109 Rajesh Ahlawat,1 Sohrab Arora,2 & Mani Menon2 1 Medanta Kidney and Urology Institute, Gurgaon, India 2 Vattikuti Urology Institute, Detroit, MI, USA The prevalence of chronic kidney disease (CKD) is rising along with increasing life expectancy. There has been a 30% increase in the prevalence of CKD in the United States in the last decade [1]. Similar data from developing countries such as India are scarce, but even conservative estimates reveal an age‐adjusted incidence of 229 persons per million [2]. The numbers of endstage renal disease (ESRD) cases, and with that the number of patients waiting for a transplant, are increasing. Among the available methods of renal replacement therapy, kidney transplantation is associated with the best quality of life, best survival rates, and thus remains the treatment of choice for late stages of CKD [3]. Open surgery has been the gold standard for kidney transplant from the beginning and Carrel’s technique of vascular anastomosis has been in use for over a hundred years. Although the introduction of minimally invasive techniques has completely transformed other surgical specialties, kidney recipient surgery has seen little change since its inception. In recent years, the indications for minimally invasive surgery have expanded with the increasing use of surgical robots, and the field of kidney transplantation has not remained untouched. Evidence‐based development of robotic kidney transplantation (RKT) in the last few years has opened a new frontier in recipient surgery. Reduction in perioperative complications remains a priority in frail, immunocompromised kidney recipients, who thus remain the ideal candidates for minimally invasive surgery. Obese transplant recipients in particular are a surgical challenge. Obesity leads to longer waiting times for transplant, higher risks of surgical site infections, and increased complications. In severe cases, such patients have been denied the opportunity for transplant in some centers. Early results of RKT have shown shorter convalescence times, less perioperative morbidity, and better cosmesis. In addition to these obvious benefits, RKT has been shown to be associated with decreased surgical site infections, and lower incidence of lymphoceles and vascular complications. This chapter reviews the development, technique, and current status of RKT. The use of a surgical robot in kidney transplant was first described in a case of deceased donor transplant by Hoznek et al., from France, in 2001 [4]. The robot was used for vascular anastomosis and ureteroneocystostomy after making an open incision. Although the ability of the da Vinci® surgical robot (Intuitive Surgical, Sunnyvale, CA, USA) to handle fine sutures, such as 6‐0 polydioxanone and 5‐0 polypropylene, was demonstrated in this case, as was the ability of robotic instruments in dissection, lack of haptic feedback required the bedside assistant to follow the suture. Little enthusiasm was shown for this procedure in the next decade, until Antonio Rosales from Spain reported the first laparoscopic transplant in 2009. In this surgery, the kidney was introduced into the abdomen through a Pfannenstiel incision and the anastomosis was performed laparoscopically in 53 minutes. The cold ischemia time was 182 minutes [5]. Soon, Modi et al. from India described the procedure in four patients, in a deceased donor program [6]. They used the left kidney from the deceased donor for the laparoscopic procedure. A Carrel’s patch was used to carry out a wide arterial anastomosis. The mean anastomosis time for laparoscopic procedure was reported as 65 minutes, which is not significantly longer than that for open surgery. More importantly, they reported equivalent renal function outcomes at 1 year, six months, and 1 year following surgery, for both open and laparoscopic recipients. The same group reported a series of 72 more cases in the following years [7]. The rewarming time (time taken after the graft is placed in the recipient until the graft is revascularized) was significantly longer in the laparoscopic group compared to the open group (60.3 vs. 30.3 minutes). Even though the estimated glomerular filtration rate (eGFR) at 7 and 30 days after transplant was lower in the laparoscopic group, the graft survival was excellent at six months. There was no difference in graft survival at 3, 6, 12, and 18 months postoperatively. Interestingly, since the graft was free‐floating in the peritoneal cavity, there were two cases of torsion of graft leading to graft loss. The technique was subsequently modified to fix the graft using a peritoneal flap. Even as this study proved the feasibility of minimally invasive transplant, the operation remained extremely challenging. As a result, it did not see widespread adoption. The first RKT was reported from the University of Illinois at Chicago by Giulianotti et al. in 2010 [8]. A 7 cm periumbilical incision, and a hand‐assist device was used for this procedure, in a morbidly obese patient with a body mass index (BMI) of 41 kg/m2. Total operative time was 223 minutes and warm ischemia time was 50 minutes. The blood loss was less than 50 ml. Soon afterwards, the first case from Europe was reported by Boggi et al. A Pfannenstiel incision was used in this case, through which the ureterovesical anastomosis was performed in an open fashion. The operative time was 154 minutes and warm ischemia time 51 minutes [9]. The Chicago group subsequently reported RKT case series of 28 obese recipients (BMI 42.6 ± 7.8 kg/m2). In the later part of the series, robot‐assisted clamping was used instead of the hand‐assist device used in the initial cases [10]. For the preparation of transplant bed and vascular anastomosis, a right flank position was used. For the ureteroneocystostomy, the patient has to be repositioned and the robot had to be redocked. The graft was left intraperitoneal and for a renal biopsy, when required, laparoscopy had to be used. According to this study, although there was no difference in cold or warm ischemia times between open kidney transplant (OKT) and RKT groups (RKT: 2.8 and 47.7 minutes; controls: 2.0 and 49.2 minutes; P ≥ 0.48), the creatinine at discharge was higher in the RKT group than in the OKT group (2.0 mg/dl vs. 1.4 mg/dl; P = 0.04). The higher creatinine at discharge may be explained by poor allograft perfusion due to pneumoperitoneum [11]. The renal function at six months postoperatively was similar (serum creatinine 1.5 ± 0.4 mg/dl vs.1.6 ± 0.6 mg/dl; P = 0.47). Surgical site infections were found to be significantly less in the RKT group than in the OKT group (0/28 (0%) in RKT vs. 8/28 (28.6%) in OKT; P = 0.004). These early experiences with minimally invasive transplant were pioneering, but critical analysis showed a slower return of graft function postoperatively. This was probably a result of increased anastomosis time, with the graft at body temperature, and lack of methods for intracorporeal cooling of the graft during anastomosis, which may cause slower return of graft function postoperatively. This effect could have been compounded by longer anastomosis times during the learning curve. The experimental studies by Wickham showed that the ideal temperature for maximal reno‐protection during nonvascularized phase was around 20 °C [12]. Regional hypothermia using ice slush introduced into the pelvis was evaluated in >300 robotic prostatectomy patients at Vattikuti Urological Institute (VUI) in Detroit, USA. The ice slush was introduced through a GelPOINT® device (Applied Medical Inc., Rancho Santa Margarita, CA, USA). It was demonstrated that an average pelvic temperature of 15.8 °C could be achieved within 15 minutes of icing, with no change in core body temperature [13]. This finding led to the concept of regional hypothermia for RKT, which was then put into practice by collaboration between the VUI team and the Medanta team from India. The new procedure was developed according to IDEAL (idea, development, exploration, assessment, long‐term follow‐up) guidelines [14]. Phase 0 IDEAL studies were conducted in two fresh cadavers. This phase led to standardization of patient positioning, port placement, docking of the robot, and the choice of instruments and sutures. In this phase, the use of a GelPOINT device to introduce the kidney and ice slush into the pelvis was also established. The standardized pelvic docking also eliminated the need to reposition the robot for urethrovesical anastomosis, as was needed in previously reported efforts at robotic transplantation [15]. Phase 0 was followed by phase 1 study, during which seven patients underwent RKT with regional hypothermia by the combined VUI and Medanta team in India in January 2013. In this phase a mean kidney surface temperature of 22.5 °C could be achieved using regional hypothermia, with no patient developing systemic hypothermia. The mean arterial, venous, and ureterovesical anastomosis times were 14.4, 14, and 23.4 minutes, respectively. The mean rewarming time was 51.4 minutes, while the mean warm ischemia time was 2 minutes. Mean serum creatinine on postoperative days 1 and 7 were 2.2 mg/dl and 1.2 mg/dl, respectively. One patient required re‐exploration due to increased drain output, but no specific bleeding point could be detected on exploration. Next phase of the development of RKT consisted of 43 patients. Mean operative and console times were 214.1 ± 39.8 (156–293) and 135.4 ± 31.2 (94–201) minutes, respectively. Mean warm ischemia, rewarming, and arterial and venous anastomosis times were 2.4 ± 1.1 (1.5–6.0), 46.6 ± 9.3 (27–66), 12.0 ± 2.6 (7–17), and 13.4 ± 3.4 (8–21) minutes, respectively. The anastomosis times decreased in this phase compared to the phase 1 study. Mean intraoperative renal surface temperature was 20.3 ± 2.9 °C (14.5–27.8) and the mean blood loss was 151.7 ± 103.5 (50–450) ml. The average incision length was 6.1 ± 0.5 (5.4–7.1) cm. Mean serum creatinine at discharge was 1.3 ± 0.6 (0.8–3.1) mg/dl. No patient experienced delayed graft function, vascular or urine leaks, wound complications, or wound infections. There was no peri‐graft collection on computed tomography in any patient at three months. No further complications were recorded at six months follow‐up. One patient died at 1.5 months due to acute congestive heart failure secondary to a cardiac condition [11]. Presently, the evolution of RKT is in the IDEAL phase 3, and is being compared with OKT. Standard pretransplant medical evaluation includes assessment of the recipient for infectious and immunological risks, and malignancy. Modifiable risk factors for morbidity such as coronary artery disease, hypertension, and diabetes mellitus are then optimized. Patient education for relevant lifestyle modifications such as smoking cessation, risks of immunosuppression, and medication compliance is important. Surgical risk assessment is then done for RKT which includes evaluation for peripheral vascular disease and obesity. Obesity is an independent risk factor for surgical site infections [16]. The indications and contraindications for RKT are listed in Boxes 109.1 and 109.2. The GelPOINT device is placed through a 5–6 cm vertical midline incision curving around the umbilicus. The incision could be predominantly extended above the umbilicus in smaller patients. The GelSeal® cap is prepared with a 12 mm camera port and a 5 mm assistant port placed through it as shown in Figure 109.1. This 5 mm port will be the assistant’s port. Optimal positioning of these ports into the cap is important, as placing these two ports too close to each other may lead to restriction of the assistant’s movement by the camera arm, and may hinder proper suctioning. Figure 109.1 Preparation of GelSeal cap, with a 12 mm camera port (C) and a 5 mm assistant port (A). Source: Menon M, Sood A, Bhandari M et al. Robotic kidney transplantation with regional hypothermia: a step‐by‐step description of the Vattikuti Urology Institute‐Medanta Technique (IDEA phase 2a). Eur Urol 2014;65(5):991–1000. Reproduced with permission of Elsevier.
Robotic Kidney Transplantation
Introduction
A brief history of robotic kidney transplantation
History of laparoscopic kidney transplantation
Early development of robotic kidney transplant
Development of the Vattikuti Urology Institute RKT technique with regional hypothermia
Preoperative preparation of patients for RKT
Step‐by‐step technique (Video 109.1)
Step 1: Preparation of GelPOINT device
Step 2: Port placement
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