Robotic Assisted Living Donor Nephrectomies: A Safe Alternative to Laparoscopic Technique for Kidney Transplant Donation

Robotic versus open mini-incision living donor nephrectomy: Single centre experience

BACKGROUND

Robotic surgery is associated with less tissue manipulation and earlier recovery with minimal incision. The aim of this study was to compare the short-term clinical outcomes between robotic-assisted donor nephrectomy (RDN) and open mini-incision donor nephrectomy (ODN).

METHODS

From 2016 to 2019, 141 cases involving RDN were analysed. Patient outcomes were compared with those of 191 patients who underwent ODN from 2010 to 2015. Demographics, operation factors, perioperative outcomes, and complications were retrospectively reviewed.

RESULTS

The RDN group presented with less blood loss than the ODN group (p = 0.023). The length of hospital stay was significantly shorter in the RDN group than in the ODN group (p < 0.005). The overall rate of complications was low and there was no significant difference in complication rates between the groups.

CONCLUSION

The robotic approach has benefits over the traditional open approach, including shorter length of hospital stay and reduced intraoperative blood loss.

Robotic performance metrics model fellow proficiency in living donor nephrectomy

We investigated the use of robotic objective performance metrics (OPM) to predict number of cases to proficiency and independence among abdominal transplant fellows performing robot-assisted donor nephrectomy (RDN). 101 RDNs were performed by 5 transplant fellows from September 2020 to October 2023. OPM included fellow percent active control time (%ACT) and handoff counts (HC). Proficiency was defined as ACT ≥ 80% and HC ≤ 2, and independence as ACT ≥ 99% and HC ≤ 1. Case number was significantly associated with increasing fellow %ACT, with proficiency estimated at 14 cases and independence at 32 cases (R2 = 0.56, p < 0.001). Similarly, case number was significantly associated with decreasing HC, with proficiency at 18 cases and independence at 33 cases (R2 = 0.29, p < 0.001). Case number was not associated with total active console time (p = 0.91). Patient demographics, operative characteristics, and outcomes were not associated with OPM, except for donor estimated blood loss (EBL), which positively correlated with HC. Abdominal transplant fellows demonstrated proficiency at 14-18 cases and independence at 32-33 cases. Total active console time remained unchanged, suggesting that increasing fellow autonomy does not impede operative efficiency. These findings may serve as a benchmark for training abdominal transplant surgery fellows independently and safely in RDN.

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 assisted living donor nephrectomy - the first in the Czech Republic

INTRODUCTION

A kidney transplant is the best method for treating terminal kidney failure. Long-term results of kidney transplants from living donors are significantly better than transplants from dead donors. Living kidney donors are healthy people who undergo a major operation in order to improve the health of another person. Therefore, major emphasis is on safety, low level of invasiveness and a desirable cosmetic effect of the donor nephrectomy. Since 2012, the Department of Urology at the University Hospital in Olomouc has performed 12 kidney harvestings from living donors. The kidney harvesting was conducted using various techniques.

CASE REPORT

The first robotic assisted kidney harvesting in the Czech Republic was performed in June 2022. The donor was a 57-year-old man who donated his kidney to his 32-year-old daughter. The left kidney was evaluated as suitable for kidney harvesting. The operation took 174 min. The kidney's warm ischemia was 145 s. Based on the Clavien Dindo classification, no 2nd degree or high post-operative complications were recorded. The donor's pre-operative glomerular filtration was 1.63 mL/s. Six months post-operation, it went down to 1.19 mL/s. This represents a 27% decrease. The kidney recipient did not require early dialysis. Six months post-operation, the recipient's glomerular filtration was 2.03 mL/s.

CONCLUSION

In the hands of experienced professionals and transplantation centres, robotic assisted donor nephrectomy is a feasible and safe option for this operation. It not only provides all the advantages of a laparoscopic operation but it also adds other technical improvements and minimizes intraoperative stress on the surgeon. Currently, the global trend is moving towards increasing the ratio of robotic assisted donor nephrectomies.

Robot-assisted laparoscopic retroperitoneal donor nephrectomy: a safe and efficient improvement

PURPOSE

Reducing operative injuries is important in living donor nephrectomy. The robot-assisted transperitoneal approach has some advantages than traditional laparoscopic techniques. However, longer operation time and risks of abdominal complications indicate the need for improved techniques. The aim of this study is to present the robot-assisted laparoscopic retroperitoneal donor nephrectomy and evaluate its safety and feasibility.

METHODS

This was a retrospective study. From June 2016 to December 2020, 218 living donors underwent robot-assisted laparoscopic retroperitoneal donor nephrectomy. Perioperative data such as operation time, warm ischemia time, length of stay and complications were collected and analyzed. To evaluate the feasibility of this surgical technique, the cumulative summation method was used to construct a learning curve.

RESULTS

There were 60 male and 158 female donors aged 36-72 years, with an average age of 53.1 ± 6.8 years. Three patients (1.4%) were converted to open surgery. The mean operation time was 115.4 ± 41.9 min, the warm ischemia time was 206.6 ± 146.7 s, and the length of stay was 4.1 ± 1.4 days. Complications were reported in 22 patients (10.1%), three of whom (1.4%) had Clavien‒Dindo IIIa complications. No ileus occurred. No donors were readmitted. Four patients had delayed graft function. The cumulative summation curve showed that the number needed to reach proficiency was 33. The operation time and warm ischemia time after technical proficiency were 100.4 ± 21.6 min and 142.5 ± 50.7 s, respectively.

CONCLUSION

Robot-assisted laparoscopic retroperitoneal donor nephrectomy is a safe and efficient technique that offers advantages of shorter operation time and no abdominal organ interference.

Laparoscopic to robotic living donor nephrectomy: Is it time to change surgical technique?

BACKGROUND

We aimed to explore differences in outcomes of robotic and laparoscopic donor nephrectomies (LDN).

METHODS

This study compared robotic and laparoscopic surgical techniques for live donor nephrectomies in 153 patients at a single centre.

RESULTS

Left nephrectomies were more common in both groups, but with no significant difference between the groups (76.6% vs. 77.6%, p = 0.88). The robotic donor nephrectomies (RDN) group experienced significantly less blood loss (60 vs. 134 mL, p < 0.01), but warm ischaemia time was similar between groups (3.2 vs. 3.7 min, p = 0.54).The RDN group had decreased subjective pain scores (3.54 vs. 4.21, p = 0.04) and shorter length of hospitalisation (2.22 vs. 3.04 days, p < 0.01).There were also fewer complications in the RDN than the LDN group (4 vs. 8, p = 0.186).

CONCLUSION

This study demonstrated that RDN is a safe and alternative to LDN. Decreased blood loss and hospital stays and fewer complications may reflect decreased tissue manipulation with robotic assistance.

Robotic Versus Laparoscopic Donor Nephrectomy: A Retrospective Bicentric Comparison of Learning Curves and Surgical Outcomes From 2 High-volume European Centers

BACKGROUND

Although laparoscopic donor nephrectomy (LDN) represents the gold-standard technique for kidney living donation, robotic donor nephrectomy (RDN) settled as another appealing minimally invasive technique over the past decades. A comparison between LDN and RDN outcomes was performed.

METHODS

RDN and LDN outcomes were compared, focusing on operative time and perioperative risk factors affecting surgery duration. Learning curves for both techniques were compared through spline regression and cumulative sum models.

RESULTS

The study analyzed 512 procedures (154 RDN and 358 LDN procedures) performed between 2010 and 2021 in 2 different high-volume transplant centers. The RDN group presented a higher prevalence of arterial variations (36.2 versus 22.4%; P  = 0.001) compared with the LDN cohort. No open conversions occurred; operative time (210 versus 195 min; P  = 0.011) and warm ischemia time (WIT; 230 versus 180 s; P  < 0.001) were longer in RDN. Postoperative complication rate was similar (8.4% versus 11.5%; P  = 0.49); the RDN group showed shorter hospital stay (4 versus 5 d; P  < 0.001). Spline regression models depicted a faster learning curve in the RDN group ( P  = 0.0002). Accordingly, cumulative sum analysis highlighted a turning point after about 50 procedures among the RDN cohort and after about 100 procedures among the LDN group.Higher body mass index resulted as an independent risk factor for longer operative time for both techniques; multiple arteries significantly prolonged operative time in LDN, whereas RDN was longer in right kidney procurements; both procedures were equally shortened by growing surgical experience.

CONCLUSIONS

RDN grants a faster learning curve and improves multiple vessel handling. Incidence of postoperative complications was low for both techniques.

Retroperitoneal robot-assisted live-donor nephrectomy: A single-center study

Background

As the demand for kidney transplants continues to increase globally, healthcare institutions face a challenge to bridge the gap between patients waitlisted for kidney transplants and the number of donors. A major factor influencing the donor's decision is the operative risk and potential complications of the surgery. Open surgical approaches have been vastly replaced with laparoscopic donor nephrectomies as the standard of practice. However, there is a growing body of evidence pointing towards its potential superiority over laparoscopic methods. In this study, we aim to present our experience on outcomes of Robotic-Assisted Live Donor Nephrectomies (RALDN), the first series of its kind in the United Arab Emirates (UAE).

Methods

We retrospectively collected data from patients who underwent RALDN at Mediclinc City Hospital. Demographic data, laboratory investigations, and operative details were collected and analyzed.

Results

Seven patients underwent RALDN between 2021 and April 2022 at our facility. Four donors were male while three were female. Median length of hospital stay was 4 days. In our study, one of the patients suffered from a Clavien-Dindo grade IV complication which necessitated prolonged admission.

Conclusion

We conclude that RALDN is a safe method for donor kidney procurement, carrying a low risk of morbidity and mortality. This method could potentially evolve the number of kidney donors to address the issue of high kidney transplant demand.

Two- and three-dimensional laparoscopic donor nephrectomy: a comparative study of a single-center experience

Background

This is the first report on three-dimensional (3D) laparoscopic donor nephrectomy performed in the Central Asian region and Commonwealth of Independent States countries. This study presents the results of our initial experiences of 3D hand-assisted laparoscopic donor nephrectomy (3D-HALDN) in comparison with the outcomes of two-dimensional hand-assisted laparoscopic donor nephrectomy (2D-HALDN) at a single center.

Methods

From 2015 to 2019, 19 3D-HALDN and 19 2D-HALDN procedures were performed at the same center by two surgeons. All 38 procedures used identical techniques. Between-group differences were considered statistically significant at P<0.05.

Results

The baseline characteristics in both groups were statistically comparable (P>0.05). All donors underwent left nephrectomy. Donors who underwent 3D-HALDN had better outcomes than those who underwent 2D-HALDN, as shown by a shorter warm ischemic time (P<0.05), a shorter operative time (P<0.05), and less blood loss (P<0.05). There were no conversions or major complications (according to the Clavien-Dindo classification) in either group. The average drainage duration and postoperative hospitalization were significantly shorter in the 3D-HALDN group (P<0.05). The between-group differences in the mean postoperative creatinine level and glomerular filtration rate were not significant.

Conclusions

The 3D-HALDN approach is more beneficial than traditional 2D-HALDN by providing a shorter warm ischemic time, less blood loss, and shorter durations of drainage and postoperative hospitalization. Postoperative complications and the functional condition of the kidney in donors in the early and late postoperative periods did not depend on the type of laparoscopic donor nephrectomy.

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 Living Donor Nephrectomy - Technical Aspects and Initial Evidence]

Minimally invasive donor nephrectomy has become the standard procedure in most transplant centres over the past two decades and has contributed to a reduction in postoperative morbidity for the donor. Robot-assisted technology is an alternative to conventional (hand-assisted) laparoscopic technology and will find increasing use in the future. In this review article, we address technical aspects of robotic-assisted donor nephrectomy, in accordance with our own experience and will provide an overview of the currently available literature. Robot-assisted living kidney donation is a safe procedure with a very low postoperative complication rate. The procedure offers advantages over the open surgical technique with respect to the reduction in the postoperative need for analgesia and the duration of hospital stay, with longer operating times and warm ischemia times, but without a measurable effect on transplant function. The postoperative outcome parameters are comparable to those of the laparoscopic technique, indicating a further acceleration of postoperative convalescence. The advantages of robot-assisted technology, due to the better exposure options, are most relevant in patients with a high BMI and multiple renal arteries, as well as in right-sided nephrectomies in which a longer transplant artery can be obtained. Robot-assisted living kidney donation will play a major role in the future of transplant surgery and is a serious alternative to conventional laparoscopic technology.

The Evolution of Living Donor Nephrectomy Program at A Hellenic Transplant Center. Laparoscopic vs. Open Donor Nephrectomy: Single-Center Experience

Since its introduction in 1995, laparoscopic nephrectomy has emerged as the preferred surgical approach for living donor nephrectomy. Given the ubiquity of the surgical procedure and the need for favorable outcomes, as it is an elective operation on otherwise healthy individuals, it is imperative to ensure appropriate preoperative risk stratification and anticipate intraoperative challenges. The aim of the present study was to compare peri-and postoperative outcomes of living kidney donors (LD), who had undergone laparoscopic nephrectomy (LDN), with a control group of those who had undergone open nephrectomy (ODN). Health-related quality of life (QoL) was also assessed using the validated SF-36 questionnaire. Data from 252 LD from a single transplant center from March 2015 to December 2020 were analyzed retrospectively. In total, 117 donors in the LDN and 135 in the ODN groups were assessed. Demographics, type of transplantation, BMI, duration of surgery, length of hospital stay, peri- and postoperative complications, renal function at discharge and QoL were recorded and compared between the two groups using Stata 13.0 software. There was no difference in baseline characteristics, nor in the prevalence of peri-and postoperative complications, with a total complication rate of 16% (mostly minor, Clavien–Dindo grade II) in both groups, while a different pattern of surgical complications was noticed between them. Duration of surgery was significantly longer in the ODN group (median 240 min vs. 160 min in LDN, p < 0.01), warm ischemia time was longer in the LDN group (median 6 min vs.2 min in ODN, p < 0.01) and length of hospital stay shorter in the LDN group (median 3 days vs. 7 days in ODN). Conversion rate from laparoscopic to open surgery was 2.5%. There was a drop in estimated glomerular filtration rate (eGFR) at discharge of 36 mL/min in the LDN and 32 mL/min in the ODN groups, respectively (p = 0.03). No death, readmission or reoperation were recorded. There was a significant difference in favor of LDN group for each one of the eight items of the questionnaire (SF1–SF8). As for the two summary scores, while the total physical component summary (PCS) score was comparable between the two groups (57.87 in the LDN group and 57.07 in the ODN group), the mental component summary (MCS) score was significantly higher (62.14 vs. 45.22, p < 0.001) in the LDN group. This study provides evidence that minimally invasive surgery can be performed safely, with very good short-term outcomes, providing several benefits for the living kidney donor, thereby contributing to expanding the living donor pool, which is essential, especially in countries with deceased-donor organ shortage.

Outcomes and surgical complications following living-donor renal transplantation using kidneys retrieved with trans-peritoneal or retro-peritoneal hand-assisted laparoscopic nephrectomy

The best minimally invasive procedure for living-donor kidney retrieval remains debated. Our objective was to assess trans-peritoneal (TP) and retro-peritoneal (RP) hand-assisted laparoscopic donor nephrectomy (HALDN). In this single-center retrospective study, we analyzed results from 317 living-donor renal transplants (RT) performed between 2008 and 2016. Donor and recipient outcomes were compared between TP-HALDN (n = 235) and RP-HALDN (n = 82). Conversion to open nephrectomy (0.4% vs 0%; P = 1.000), intra-operative complications (1.7% vs 1.2%; P = 1.000), and 1-year overall post-operative complications (11.9% vs 17.1%; P = .258) rates were similar in TP-HALDN and RP-HALDN. Overall surgical site infections were higher in RP-HALDN (6.1% vs 1.7%; P = .053), whereas incisional hernias were only recorded following TP-HALDN (3.4% vs 0%; P = .118). The duration of the procedure was 11-minute shorter for TP-HALDN than RP-HALDN (P < .001) but extraction time was equivalent (2, IQR 1.5-2.5 minutes; P = 1.000). RT following TP-HALDN and RP-HALDN showed comparable one-year death-censored allograft survival (97% vs 98.8%; P = .685), primary non-function (0.4% vs 0%; P = .290), delayed graft function (1.3% vs 4.9%; P = .077), and urological complications (2.6% vs 4.9%; P = .290) rates. In our series, donor and recipient outcomes were not substantially affected by the approach used for donor nephrectomy. TP-HALDN and RP-HALDN were both safe and effective.