sequence at certain steps to prevent bleeding and vascular complications after RKT.

1.

The graft kidney , after harvest, is prepared by enclosing it in a jacket made of surgical gauze and enclosing within it with some ice slush. A hole in the jacket allows vessels to be brought out medially. A long silk suture is left at the upper pole for correct orientation of the graft while placing it intraperitoneally. The jacket helps maintain intracorporeal cooling as well as enables holding and moving the graft atraumatically. It also helps retract hilar fat, presenting the vessels for a hassle-free anastomosis.
2.

Ice slush is placed over bladder flap in pelvis before placing the prepared graft and starting vascular anastomoses. Local hypothermia using ice slush brings down pelvic temperature to approximately 20 °C, without any significant change in core body temperature [5]. This prevents any ischemic injury to the graft, since surrounding temperatures faced by kidney during RKT within peritoneal cavity are higher (at 32 °C), compared to significantly lower OR temperature (22 °C) which surrounds the kidney during OKT. Pneumoperitoneum, with constant hot gas flows, may otherwise bring up the graft temperature rapidly.
3.

The dissected length of the external iliac vein is isolated with bulldog clamps proximally and distally. Renal vein is anastomosed to the clamped external iliac vein in an end to side fashion. The graft renal vein is then clamped and the continuity of the iliac vein is restored by removing the proximal clamp, then observing for any leaks before releasing the distal clamp. A small gauze pack or a surgicel piece may be packed at the site before proceeding to arterial anastomosis. The bulldog clamps removed from the external iliac vein are now applied on either end of the dissected external iliac artery.
4.

A small arteriotomy incision is made using robotic Snapfit® or a Pott’s scissor and a desired rounded opening is then created using 3.6 mm vascular punch. The graft artery is anastomosed end to side with the external iliac artery. A small bulldog clamp is now placed on the renal artery. The distal bulldog clamp is removed from the external iliac artery to check anastomotic integrity. Any small bleeding points in arterial anastomosis may be managed at this point. The graft is then perfused removing the clamps from the renal vein and renal artery, while the proximal clamp on the external iliac is still in place. The proximal clamp is now slowly released while watching for any brisk bleed or abnormal blood filling of field. This last clamp may be applied back on the external iliac artery proximally to reduce the bleed and to manage it with packs, diathermy or additional sutures, while the graft is still being perfused from the distal end with back perfusion. The iliac artery may also be clamped both proximally and distally for control of significant bleeding, especially a major hilar arterial repair.
5.

The graft jacket is now released cutting it from its hilar opening proximally and distally to bare the graft and allowing its visual inspection for color and turgidity. Small bleeding perforators are managed with bipolar diathermy at this point.
6.

The revascularized graft is flipped from the pelvic hollow to the right iliac fossa, turning it at 180° around the external iliacs. The proximal and distal peritoneal flaps prepared during the bed preparation are brought together over the graft. The external iliac vessels and both anastomoses may again be inspected before proceeding to ureterovesicostomy.
7.

An on table vascular Doppler of the graft is obtained to confirm its vascularity before shifting the patient out to the transplant ICU.

Hematoma

Hematoma in an RKT is heralded by falling hemoglobin or increased drain output. This hematoma is intraperitoneal, in contrast to the hematoma in an open transplant which is retroperitoneal. The intraperitoneal location theoretically limits the pressure effect on the transplanted kidney and thus causes minimal effect on renal blood flow or ureteral compression. On the other hand, it requires a high index of suspicion. One case of re-exploration has been reported due to increased drain output during IDEAL stage 1 of development of RKT (Clavien-Dindo grade 3b). The patient had a recent coronary angioplasty and was on antiplatelet agents (aspirin and clopidogrel). On exploration, the vascular anastomoses were intact , and only generalized bleeding was noted. This case was managed by topical hemostatic agents and blood transfusion.

Transplant Renal Artery Stenosis (TRAS)

TRAS occurs most commonly 3 months to 2 years after renal transplant . This complication may present as an incidental finding on Doppler ultrasound, refractory hypertension, or graft dysfunction [6].

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