Robotic-assisted dual kidney transplantation.

AIM: The aim of this study was to report the feasibility of robotic-assisted dual kidney transplantation (DKT) in a marginal donor.
MATERIALS AND METHODS: The case was a 53-year-old male, who with IgA nephropathy underwent a robotic-assisted robotic DKT.
RESULTS: The total operating time was 265 min, total console time was 215 min, and anastomotic time was 39 min for both the kidneys, and blood loss was 220 ml. The total drain output was 150 ml on the 1st day. The drain was removed after 48 h and Foley catheter was removed after 5 days. Nadir creatinine was 1.1 mg/dl and time to nadir creatinine was 7 days. The patient received one unit of blood transfusion. Total postoperative hospital stay was 7 days and bilateral ureteric stents were removed after 14 days. At the end of 3 months, creatinine was 1.0 mg% and epidermal growth factor receptor was 82 ml/min/1.73 m2.
CONCLUSION: Robotic DKT offers solutions to the challenges faced in open DKT.

INTRODUCTION

Expanded criteria donors (ECDs) are defined as older than 60 or over 50 years with complicating comorbidities including hypertension, diabetes, cerebrovascular accident as a cause of death, or a terminal serum creatinine of 2.0 mg/dl or higher.[12] In order to increase the utilization of deceased donor organs, the United Network of Organ Sharing has implemented new policies to use organs from ECDs.[12] The first adult dual kidney transplantation (DKT) was performed in 1996 by Johnson et al.[3] The premise of transplanting both donor kidneys into a recipient is to increase the functional nephron mass.[3] The DKT involves longer surgical time and is prone to surgical complications due to the complexity of procedure. The original technique included bilateral Gibson incision and transplanting one kidney to each side.[3] Later on, surgical modifications such as unilateral placement of the kidney and en bloc transplantation had been described.[4567] In the past few years, robotic kidney transplantation is gaining popularity across the world.[89] The first case of robotic-assisted DKT was reported by Frongia et al.[10] We report our initial case of robotic DKT and, to our knowledge, this is the second case reported so far.

MATERIALS AND METHODS

A 53-year-old patient with IgA nephropathy was on hemodialysis with a history of recent laparotomy for splenic trauma. The deceased donor was a 63-year-old diabetic patient who had a cerebrovascular accident and subsequent brainstem death. He was a known diabetic for 5 years with a creatinine of 1.5 mg% at the time of retrieval. The ports are placed in a similar fashion to robotic radical prostatectomy with cephalad displacement of the ports by 4 cm. The procedure started with incision of peritoneum at the level of umbilicus to iliac fossa on both sides. This enables to fashion a flap of peritoneum along with bladder [Figures 1a and b]. Subsequently, iliac vessels were dissected and prepared for anastomosis. A Pfannenstiel incision was made and a GelPOINT® (Applied Medical Resources Corp, Rancho Santa Margarita, CA, USA) was inserted through it [Figure 1c]. The graft was wrapped in a gauze jacket and placed through this incision [Figure 1d]. A marking stich was placed on the upper pole on the gauze jacket to orient the kidney while performing anastomosis. Initially, the left donor kidney was placed in the right iliac fossa [Figure 2a]. Arterial and venous anastomoses were performed using 6.0 Gortex suture (Gore-Tex CV-6; W.L. Gore and Associates Inc., Flagstaff, AZ, USA). A custom-made punch was utilized for arteriotomy. Once the clamps were released, the right donor kidney was placed inside and anastomosis was performed to the left external iliac vessels [Figure 2b]. The peritoneum was approximated to the anterior abdominal wall [Figure 2c] and an extraperitoneal drain was placed [Figure 2d]. The vascularity of both kidneys was confirmed by a Doppler scan using a robotic drop-down probe (Hitachi Aloka Medical America Inc., CT, USA). After the release of pneumoperitoneum, the position of the graft was verified by inserting the camera through the GelPOINT®. Vesicoureteric anastomosis was completed through the Pfannenstiel incision using a 4.0 Polygalactin suture (Ethicon Inc., Cincinnati, OH, USA) and a 5-Fr 15-cm double J stent was placed. The detrusor layer was closed using 6” V-Loc™ 3-0 CV23 (Covidien Inc., New Haven, CT, USA). The Pfannenstiel incision and port sites were closed subsequently [Figure 2d].

Figure 1

(a) Development of extraperitoneal space, (b) the extraperitoneal flap, (c) the GelPOINT® in situ, (d) graft in position with ice slush

Figure 2

(a) Right allograft being anastomosed with left external iliac vessels, (b) left-sided graft being placed and anastomosed, (c) peritoneal flap after closure, (d) postoperative appearance

RESULTS

The total operating time was 265 min, total console time was 215 min, and anastomotic time was 39 min for both the kidneys, and blood loss was 220 ml. The total drain output was 150 ml on the first day. The drain was removed after 48 h and Foley catheter was removed after 5 days. Nadir creatinine was 1.1 mg/dl and time to nadir creatinine was 7 days. The patient received one unit of blood transfusion. Total postoperative hospital stay was 7 days and bilateral ureteric stents were removed after 14 days. At the end of 3 months, creatinine was 1.0 mg% and epidermal growth factor receptor was 82 ml/min/1.73 m2.

DISCUSSION

DKT recipients have comparable outcomes in terms of function, graft loss, and survival versus those in elderly patients with younger grafts.[1112] DKT carries a potentially higher risk of surgical complications because of the longer surgical procedure and multiple anastomosis involved.[111213] Conventional technique described is that of bilateral Gibson incision and transplanting one kidney to each side. The drawbacks of this method are higher tissue dissection, a longer operative time, and increased chance of wound complications.[3] A midline extraperitoneal approach was described to minimize dissection, operative time, and wound dissection by Haider et al. in 2007.[4] Unilateral placement of both kidneys was described by Mason and Hefty in 1998.[5] The right kidney was placed superiorly, with renal artery anastomosed into the common iliac artery and renal vein into the inferior vena cava. With this method, both ureters were spatulated and joined to each other. This technique reduced trauma from the surgical procedure and operative time. Moreover, the contralateral side remained untouched for possible future transplant.[67] The drawbacks of this technique include higher incidence of lymphoceles, high risk of hemorrhage, and increased risk of single graft loss.[1415]

The first ever robotic DKT was performed by Frongia et al. in 2014 which resulted in favorable outcome at 24 months.[10] They have utilized an epigastric incision to introduce the graft and reported 400 min operating time. In our case, we have employed a Pfannenstiel incision and a GelPOINT® to introduce the graft. The GelPOINT® allows in maintaining the pneumoperitoneum while introducing the graft. The Pfannenstiel incision enabled us to perform open technique to perform ureterovesical anastomosis. The ureterovesical anastomosis can be performed comfortably through the graft insertion incision as it is directly placed over the bladder. This reduces the operating time, duration of pneumoperitoneum, and Trendelenburg position.

CONCLUSION

Robotic DKT offers solutions to the challenges faced in open DKT.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.