Robot-assisted Transplant Ureteral Repair after Robot-assisted Kidney Transplant

Objective: To use a video to describe steps of robotic-assisted transplant ureteral repair (RATUR) for treating transplant ureteral stricture (TUS) in a patient who had undergone robot assisted kidney transplant (RAKT). Method: We recorded and edited the operation of a patient who experienced TUS by distal obstruction due to a calcification after RAKT and underwent RATUR in 2020. Results: We present a case of a 65-year-old male who developed graft dysfunction. He was found to have a short intrinsic obstruction of the distal transplant ureter due to a calcification that formed around the suture line at the ureteroneocystostomy. The video covers the steps of the operation which include positioning, placement of the ports, orientation, dissection of the paravesicle space, identification and dissection of the ureter, stent placement, reconstruction and post-operative course. We try to include tips and tricks that could be useful in other similar robotic cases. Conclusion: Open surgical repair of the transplant ureter is the standard of care for transplant ureteral stenosis. However, it requires the morbidity of a large surgical incision. Robotic assisted transplant ureteral repair can be done successfully while limiting convalescence from an open reoperation

Ex-vivo ureteroscopy for the treatment of nephrolithiasis in a deceased donor kidney prior to transplantation

Background: There are over 100,000 adult patients awaiting renal transplantation in the United States, with less than 25% who undergo eventual transplantation [1]. This disparity has motivated providers to seek ways to increase the number of kidneys available for transplantation. Historically, the presence of kidney stones in a renal allograft was a relative contraindication for renal transplantation [2]. Ex-vivo ureteroscopy, or, “back-table ureteroscopy”, is a technique which has been employed as a potential solution to increase the total number of available kidneys which were initially deemed ineligible [3,4]. Objective: To demonstrate our step by step technique for ex-vivo ureteroscopy and to demonstrate its safety and efficacy as a method of stone removal prior to transplantation. Methods: Following procurement and back table preparation of the donor kidney by the transplant surgery team, the kidney was replaced in an ice bath for ex-vivo ureteroscopy. A combination of holmium laser lithotripsy and stone basketing were used to extract the stone. Following complete removal of the renal calculus, the renal allograft was reprepared and the renal transplantation was carried forth in the standard fashion by the transplant surgery team. Results: The total operative time for the ex-vivo ureteroscopy was 70 min. No intra-operative complications were identified during ex-vivo ureteroscopy or during allograft transplantation. Six months following transplantation, the patients renal function remains normal. Conclusions: Ex-Vivo ureteroscopy can be a safe and effective treatment for the management of renal stones prior to transplantation. This method can be used with existing resources to increase the number of donor kidneys available for transplantation each year

Robotic-Assisted Versus Open Techniques for Living Donor Kidney Transplant Recipients: A Comparison Using Propensity Score Analysis

Background: Following the rapid advancements in minimally invasive urology, living donor robotic-assisted kidney transplantation (RAKT) has developed into a feasible alternative to open kidney transplantation (OKT). The procedure has been performed in multiple international programs, but a relative dearth of experience exists in the US. In this investigation, we compare RAKT to OKT using a propensity score analysis, to elucidate the safety and feasibility of RAKT as a suitable alternative to OKT. Methods: A retrospective review of 101 living kidney transplants (36 RAKT, 65 OKT), which occurred between January 2016 and June 2018, was conducted. Selection for RAKT was based on Robot availability. Recipient and donor demographic variable were collected, in addition to perioperative parameters. A propensity score analysis was conducted, matching for recipient age, gender, body mass index, race, pre-operative dialysis, preoperative serum creatinine, panel reactive antibody, and donor age. Primary outcomes assessed included perioperative factors such as estimated blood loss (EBL), cold ischemic time (CIT), warm ischemic time (WIT), operative time, as well as several patient outcomes including, length of stay, narcotics consumed on postoperative days one and two, and change in serum creatinine (SCr) at five time points (day 3, day 7, day 14, 6 months, and 1 year). Final analysis included 35 patients in each group. Results: Recipients’ (N=101) mean age was 49 years (range 19-74), with RAKT recipients slightly younger than OKT recipients (46 vs 51 years). 61 recipients were male and 62 white (29 Black, 10 other). Average recipient BMI was 29 (range 20-40), with equivalent BMIs in RAKT and OKT subsets. Following propensity score analysis, RAKT recipients demonstrated significantly greater WIT (49 vs 38 minutes, p\u3c0.001) and less EBL (62.5 vs 150 mL, p\u3c0.001). However, total operative time and overall length of stay were not significantly different in the groups. Postoperative narcotics consumed on postoperative days one and two were similar between the groups (31.8 vs 32.3 morphine equivalents). Additionally, SCr was evaluated at days 3, 7, and 14 as well as 6 months and 1 year, without significant differences between the groups. Conclusion: RAKT offers an important minimally invasive alternative to OKT, with a short learning curve, and similar graft and patient outcomes. Notably, this study compares RAKT to OKT with a heterogeneous study population, using propensity scoring. The largest limitation of this study is a small sample size. Interestingly, despite the significantly longer WIT in RAKT, we found an equivalence of SCr between groups in the early and intermediate postoperative period. Although the small sample size limits our ability to detect differences in graft and patient outcomes, trends demonstrate shorter lengths of stay, shorter operative times, and smaller amounts of blood loss for RAKT recipients. Additionally, trends demonstrate fewer narcotics administered by the second postoperative day. Similar to the advent of laparoscopic technology in living donor nephrectomy, early findings in RAKT demonstrate a safe and reasonable alternative for living donor kidney transplantation in various populations.https://scholarlycommons.henryford.com/merf2019clinres/1052/thumbnail.jp

Robotic-assisted Versus Open Technique for Living Donor Kidney Transplantation: A Comparison Using Propensity Score Matching for Intention to Treat

Living donor robotic-assisted kidney transplantation (RAKT) is an alternative to open kidney transplantation (OKT), but experience with this technique is limited in the United States. METHODS: A retrospective review of living donor kidney transplants performed between 2016 and 2018 compared RAKT with OKT with regard to recipient, donor, and perioperative parameters. A 1:1 propensity score matching was performed on recipient/donor age, sex, body mass index, race, preoperative dialysis, and calculated panel reactive antibodies. RESULTS: Outcomes of patient survival, graft survival, and postoperative complications were assessed for 139 transplants (47 RAKT and 92 OKT). Propensity score analysis (47:47) showed that RAKT recipients had longer warm ischemic times (49 versus 40 min; P \u3c 0.001) and less blood loss (100 versus 150 mL; P = 0.005). Operative time and length of stay were similar between groups. Postoperative serum creatinine was similar during a 2-y follow-up. Post hoc analysis excluding 4 open conversions showed lower operative time with RAKT (297 versus 320 min; P = 0.04) and lower 30-d (4.7% versus 23.4%; P = 0.02) and 90-d (7% versus 27.7%; P = 0.01) Clavien-Dindo grade ≥3 complications. CONCLUSIONS: Our findings suggest that RAKT is a safe alternative to OKT

The Effects of Simultaneously Training Additional Surgeons in the Living Donor Robotic Assisted Kidney Transplant

Purpose: Minimally invasive surgery is an ever-developing field in surgery. Numerous international transplant programs have reported the success and safety of robotic assisted kidney transplant surgery. The first robotic assisted kidney transplant (RAKT) at Henry Ford was performed on May 13, 2014. In August 2018, the lead surgeon started training an additional senior staff surgeon at Henry Ford in addition to a junior transplant surgery fellow. Studies have shown that the learning curve for RAKT is short, but the details regarding a training program in the US has not been reported. This study hopes to validate the safety of simultaneously training multiple surgeons in the RAKT. Methods: 50 living donor RAKT were performed between January 2014 and November 2018. 3 recipients were converted to open and were thus excluded from this study. The number of surgeons involved with each transplant was used to stratify the surgeries. Single surgeon operations were compared to two and surgeon operations where there was either one or two trainees participating respectively Total operative time and post operative creatinine trends were analyzed. Results: 47 living donor robotic assisted kidney transplants were evaluated. One surgeon cases totaled 11. Two surgeon cases totaled 14. Three surgeon cases totaled 7. Cold ischemia time and warm ischemia time did not differ between one surgeon. two surgeon and three surgeon cases (7. 8, 94. 6, 87. 1 and 46. 8, 48. 9, 45. 7 respectively; p= 0. 48 and 0. 81). Serum creatinine levels were measured at days 3, 7, 14, 6 months and 1 year. Serum creatinine levels were no different when comparing one surgeon, two surgeon and three surgeon cases. EBL and operative times were also no different (p = 0. 76 and 0. 87 respectively). Conclusions: In order to gain adequate experience with robotic assisted minimally invasive surgery, and in attempt to utilize safe technology, training multiples surgeons does not appear to affect operative times or post operative creatinine levels. Simultaneous training of multiple surgeons on the Da Vinci robotic console appears to be a safe way of training surgeons in RAKT

Frailty Testing Pilot Study: Pros and Pitfalls

Background: Frailty can be defined as an inflammatory state with a loss of physiologic reserve in multiple systems that manifests as a decreased ability to respond to stressors that ultimately leads to an increased risk of adverse outcomes. The aim of this study was to determine the ease of frailty testing in a pre-kidney transplant clinic and the resources required to do so. A secondary goal was to better understand the utility of frailty testing when evaluating potential kidney transplant recipients. Methods: Frailty testing was conducted at a pre-kidney transplant clinic in three phases using Fried\u27s frailty phenotype (shrinking, exhaustion, low physical activity, slowness, and grip strength). Results: A total of 132 frailty tests were completed on 128 patients. Frail patients had significantly higher rates of shrinking (26% vs. 8.5%, P \u3c 0.05), exhaustion (82.6% vs. 27.6%, P \u3c 0.05), low physical activity (78.2% vs. 19.0%, P \u3c 0.05), slow walking (60.8% vs. 15.2%, P \u3c 0.05), and grip strength (73.9% vs. 25.7%, P \u3c 0.05). When comparing the listing of frail and non-frail patients for transplant, a significantly lower proportion of frail patients were listed compared to non-frail patients (30.4% vs. 57.6%, P \u3c 0.05). Frailty testing was most complete when an examiner dedicated to frailty testing performed the testing. Conclusions: Frailty testing is feasible to complete in a pre-transplant clinic with an appropriate investment in personnel and resources

Liposomal bupivacaine: Friend or foe in kidney donation?

Background: Pain following nephrectomy and concerns for opioid dependence are disincentives to living kidney donors (LKD). Efficacy of liposomal bupivacaine (LB) in post-operative care of LKD is variable. We evaluated the efficacy of a LBcontaining versus non-LB-containing pain control regimen in LKD. Methods: This was a retrospective review of LKD with complete electronic medical records. Primary endpoints were pain scores (PS) and change in PS at various time points (first PS, PS at 4, 8, 12, 16, 20, 24, 48 and 72 hours, last PS prior to discharge, and minimum and maximum PS). Secondary endpoints were opioid use in intravenous morphine equivalents (IV ME), length of stay (LOS), and adverse effects (AE) from opioid therapy. Results: Of 117 patients who met criteria, 62 patients received LB and 55 patients received a non-LB regimen. The reported PS and change in PS were comparable between groups except for minimum PS (p=0.02) (Tables 1 and 2). LB group received less oxycodone (10 mg IV ME vs. 15 mg IV ME; p=0.01) and hydrocodoneacetaminophen (6.7 mg IV ME vs. 13.3 mg IV ME, p=0.04) within the first 24 hours, while overall post-operative opioid use (30.8 mg IV ME vs. 24 mg IV ME; p=0.85) was no different. Median LOS and AEs were comparable. Table 1. Pain scores (Table presented) Conclusion: Post-operative pain outcomes were similar between LB and non-LB regimens, however significantly less opioid use was required in the first 24 hours in the LB group and may indicate a benefit with use of LB

Liposomal bupivacaine: Friend or foe in kidney donation?

Background: Pain following nephrectomy and concerns for opioid dependence are disincentives to living kidney donors (LKD). Efficacy of liposomal bupivacaine (LB) in post-operative care of LKD is variable. We evaluated the efficacy of a LBcontaining versus non-LB-containing pain control regimen in LKD. Methods: This was a retrospective review of LKD with complete electronic medical records. Primary endpoints were pain scores (PS) and change in PS at various time points (first PS, PS at 4, 8, 12, 16, 20, 24, 48 and 72 hours, last PS prior to discharge, and minimum and maximum PS). Secondary endpoints were opioid use in intravenous morphine equivalents (IV ME), length of stay (LOS), and adverse effects (AE) from opioid therapy. Results: Of 117 patients who met criteria, 62 patients received LB and 55 patients received a non-LB regimen. The reported PS and change in PS were comparable between groups except for minimum PS (p=0.02) (Tables 1 and 2). LB group received less oxycodone (10 mg IV ME vs. 15 mg IV ME; p=0.01) and hydrocodoneacetaminophen (6.7 mg IV ME vs. 13.3 mg IV ME, p=0.04) within the first 24 hours, while overall post-operative opioid use (30.8 mg IV ME vs. 24 mg IV ME; p=0.85) was no different. Median LOS and AEs were comparable. Table 1. Pain scores (Table presented) Conclusion: Post-operative pain outcomes were similar between LB and non-LB regimens, however significantly less opioid use was required in the first 24 hours in the LB group and may indicate a benefit with use of LB