Robot-Assisted Kidney Transplantation

In this protocol, we have suggested step-by-step procedures for robot-assisted kidney transplantation without flipping. It is more natural to perform vascular anastomosis with a allograft in the peritoneal pouch and the renal vessels in the proper position. This technique can be applied to other solid organ transplants, such as the liver and pancreas.

We hope to expand the utility of minimally invasive surgical approaches using the robotic system in the field of transplantation. Robotic-assisted kidney transplantation can be studied only after getting some education about the robotic system. It is better to get help from an experienced surgeon.

Before starting the procedure, prepare the robotic arms with the surgical instruments to perform intra-abdominal dissection. Place monopolar curved scissors in arm two, fenestrated bipolar forceps in arm three, and ProGrasp Forceps in arm four. Initiate the operative procedure by making an incision in the peritoneum along the right paracolic gutter to make a pouch for the kidney allograft.

After the incision, dissect the right internal iliac vessels along their entire length and encircle each vessel with a vessel loop. For ureteroneocystostomy, dissect the bladder in the right corner and separate the bladder from the peritoneal incision. Open a cap of the gel port and insert slushed ice through the six-centimeter Pfannenstiel incision, followed by the kidney allograft wrapped in the ice-packed gauze.

Then, place the allograft on the peritoneal pouch lateral to the iliac vessels on the right side. With the control of ProGrasp Forceps in robotic arm four, clamp the right external iliac vein by bulldog clamps. Then use Potts Scissors in a linear or oblique fashion to make a venotomy considering the diameter of the renal vein.

Use a 6/0 ePTFE suture to anastomose to renal vein allograft to the right external iliac vein in an end-to-side continuous manner. Make a knot at the caudal end of veins, before intraluminally and continuously suturing the posterior wall of the external iliac vein and renal vein. Afterward, suture the anterior wall of the iliac vein in a continuous manner.

And flush the lumen with the heparinized normal saline. Then, use a Silastic tube through the gel port to knot the anastomosis. Clamp the allograft renal vein with a bulldog clamp.

Then, de-clamp the right external iliac vein, followed by clamping of the right external iliac artery with bulldog clamps. Make an arteriotomy in the right external iliac artery by creating a round hole with Potts Scissors without an arterial punch. And proceed to anastomose the allograft renal artery to the right external iliac artery, as demonstrated.

If there is no evident bleeding at the anastomosis site, de-clamp the allograft renal vein and artery. And remove the ice-packed gauze. Then, use an irrigation tube to apply warm normal saline to the allograft through the gel port.

To perform ureteroneocystostomy according to the Lich-Gregoir technique, put the distal end of the double J ureteral stent into the urinary bladder. Starting at the posterior corner of the incised bladder mucosa, perform a continuous suture using a 6/0 polydioxanone suture. And make a suture at the anterior corner.

From the anterior corner to the posterior corner, perform a continuous suture. And use a 4/0 Polyglactin multi-filament absorbable suture to close the detrusor muscle anti-reflux tunnel in an interrupted manner. With the help of polymer locking clips, intermittently cover the kidney allograft with the incised peritoneum along the right paracolic gutter.

Robot-assisted kidney transplantation, or RAKT, was performed on 21 recipients, including three obese patients. One patient suffered primary non-function due to renal vein thrombosis. The graftectomy was performed at three days after the kidney transplant and no delayed graft function was observed in the patient.

A small number of patients had to undergo angioplasty of renal artery or renal vein on the back table before kidney transplant. The mean hospitalization days after the kidney transplant was 7.4. The mean estimated glomerular filtration rate, or eGFR, one month after RAKT was 74.9 milliliters per minute per meter squared.

Unlike previous reports, we positioned the kidney allograft on the lateral side of the iliac vessels before vascular anastomosis, similar to the conventional open technique. This technique can help to prevent unexpected torsion or kinking of renal vessels. Following positioning the kidney allograft on the lateral side, venous and arterial anastomoses can be performed at the proper angle and length.

It is necessary to compare the long-term clinical outcomes, including kidney allograft survival and biopsy-proven acute rejection between robotic-assisted and open kidney transplantation, especially in high-immunologic risk patients.