Robotic Donor Nephrectomy: Against

Robotic-Assisted Nephrectomy for Living Kidney Donation-Single Center Initial Experience (Case Series) and Review of the Literature

Background: Robotic-assisted nephrectomy for living kidney-donation (RANLD) has the potential of becoming the leading technique of harvesting kidney, if expertise is available. The aim of this work is to present our initial experience with robotic technique with additional hand-assistance. Materials and Methods: We initiated RANLD at our clinic using the DaVinci System in September 2022, since then harvesting six kidneys, four left and two right; in two cases, multiple arteries existed. The renal vessels were ligated using vascular staplers. All the operations included a hand-assist with the use of Gelport. The mean operation time was 119.2 min (SD 12 min). Results: There were no conversions or donors' post-operative complications. Time of discharge from the hospital was 4.5 days post-operatively. Total hospital length of stay was 7.8 days. All the harvested kidneys were transplanted, five of them with adequate function, three with initially delayed function, and one needed to be removed due to thrombotic complications. Post-operative was pain assessed on the VAS scale and overall pain was assessed according to the NRS scale. At the discharge day, donors' performance status was about 87.5% according to the Karnofsky scale. The donors resumed their normal life activity within 15.7 days and returned to work within 45.2 days. The serum mean creatinine level before the donation was 0.85 mg/dL (SD 0.1 mg/dL), and mean eGFR (MDRD) = 91.8 mL/min/1.73 m2 (SD 16.1 mL/min/1.73 m2). Conclusions: Further development of RANLD could lead to an increase in the number of living kidney donors, particularly in Poland where the number is currently lower than that of deceased donors. Prolonged operation time, longer warm ischemic time, and high equipment costs are significant drawbacks of RANLD.

Robotic versus hand-assisted laparoscopic living donor nephrectomy: comparison of two minimally invasive techniques in kidney transplantation

Robot-assisted donor nephrectomy (RDN) is increasingly used due to its advantages such as its precision and reduced learning curve when compared to laparoscopic techniques. Concerns remain among surgeons regarding possible longer warm ischemia time. This study aimed to compare patients undergoing robotic living donor nephrectomy to the more frequently used hand-assisted laparoscopic nephrectomy (HLDN) technique, focusing on warm ischemia time, total operative time, learning curve, hospital length of stay, donor renal function and post-operative complications. Retrospective study comparing RDN to HLDN in a collaborative transplant network. 176 patients were included, 72 in RDN and 104 in HLDN. Left-sided nephrectomy was favored in RDN (82% vs 52%, p < 0.01). Operative time was longer in RDN (287 vs 160 min; p < 0.01), while warm ischemia time was similar (221 vs 213 secs, p = 0.446). The hospital stay was shorter in RDN (3.9 vs 5.7 days, p < 0.01).Concerning renal function, a slightpersistent increase of 7% of the creatinine ratio was observed in the RDN compared to the HLDN group (1.56 vs 1.44 at 1-month checkup, p < 0.01). The results show that RDN appears safe and efficient in comparison to the gold-standard HLDN technique. Warm ischemia time was similar for both techniques, whereas RDN operative time was longer. Patients undergoing RDN had a shorter hospital stay, this being possibly mitigated by differences in center release criteria. Donor renal function needs to be assessed on a longer-term basis for both techniques.

Robot-Assisted Laparoscopic Living Donor Nephrectomy: The University of Florence Technique

Objective: To provide a step-by-step overview of the University of Florence technique for robotic living donor nephrectomy (LDN), focusing on its technical nuances and perioperative outcomes.

Methods: A dedicated robotic LDN program at our Institution was codified in 2012. Data from patients undergoing robotic LDN from 2012 to 2019 were prospectively collected. All robotic LDNs were performed by a highly experienced surgeon, using the da Vinci Si robotic platform in a three-arm configuration. In this report we provide a detailed overview of our surgical technique for robotic LDN. The main objective of the study was to evaluate the technical feasibility and safety of the technique, including perioperative surgical complications rate and mid-term functional outcomes.

Results: Overall, 36 patients undergoing robotic LDNs were included in the study. Of these, 28 (78%) were left LDNs. Median (IQR) donor pre-operative eGFR was 88 (75.6–90) ml/min/1.73 m². In all cases, robotic LDN was completed without need of conversion. The median (IQR) overall operative time was 230 (195–258) min, while the median console time was 133 (IQR 117-166) min. The median (IQR) warm ischemia time was 175 (140–255) s. No intraoperative adverse events or 90-d major surgical complications were recorded. At a median (IQR) follow-up of 24 months (IQR 11-46), median (IQR) eGFR patients undergoing in living donor nephrectomy was 57.4 (47.9; 63.9) ml/min/1.73 m².

Conclusions: In our experience, robotic LDN is technically feasible and safe. The use of robotic surgery for LDN may provide distinct advantages for surgeons while ensuring optimal donors' perioperative and functional outcomes.

Robot-Assisted versus Laparoscopic Donor Nephrectomy: A Comparison of 250 Cases

Living kidney donation is the best treatment for end-stage renal disease, however, the best surgical approach for minimally-invasive donor nephrectomy (DN) is still a matter of debate. This bi-centric study aimed to retrospectively compare perioperative outcomes and postoperative kidney function after 257 transperitoneal DNs including 52 robot-assisted (RDN) and 205 laparoscopic DNs (LDN). As primary outcomes, the intraoperative (operating time, warm ischemia time (WIT), major complications) and postoperative (length of stay, complications) results were compared. As secondary outcomes, postoperative kidney and graft function were analyzed including delayed graft function (DGF) rates, and the impact of the surgical approach was assessed. Overall, the type of minimally-invasive donor nephrectomy (RDN vs. LDN) did not affect primary outcomes, especially not operating time and WIT; and major complication and DGF rates were low in both groups. A history of smoking and preoperative kidney function, but not the surgical approach, were predictive for postoperative serum creatinine of the donor and recipient. To conclude, RDN and LDN have equivalent perioperative results in experienced centers. For this reason, not the surgical approach, but rather the graft- (preoperative kidney function) and patient-specific (history of smoking) aspects impacted postoperative kidney function.