Robotic-assisted kidney transplantation in obese recipients compared to non-obese recipients: the European experience.World J Urol. 2021;39:1287-1298. [PMID: 32562044 DOI: 10.1007/s00345-020-03309-6]

Robotic kidney transplantation

Kidney transplantation is the best treatment option for patients with end-stage renal disease owing to improved survival and quality of life compared with dialysis. The surgical approach to kidney transplantation has been somewhat stagnant in the past 50 years, with the open approach being the only available option. In this scenario, evidence of reduced surgery-related morbidity after the introduction of robotics into several surgical fields has induced surgeons to consider robot-assisted kidney transplantation (RAKT) as an alternative approach to these fragile and immunocompromised patients. Since 2014, when the RAKT technique was standardized thanks to the pioneering collaboration between the Vattikuti Urology Institute and the Medanta hospital (Vattikuti Urology Institute-Medanta), several centres worldwide implemented RAKT programmes, providing interesting results regarding the safety and feasibility of this procedure. However, RAKT is still considered an alternative procedure to be offered mainly in the living donor setting, owing to various possible drawbacks such as prolonged rewarming time, demanding learning curve, and difficulties in carrying out this procedure in challenging scenarios (such as patients with obesity, severe atherosclerosis of the iliac vessels, deceased donor setting, or paediatric recipients). Nevertheless, the refinement of robotic platforms through the implementation of novel technologies as well as the encouraging results from multicentre collaborations under the umbrella of the European Association of Urology Robotic Urology Section are currently expanding the boundaries of RAKT, making this surgical procedure a real alternative to the open approach.

[Robot-assisted kidney transplantation-what is new?]

BACKGROUND

The first robot-assisted kidney transplantation (RAKT) was conducted in 2010, and the first time in Germany in 2016. As more than 5 years have passed, current evidence, technological developments and the latest (German) experience are presented.

OBJECTIVES

The current evidence and experience of RAKT was investigated from an international and German perspective.

MATERIALS AND METHODS

In a systemic search, relevant publications were analyzed and compared with the experiences at a German urological transplant department.

RESULTS

From an international perspective, RAKT can now be considered a standard procedure at experienced departments, as more than 680 RAKT have been documented in Europe. The functional results are excellent with low complication rates and good mid- to long-term functional outcomes. Although RAKT was initially only performed with living organ donations, it has also been successfully conducted with cadaveric grafts. The surgical technique can be applied in challenging and complex situations, such as for arteriosclerotic recipient vessels or for kidney transplantations in children. Although RAKT is still not widely performed in Germany, the university hospital in Marburg, the third urological department in Germany, has successfully initiated a robotic transplant program.

CONCLUSIONS

Compared to open kidney transplantation, robot-assisted kidney transplantation enables at least noninferior results. It further appears to translate the well-documented advantages of minimally invasive surgery to kidney transplantation. However, its spread throughout Germany is only slowly increasing, possibly because only a handful of urological departments still perform kidney transplantations.

Does obesity really affect renal transplantation outcomes?

INTRODUCTION

Kidney transplantation is the treatment of choice for patients with stage 5 chronic kidney disease (CKD). About 60% of CKD patients are overweight or obese at the time of kidney transplantation, and post-transplant obesity occurs in 50% of patients, with a weight gain of 10% in the first year and high risk of cardiovascular mortality. Obesity is associated with an increased risk of delayed graft function (DGF), acute rejection, surgical complications, graft loss and mortality. The aim of this study is to assess the clinical evolution of obese and overweight patients that have received a kidney transplant, based on short- and long-term complications associated with a higher BMI.

MATERIAL AND METHODS

A descriptive, observational, cross-sectional study was conducted with 104 kidney or pancreas-kidney transplant patients between March 2017 and December 2020, with a follow-up until April 2021. For comparative analysis, patients were grouped according to BMI.

RESULTS

Mean age was of 56.65 years, 60.6% male and 39.4 % female. Overweight patients experienced prolonged surgeries, more surgical wound dehiscence, delayed graft function, hernias, proteinuria and more indications for renal biopsies. Additionally, obese patients displayed more DGF, indications for renal biopsies, proteinuria, development of diabetes mellitus, atrial fibrillation and needed prolonged hospital stays.

CONCLUSIONS

Despite a high prevalence of comorbidity in the overweight and/or obese population, we found no reduction in patient and/or graft survival. However, longer follow-up is needed.

Effect of Recipient Body Mass Index on Kidney Transplantation Outcomes: A Systematic Review and Meta-analysis by the Transplant Committee from the French Association of Urology

CONTEXT

The impact of recipient obesity on kidney transplantation (KT) outcomes remains unclear.

OBJECTIVE

The aim of this study was to perform a systematic review and meta-analysis to appraise all available evidence on the outcomes of KT in obese patients (body mass index [BMI] ≥30 kg/m2) versus nonobese patients (BMI <30 kg/m2).

EVIDENCE ACQUISITION

A systematic review and meta-analysis was performed. Search was conducted in the MEDLINE OvidSP, Web of Science, Google Scholar, Embase, and Cochrane databases to identify all studies reporting the outcomes of KT in obese versus nonobese recipients.

EVIDENCE SYNTHESIS

Fifty-two articles met the inclusion criteria. Delayed graft function and surgical complications were significantly higher in obese recipients (delayed graft function: relative risk [RR]: 1.44, 95% confidence interval [CI]: 1.32-1.57, p < 0.01; surgical complications: RR: 1.74, 95% CI: 1.36-2.22, p < 0.0001). Five-year patient survival (RR: 0.96, 95% CI: 0.92-1.00, p = 0.01), 10-yr patient survival (RR: 0.90, 95% CI: 0.84-0.97, p = 0.006), and 10-yr graft survival (RR: 0.87, 95% CI: 0.79-0.96, p = 0.01) were significantly inferior in the obese group.

CONCLUSIONS

KT in obese recipients was associated with lower patient and graft survival, and higher delayed graft function, acute rejection, and medical and surgical complications than nonobese recipients. In the current situation of organ shortage and increasing prevalence of obesity, ways to optimize KT in this setting should be investigated.

PATIENT SUMMARY

Compared with nonobese population, kidney transplantation in obese recipients has inferior patient and graft survival, and higher medical and surgical complications.

Open versus robotic-assisted kidney transplantation: A systematic review by the European Association of Urology (EAU) - Young Academic Urologists (YAU) Kidney Transplant Working Group

INTRODUCTION

In the last 20 years, robotic assisted procedures were evaluated in the field of kidney transplantation to provide a mini-invasive approach for this particularly fragile population. As a relatively new issue, few studies compared open kidney transplantation (OKT) and robotic-assisted kidney transplantation (RAKT), mostly in small cohorts. To improve current knowledge, we wanted here to gather comparative data of OKT vs RAKT in a systematic review.

METHODS

A systematic review was performed according to preferred reporting items for systematic reviews and meta-analyses. Medline, Embase, and Cochrane databases were searched to identify all studies reporting post-operative outcomes of RAKT versus OKT.

RESULTS

A total of 2136 patients in 13 studies were included. Median recipient age was 42.6 years (OKT: 43.5 years and RAKT: 40.3 years). Median preemptive kidney transplantation rate was 27.1 % (OKT: 23.3 % and RAKT: 33.2 %). Median total operative time and rewarming were respectively: 235 and 49 min in OKT population; 250 and 60 min in RAKT population. Post-operative complications rates were: 26.2 % in OKT population and 17.8 % in RAKT population. Delayed graft function rates were: 4.9 % in OKT population and 2.3 in RAKT population. Mid-term functional outcomes, patient and graft survival were similar in OKT and RAKT population.

CONCLUSION

This systematic review showed that RAKT may be associated with a lower incidence of delayed graft function and post-operative surgical complications and similar mid-term functional outcomes, patient and graft survival, compared to OKT for end-stage renal disease patients.

Impact of robotic-assisted kidney transplantation on post-transplant infections: a case-control study

BACKGROUND

The aim of this study was to determine the differences in the incidence, epidemiology, clinical characteristics and risk factors of infections in living donor kidney transplant recipients using robotic-assisted kidney transplantation (RAKT) and open approach.

METHODS

We conducted a retrospective observational study from January 2016 to December 2019. For the risk factor analysis, a matched case-control study (1:1 ratio) was performed (robotic vs open). Control subjects were matched for living donor and time of transplantation. The data included de novo immunosuppressive regimen, delayed graft function, urological complications, acute allograft rejection and incidence, clinical features, microbiological findings and outcomes of infections.

RESULTS

Ninety-four RAKT and 84 controls were included. There were no differences between groups in terms of age, gender, BMI, median days of hospitalization, immunosuppressive regimen, need for surgical urologic procedures post-transplantation, presence of urinary leak or acute allograft rejection. Thirty-five percent of all recipients analyzed presented an infection, mostly asymptomatic bacteriuria (49%), symptomatic urinary tract infection (31%) and surgical site infection (10%). Pseudomonas aeruginosa was the most frequent isolated microorganism in 67%, followed by E. coli (20%), Enterococcus faecalis (17%) and Klebsiella pneumoniae (10%). Eight percent of the microorganisms were multidrug resistant. The open kidney transplantation group presented more infections compared to RAKT (43 vs 27%, p = 0.04). After multivariate analysis, need for surgical urologic procedure post-transplantation (OR 6.2, 95% CI 1.1-35), BMI ≥ 30 (OR 3.6, 95% CI 1.5-9) and acute allograft rejection (OR 3.2, 95% CI 1.2-8.5) were associated with infection, whereas RAKT (OR 0.5, 95% CI 0.2-0.9) and the use of JJ catheter (OR 0.36, 95% CI 0.17-0.72) were protective factors.

CONCLUSIONS

Infection is a frequent event in patients receiving a living donor kidney transplant. Acute allograft rejection, need for surgical urologic procedure post-transplantation and BMI were associated with infection, whereas robotic surgery was a protective factor in living donor kidney transplantation.

Obesity and Kidney Transplantation-How to Evaluate, What to Do, and Outcomes

Obesity is a growing issue that is spreading worldwide; its prevalence is ever increasing in patients with end-stage renal disease and represents a potential barrier to transplantation. The lack of unanimous guidelines exacerbates the current disparity in treatment, which can affect outcomes, leading to a significantly longer time on the waiting list. Multidisciplinary and multimodal management (encompassing several healthcare professionals such as nephrologists, transplant physicians and surgeons, primary care providers, and nurses) is of paramount importance for the optimal management of this patient population in a continuum from waitlisting to transplantation. Development of this guideline followed a standardized protocol for evidence review. In this review, we report on our clinical experience in transplantation of obese patients; strategies to manage this condition, including bariatric surgery, suitable timing for transplantation among this patient population, and clinical experience in robotic sleeve gastrectomy; and simultaneous robotic kidney transplantation to achieve optimal outcomes.

Outcomes of kidney transplantation from uncontrolled donors after circulatory death vs. expanded-criteria or standard-criteria donors after brain death at an Italian Academic Center: a prospective observational study

BACKGROUND

The use of kidneys from "expanded criteria" donors after brain death (ECD) and uncontrolled donors after circulatory death (uDCD) has been warranted to increase the pool of donors for kidney transplantation (KT). However, there is lack of evidence on the feasibility and safety of KT from such donors in the Italian setting.

METHODS

We queried our prospectively KT database to select patients undergoing KT from deceased donors (uDCDs, ECDs, and standard-criteria donors [SCD] after brain death) from January 2017 to December 2020, comparing the perioperative and mid-term functional outcomes.

RESULTS

Overall, 172 KTs were included. The donor's profile was different among the study groups, while recipients' characteristics were similar expect for median age. Grafts from uDCDs and ECDs had longer median cold ischemia times as compared to grafts from SCDs. The proportion of patients experiencing DGF, the median hospitalization, as well as the overall and major complications rate, were significantly higher among recipients from uDCDs. The proportion of patients needing dialysis at last follow-up was significantly higher among recipients from uDCDs (33.3% vs. 8.5% vs. 5.4%, P<0.001). However, the median eGFR at the last follow-up was lower for recipients from ECDs compared to those from uDCDs and SCDs, respectively (P<0.001).

CONCLUSIONS

While "marginal" donors represent a relevant source of organs, KTs from uDCDs carry higher risks of major surgical complications, DGF, and worse graft survival as compared to KT from both ECDs and SCDs. As such, the use of grafts from uDCDs should be carefully assessed balancing the potential benefits with the risk of primary no function and the subsequent immunological sensitization.

Three-dimensional Augmented Reality-guided Robotic-assisted Kidney Transplantation: Breaking the Limit of Atheromatic Plaques

BACKGROUND

Robotic-assisted kidney transplantation (RAKT) has shown solid results as a minimally invasive alternative to the standard open approach (open kidney transplantation [OKT]). However, RAKT is still limited in those cases where the recipient's iliac vessels present atherosclerotic plaques, frequently found in elder patients and in those subjected to long-term hemodialysis. Unlike OKT, where the surgeon can palpate the arterial plaques, in minimally invasive surgery the haptic feedback is missing, making the vascular clamping and arteriotomy unsafe.

OBJECTIVE

To employ three-dimensional (3D) imaging reconstruction using augmented reality (AR) to intraoperatively locate the plaques during the crucial steps of kidney transplantation.

DESIGN, SETTING, AND PARTICIPANTS

Our study was conducted according to the Idea, Development, Exploration, Assessment, and Long-term follow-up (IDEAL) model for surgical innovation. Three-dimensional virtual models were obtained from high-accuracy computed tomography scan imaging and superimposed on the vessels during RAKT using the Da Vinci console software.

SURGICAL PROCEDURE

Three-dimensional AR-guided robotic-assisted kidney transplantation.

MEASUREMENTS

The correspondence of virtual models with the real anatomy of patients was assessed comparing vessels' and plaques' measures.

RESULTS AND LIMITATIONS

We tested the possibility of using the AR in the setting of vascular surgery by checking the correspondence of the virtual models to the real vessels. During the accuracy assessment, we investigated the anatomy of the iliac plaques and the capacity of the virtual models to correctly represent them. Finally, we tested the efficacy of the virtual model superimposition on the real vessels with plaques during RAKT in the recipients of living donor grafts. The main limitation consists in training needed to correctly superimpose virtual models on the real field.

CONCLUSIONS

The employment of 3D AR allowed surgeons to overcome one of the main limitations of RAKT, setting the foundation to expand its indications to patients with advanced atheromatic vascular disease.

PATIENT SUMMARY

The use of three-dimensional augmented reality guidance during kidney transplantation (KT) has the potential to "navigate" the surgeon during KT, allowing a safer procedure in patients with atheromatic vascular disease.

Donor obesity and weight gain after transplantation: two still overlooked threats to long-term graft survival

The effect of donor obesity on kidney transplantation success has long been an overlooked clinical research area. Even though there is no strict guideline in most countries prohibiting donation from obese individuals, most candidates with a body mass index >35-40 kg/m² are rejected due to concerns regarding long-term renal functional deterioration in the donor. The effects of excessive fat mass on renal function and allograft survival have been analysed by several longitudinal and follow-up studies. These studies have documented the deleterious effect on long-term graft outcomes of excessive body mass in living kidney donors and de novo obesity or pre-existing obesity worsening after transplantation on kidney outcomes. However, there is a paucity of clinical trials aimed at countering overweight and obesity in living and deceased kidney donors and in transplant patients. In this review we will briefly discuss the mechanism whereby fat excess induces adverse kidney outcomes and describe the effects on graft function and survival in living obese donors.

Robot-assisted kidney transplantation: Is it getting ready for prime time?

Kidney transplantation (KT) is the treatment of choice for patients with end-stage renal disease, providing a better survival rate and quality of life compared to dialysis. Despite the progress in the medical management of KT patients, from a purely surgical standpoint, KT has resisted innovations during the last 50 years. Recently, robot-assisted KT (RAKT) has been proposed as an alternative approach to open surgery, especially due to its potential benefits for fragile and immunocompromised recipients. It was not until 2014 that the role of RAKT has found value thanks to the pioneering Vattikuti Urology Institute-Medanta collaboration that conceptualized and developed a new surgical technique for RAKT following the Idea, Development, Exploration, Assessment, Long-term follow-up recommendations for introducing surgical innovations into real-life practice. During the last years, mirroring the Vattikuti-Medanta technique, several centers developed RAKT program worldwide, providing strong evidence about the safety and the feasibility of this procedure. However, the majority of RAKT are still performed in the living donor setting, as an “eligible” procedure, while only a few centers have realized KT through a robotic approach in the challenging scenario of cadaver donation. In addition, despite the spread of minimally-invasive (predominantly robotic) surgery worldwide, many KTs are still performed in an open fashion. Regardless of the type of incision employed by surgeons, open KT may lead to non-negligible risks of wound complications, especially among obese patients. Particularly, the assessment for KT should consider not only the added surgical technical challenges but also the higher risk of postoperative complications. In this context, robotic surgery could offer several benefits, including providing a better exposure of the surgical field and better instrument maneuverability, as well as the possibility to integrate other technological nuances, such as the use of intraoperative fluorescence vascular imaging with indocyanine green to assess the ureteral vascularization before the uretero-vesical anastomosis. Therefore, our review aims to report the more significant experiences regarding RAKT, focusing on the results and future perspectives.

Abdominal Organ Transplantation: Noteworthy Literature in 2021

This review highlights noteworthy literature pertinent to anesthesiologists and critical care physicians caring for patients undergoing abdominal organ transplantation. In 2021, we identified noteworthy papers from over 1,200 peer-reviewed publications on pancreatic transplantation, over 1,400 on intestinal transplantation, and over 9,000 on kidney transplantation. The liver transplantation section focuses on clinical trials and systematic reviews and meta-analyses published in 2021 and features 20 selected papers. COVID-19 and abdominal organ transplantation are featured in an independent section.

Robotic Versus Open Kidney Transplantation from Deceased Donors: A Prospective Observational Study

Background

While robot-assisted kidney transplantation (RAKT) from living donors has been shown to achieve favourable outcomes, there is a lack of evidence on the safety and efficacy of RAKT as compared with the gold standard open kidney transplantation (OKT) in the setting of deceased donors, who represent the source of most grafts worldwide.

Objective

To compare the intraoperative, perioperative, and midterm outcomes of RAKT versus OKT from donors after brain death (DBDs).

Design, setting, and participants

Data from consecutive patients undergoing RAKT or OKT from DBDs at a single academic centre between October 2017 and December 2020 were prospectively collected.

Intervention

RAKT or OKT.

Outcome measurements and statistical analysis

The primary outcomes were intraoperative adverse events, postoperative surgical complications, delayed graft function (DGF), and midterm functional outcomes. A multivariable logistic regression analysis assessed the independent predictors of DGF, trifecta, and suboptimal graft function (estimated glomerular filtration rate [eGFR] <45 ml/min/1.73 m²) at the last follow-up.

Results and limitations

Overall, 138 patients were included (117 [84.7%] OKTs and 21 [15.3%] RAKTs). The yearly proportion of RAKT ranged between 10% and 18% during the study period. The OKT and RAKT cohorts were comparable regarding all graft-related characteristics, while they differed regarding a few donor- and recipient-related factors. The median second warm ischaemic time, ureterovesical anastomosis time, postoperative complication rate, and eGFR trajectories did not differ significantly between the groups. A higher proportion of patients undergoing OKT experienced DGF; yet, at a median follow-up of 31 mo (interquartile range 19–44), there was no difference between the groups regarding the dialysis-free and overall survival. At the multivariable analysis, donor- and/or recipient-related factors, but not the surgical approach, were independent predictors of DGF, trifecta, and suboptimal graft function at the last follow-up. The study is limited by its nonrandomised nature and the small sample size.

Conclusions

Our study provides preliminary evidence supporting the noninferiority of RAKT from DBDs as compared with the gold standard OKT in carefully selected recipients.

Patient summary

Kidney transplantation using kidneys from deceased donors is still being performed with an open surgical approach in most transplant centres worldwide. In fact, no study has compared the outcomes of open and minimally invasive (robotic) kidney transplantation from deceased donors. In this study, we evaluated whether robotic kidney transplantation using grafts from deceased donors was not inferior to open kidney transplantation regarding the intraoperative, postoperative, and midterm functional outcomes. We found that, in experienced hands and provided that there was a time-efficient organisation of the transplantation pathway, robotic kidney transplantation from deceased donors was feasible and achieved noninferior outcomes as compared with open kidney transplantation.

Prospective comparative study of postoperative systemic inflammatory syndrome in robot-assisted vs. open kidney transplantation

PURPOSE

Robot-assisted kidney transplant (RAKT) recently proved to provide functional results similar to the preferred open kidney transplant (OKT), but with inferior wound morbidity. In a comparative prospective study, we explored the systemic inflammatory response syndrome (SIRS) after KT and compared OKT with RAKT.

METHODS

Forty-nine patients underwent pre-emptive ABO-compatible kidney transplantations (KT) between January 2017 and December 2018 in 2 centers: 25 RAKT, 24 OKT. Postoperative SIRS was biologically assessed by serum markers (NGAL, CRP and IL-6) measured at: T0 (preoperative/baseline), T1(H1), T2(H6), T3(H12), T4(H24), T5(D2), T6(D3) and T7(D5) after KT.

RESULTS

Inflammatory markers + eGFR were assessed in OKT vs. RAKT. IL-6 peak value occurred at H6 and reached ×9 from baseline. CRP peak occurred at H24 and reached ×28 from baseline (All P < 0.05). NGAL decreased after surgery with a plateau (divided by 2 from baseline) from H12 to D5. There was no significant difference in IL-6, CRP and NGAL kinetics and peak values between RAKT and OKT (All P > 0.05). Serum creatinine and eGFR on postoperative days 1, 3 and 7 were similar in RAKT and OKT (All P > 0.05). Delayed graft function was not observed.

CONCLUSION

In this exploratory study, the biological evaluation of postoperative SIRS after living-donor kidney transplant revealed no significant difference between OKT and RAKT and similar functional outcomes in the short term. These results highlight the safety of RAKT as an alternative to OKT in this setting.

Robot-assisted kidney transplantation is a safe alternative approach for morbidly obese patients with end-stage renal disease

BACKGROUND

Many centres deny obese patients with a body mass index (BMI) >35 access to kidney transplantation due to increased intraoperative and postoperative complications.

METHODS

From August 2017 to December 2019, 73 consecutive cases of kidney transplantation in morbidly obese patients were enrolled at a single university at the initiation of a robotic transplant surgery program. Outcomes of patients who underwent robotic assisted kidney transplant (RAKT) were compared to frequency-matched patients undergoing open kidney transplant (OKT).

RESULTS

A total of 24 morbidly obese patients successfully underwent RAKT, and 49 obese patients received an OKT. The RAKT group developed fewer surgical site infections (SSI) than the OKT group. Graft function, creatinine, and glomerular filtration rate (GFR) were similar between groups 1 year after surgery. Graft and patient survival were 100% for both groups.

CONCLUSIONS

RAKT offers a safe alternative for morbidly obese patients, who may otherwise be denied access to OKT.

Obesity and bariatric surgery in kidney transplantation: A clinical review

Obesity is increasing worldwide, and this has major implications in the setting of kidney transplantation. Patients with obesity may have limited access to transplantation and increased posttransplant morbidity and mortality. Most transplant centers incorporate interventions aiming to target obesity in kidney transplant candidates, including dietary education and lifestyle modifications. For those failing nutritional restriction and medical therapy, the use of bariatric surgery may increase the transplant candidacy of patients with obesity and end-stage renal disease (ESRD) and may potentially improve the immediate and late outcomes. Bariatric surgery in ESRD patients is associated with weight loss ranging from 29.8% to 72.8% excess weight loss, with reported mortality and morbidity rates of 2% and 7%, respectively. The most commonly performed bariatric surgical procedures in patients with ESRD and in transplant patients are laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass. However, the correct timing of bariatric surgery and the ideal type of surgery have yet to be determined, although pretransplant LSG seems to be associated with an acceptable risk-benefit profile. We review the impact of obesity on kidney transplant candidates and recipients and in potential living kidney donors, exploring the potential impact of bariatric surgery in addressing obesity in these populations, thereby potentially improving posttransplant outcomes.

Can robot-assisted kidney transplantation provide higher quality of life than open kidney transplantation during the early postoperative period?

PURPOSE

Purpose of this study is to investigate the quality of life (QoL) in patients with end-stage renal disease who underwent open or robot-assisted kidney transplantation (OKT and RAKT).

MATERIALS AND METHODS

Patients who underwent OKT and RAKT at Bakirkoy Sadi Konuk Training and Research Hospital between June 2016 and December 2018 constituted the target population of this study. The patient group was divided into two groups as per the surgical technique (ie, open vs. robot-assisted). Demographic data, preoperative and postoperative data of all patients were collected prospectively. The QoL of the patients was assessed preoperatively and on the postoperative 30th day.

RESULTS

Sixty-seven patients who underwent OKT and 60 patients who underwent RAKT were included. The mean patient age and BMI were calculated as 40.9 ± 11.6 years and 24.4 ± 2.9 kg/m² , respectively. Patients in the RAKT group were significantly younger than the patients in the OKT group (P = .002). There were no significant differences between the two groups in terms of gender, BMI, ASA and the ratio of premptive patients. The mean preoperative hemoglobin level was significantly higher in the OKT group than the RAKT group (P = .003). While mean total ischemia time was shorter in the "open" group, intraoperative blood loss and incision length were shorter in the RAKT group. Duration of surgical drainage and hospital stay was shorter in the "robot-assisted" group. There was no significant difference between the groups in terms of SF-36 subparameters preoperatively. The physical component scores of the QoL questionnaire revealed that postoperative impairment of quality of life in the early postoperative period was more significant in the OKT than the RAKT.

CONCLUSION

Patients who underwent RAKT have a higher QoL than the patients who were treated with OKT as per their self-reported QoL scores in the early postoperative period.

Initial Experience with Single-port Robotic-assisted Kidney Transplantation and Autotransplantation

BACKGROUND

Compared with the standard open approach, multiport robotic-assisted kidney transplantation (RAKT) has emerged as a less morbid alternative. The use of a single-port robotic approach for kidney transplantation (KT) is presented in this study as having the potential for further reducing the morbidity of KT.

OBJECTIVE

To present the technique and evaluate perioperative and short-term (≤1 yr) postoperative outcomes of single-port RAKT.

DESIGN, SETTING, AND PARTICIPANTS

Prospective evaluation of peri- and postoperative outcomes in patients who underwent allograft KT (n = 6) or kidney autotransplantation (n = 3). The IDEAL model (www.ideal-collaboration.net/framework) for safe surgical innovation was used.

SURGICAL PROCEDURE

Kidney allografts from living or deceased donors were transplanted into six patients with end-stage renal disease. Single-port robotic surgery was performed through a 5-cm midline periumbilical abdominal incision with transperitoneal or extraperitoneal approaches. With similar incision and technique, the right or left kidney was removed and autotransplantation was performed in three patients.

MEASUREMENTS

Intra- and postoperative variables, and outcomes were assessed with a descriptive analysis.

RESULTS AND LIMITATIONS

Single-port RAKT procedures were completed successfully, with total operative and vascular anastomosis times ranging from 300 to 450 mins and from 52 to 92 mins, respectively. All six patients had excellent graft function with serum creatinine levels at the last follow-up (2 wk to 1 yr), ranging from 1.2 to 1.5 mg/dl. Renal autotransplantation was also completed successfully with a single-port robotic approach in three patients. The total operative and vascular anastomosis times ranged from 510 to 600 mins and from 65 to 83 mins, respectively. In all three cases, serum creatinine levels remained normal after the surgery and during follow-up, and all remained symptom-free at the time of this writing (4-8 mo after their surgeries).

CONCLUSIONS

In this initial experience, single-port RAKT is feasible with potential benefits such as offering true single-site minimally invasive surgery, extraperitoneal approach, less morbidity, and comparable short-term graft functional outcomes.

PATIENT SUMMARY

We presented the initial experience with the application of single-port robotic surgery for kidney transplantation and autotransplantation. This technique was found to be safe and effective, with promising postoperative outcomes and potentially with less morbidity.

Renal transplantation outcomes in obese patients: a French cohort-based study

Background

Whilst there are a number of publications comparing the relationship between body mass index (BMI) of kidney transplant recipients and graft/patient survival, no study has assessed this for a French patient cohort.

Methods

In this study, cause-specific Cox models were used to study patient and graft survival and several other time-to-event measures. Logistic regressions were performed to study surgical complications at 30 days post-transplantation as well as delayed graft function.

Results

Among the 4691 included patients, 747 patients were considered obese with a BMI level greater than 30 kg/m². We observed a higher mortality for obese recipients (HR = 1.37, p = 0.0086) and higher risks of serious bacterial infections (HR = 1.24, p = 0.0006) and cardiac complications (HR = 1.45, p < 0.0001). We observed a trend towards death censored graft survival (HR = 1.22, p = 0.0666) and no significant increased risk of early surgical complications.

Conclusions

We showed that obesity increased the risk of death and serious bacterial infections and cardiac complications in obese French kidney transplant recipients. Further epidemiologic studies aiming to compare obese recipients versus obese candidates remaining on dialysis are needed to improve the guidelines for obese patient transplant allocation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-021-02278-1.

Extraperitoneal Laparoscopic Kidney Transplantation: Preliminary Clinical Experiences from China

OBJECTIVE

To report on the pioneering clinical experiences of six cases of extraperitoneal laparoscopic kidney transplantation in China.

METHODS

For the first time in clinical practice, a customised, controllable double-circulation cooling device was used to protect the transplanted kidney. Of the six patients, two underwent an allograft renal transplantation because they had been diagnosed with uraemia and were on maintenance haemodialysis. The other four patients underwent kidney autotransplantation because of a central renal tumour.

RESULTS

The extraperitoneal laparoscopic kidney transplantations were successfully completed between 2017 and 2018. The operative time for the two patients undergoing the allograft transplantation was 3-3.5 h. The time for venous anastomosis was approximately 53-65 min, and the time for arterial anastomosis was approximately 25-30 min. The creatinine level was 90-80 μmol/L after surgery. The operative time of the four patients who underwent autotransplantation was 9.4-17.5 h. The times of venous and arterial anastomosis were 58-90 min and 35-48 min, respectively. The follow-up B-mode ultrasound after surgery showed good blood supply in the spared nephron. A renal graft was removed from one patient 6 months after surgery because of renal atrophy and dysfunction caused by poor blood supply. Five patients (two undergoing allografting and three undergoing autografting) completed the 12-month follow-up, and their renal graft function was good.

CONCLUSIONS

Extraperitoneal laparoscopic kidney transplantation, either allograft or autologous transplantation, is a safe and feasible procedure with a good chance of survival for the transplanted kidney. A customised cooling device is effective and practical during laparoscopic kidney transplantation.

The University of Florence Technique for Robot-Assisted Kidney Transplantation: 3-Year Experience

Objective: To report the University of Florence technique for robot-assisted kidney transplantation (RAKT) from living donor (LD) and deceased donor (DD), highlighting the evolution of surgical indications and technical nuances in light of a single surgeon's learning curve.

Materials and Methods: A dedicated program for RAKT from LDs was developed at our Institution in 2017 and implemented later with a specific framework for DDs. All RAKTs were performed by a single highly experienced surgeon. Data from patients undergoing RAKT between January 2017 and December 2019 were prospectively collected in a dedicated web-based data platform. In this report we provide a comprehensive step-by-step overview of our technique for RAKT, focusing on the potential differences in peri-operative and mid-term functional outcomes between LDs vs. DDs.

Results: Overall, 160 KTs were performed in our center during the study period. Of these, 39 (24%) were performed with a robot-assisted laparoscopic technique, both from LDs (n = 18/39 [46%]) and from DDs (n = 21/39 [54%]). Eleven (11/39 [18%]), 13(13/39 [26%]), and 15 (15/39 [30%]) RAKTs were performed in 2017, 2018, and 2019, respectively, highlighting an increasing adoption of robotics for KT over time at our Institution. Median time for arterial (19 min for LD and 18 min for DD groups), venous (21 min for LD, 20 min for DD) and uretero–vesical (18 min for LD and 15 for DD) anastomosis were comparable between the two groups (all p > 0.05), as the median rewarming time (59 min vs. 56 min, p = 0.4). The rate of postoperative surgical complications according to Clavien–Dindo classification did not differ between the two study groups, except for Clavien–Dindo grade II complications (higher among patients undergoing RAKT from DDs, 76 vs. 44%, p = 0.042). Overall, 7/39 (18%) patients (all recipients from DDs) experienced DGF; two of them were on dialysis at last FU.

Conclusions: Our experience confirms the feasibility, safety, and favorable mid-term outcomes of RAKT from both LDs and DDs in appropriately selected recipients, highlighting the opportunity to tailor the technique to specific recipient- and/or graft-characteristics. Further research is needed to refine the technique for RAKT and to evaluate the benefits and harms of robotics for kidney transplantation from DDs.