Robotic Kidney Transplantation Safe, Feasible

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Barriers to donation may explain why living donor kidney transplantation has been declining.
Barriers to donation may explain why living donor kidney transplantation has been declining.

Robot-assisted kidney transplantation (RAKT) is associated with low complication rates, rapid recovery, and excellent graft function when performed by surgeons with robotic and kidney transplantation experience, according to a European study.

In what they believe is the largest reported multicenter prospective study of RAKT, Alberto Breda, MD, of Autonoma University of Barcelona in Spain, and colleagues evaluated perioperative and early postoperative surgical outcomes among 120 patients (75 men and 45 women) from 8 European centers who underwent the procedure, of whom 118 received a kidney from a living donor. Patients had a median age at surgery of 43 years, median dialysis duration of 365 days, and a minimum follow-up period of 1 year.

The median operative and vascular suture time was 250 and 38 minutes, respectively, Dr Breda's group reported in European Urology (2018;73:273-281). The median estimated blood loss was 150 mL. The median total ischemia time was 89.5 minutes. No major intraoperative complications occurred, but 2 patients required conversion to an open procedure. The median postoperative estimated glomerular filtration rate on postoperative day 1, 3, 7, and 30 was 21.2, 45.0, 52.6, and 58.0 mL/min/1.73 m2, respectively, according to the investigators. Five patients (4.2%) experienced delayed graft function. Dr Breda and his colleagues reported 1 case of wound infection, 3 cases of ileus, and 4 cases of bleeding.

“Surgical data show that RAKT is safe, feasible, and reproducible when performed by surgeons with experience in both robotic and KT surgery,” the authors concluded. “Use of a robotic technique also has low complication rates in selected cases and yields excellent graft function.”

Dr Breda and his colleagues noted that all of the surgical teams involved in the study have thorough expertise in robotic-assisted surgery and open KT. All surgeons had rehearsed the robotic technique on animal models before using it on patients, with proctoring by a more experienced RAKT surgeon during training and when performing the first case(s) in their own center, they explained.

In general, the authors observed, the typical advantages of robotic surgery relate to the use of articulated instruments, a 3D view, superb magnification, and good surgeon ergonomics.

Patients with end-stage renal disease generally are immunocompromised and fragile, the authors explained. Consequently, they may benefit significantly from KT performed using a minimally invasive approach.

The investigators said one of the limitations of their study is possible bias in the selection process. The 8 centers that participated in the study are high-volume centers. “Despite this, a limited number of recipients were included in the study. This can be explained not only by the inclusion and exclusion criteria but also by the cost limitations of the procedure … and patient preference.”

Other limitations included the lack of a control group of patients who underwent open KT from a living donor and the fact that not all centers enrolled patients at the same time, the authors stated.

In an editorial accompanying the study, Akshay Sood, MD, and Mani Menon, MD, of the Vattikuti Urology Institute at Henry Ford Hospital in Detroit, commented: “The authors are congratulated for successfully undertaking this study and demonstrating that robotic kidney transplantation can be safely adopted by surgeons of varying robotic experience via a structured preclinical and clinical mentorship program.”

They pointed out, however, that it is important to study the patients who had complications in detail. “We understand that it may not be feasible to report institute-specific analysis for the purposes of publication, but an internal root-cause analysis must be performed.”

The importance of such an analysis was highlighted by Pranjal Modi, MD, and colleagues in their study of laparoscopic KT in 72 patients, the editorialists noted. The analysis, published in Transplantation (2013;95:100-105), revealed that grafts left intraperitoneally were associated with a high risk of delay graft torsion (5.9%), leading to routine extraperitoneal grafts, with a subsequent graft torsion rate of 0%.

References

Breda A, Territo A, Gausa L, et al. Robot-assisted kidney transplantation: The European Experience. Eur Urol. 2018;73:273-281.

Sood A, Menon M. The Gift of Life: New Opportunities from Renal Transplantation. Eur Urol. 2018;73:282-283.

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