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

New genetic loci link adipose and insulin biology to body fat distribution.

Body fat distribution is a heritable trait and a well-established predictor of adverse metabolic outcomes, independent of overall adiposity. To increase our understanding of the genetic basis of body fat distribution and its molecular links to cardiometabolic traits, here we conduct genome-wide association meta-analyses of traits related to waist and hip circumferences in up to 224,459 individuals. We identify 49 loci (33 new) associated with waist-to-hip ratio adjusted for body mass index (BMI), and an additional 19 loci newly associated with related waist and hip circumference measures (P < 5 × 10(-8)). In total, 20 of the 49 waist-to-hip ratio adjusted for BMI loci show significant sexual dimorphism, 19 of which display a stronger effect in women. The identified loci were enriched for genes expressed in adipose tissue and for putative regulatory elements in adipocytes. Pathway analyses implicated adipogenesis, angiogenesis, transcriptional regulation and insulin resistance as processes affecting fat distribution, providing insight into potential pathophysiological mechanisms

Genetic associations at 53 loci highlight cell types and biological pathways relevant for kidney function.

Reduced glomerular filtration rate defines chronic kidney disease and is associated with cardiovascular and all-cause mortality. We conducted a meta-analysis of genome-wide association studies for estimated glomerular filtration rate (eGFR), combining data across 133,413 individuals with replication in up to 42,166 individuals. We identify 24 new and confirm 29 previously identified loci. Of these 53 loci, 19 associate with eGFR among individuals with diabetes. Using bioinformatics, we show that identified genes at eGFR loci are enriched for expression in kidney tissues and in pathways relevant for kidney development and transmembrane transporter activity, kidney structure, and regulation of glucose metabolism. Chromatin state mapping and DNase I hypersensitivity analyses across adult tissues demonstrate preferential mapping of associated variants to regulatory regions in kidney but not extra-renal tissues. These findings suggest that genetic determinants of eGFR are mediated largely through direct effects within the kidney and highlight important cell types and biological pathways

Effects of sarcopenia on patients undergoing liver re-transplantation

Background: Loss of muscle mass (sarcopenia) has been found to be a measure of mortality after primary liver transplantation. We aimed to evaluate its effect in liver retransplantation patients. Study Design: 67 liver re-transplant patients between 2005 and 2017 were evaluated. Relationship between psoas muscle index (PMI; total psoas muscle area at L3 level/height) with patient characteristics and lab values along with its effects on early and late mortality were assessed. Patient survival was compared using a log-rank test. Results: Median PMI was significantly different among males (878 cm2/m) and females (693 cm2/m) (p=0.045). Based on median PMI of each gender, patients were categorized into two groups (high and low PMI; M: n=21 & 19, F: n=15 & 12). MELD scores (P=0.24) along with lab values such as albumin (p=0.20), creatinine (p=0.95), total bilirubin (P=0.84) and INR (p=0.88) were similar in both low and high male PMI groups. Similar results were observed in the female PMI groups (p=0.33, p=0.87, p=0.56, p=0.40 and, p=0.36, respectively). Rates of mortality at 3, 6, and 12 months were similar in both sets of PMI groups (Male: p=0.92, p=0.92, and p=0.84; Female: p=0.46, p=0.73, and p=0.74, respectively). Hospital length of stay was also found to be similar both male (19 vs 24.5 days, p=0.85) and female groups (22 vs 14.5 days, p=0.29). Conclusion: Sarcopenia did not correlate with post-transplant outcomes or mortality after liver re-transplantation

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

Effects of sarcopenia on patients undergoing liver re-transplantation

Background: Loss of muscle mass (sarcopenia) has been found to be a measure of mortality after primary liver transplantation. We aimed to evaluate its effect in liver re-transplantation patients. Study Design: 67 liver re-transplant patients between 2005 and 2017 were evaluated. Relationship between psoas muscle index (PMI; total psoas muscle area at L3 level/height) with patient characteristics and lab values along with its effects on early and late mortality were assessed. Patient survival was compared using a log-rank test. Results: Median PMI was significantly different among males (878 cm2/m) and females (693 cm2/m) (p=0.045). Based on median PMI of each gender, patients were categorized into two groups (high and low PMI; M: n=21 & 19, F: n=15 & 12). MELD scores (P=0.24) along with lab values such as albumin (p=0.20), creatinine (p=0.95), total bilirubin (P=0.84) and INR (p=0.88) were similar in both low and high male PMI groups. Similar results were observed in the female PMI groups (p=0.33, p=0.87, p=0.56, p=0.40 and, p=0.36, respectively). Rates of mortality at 3, 6, and 12 months were similar in both sets of PMI groups (Male: p=0.92, p=0.92, and p=0.84; Female: p=0.46, p=0.73, and p=0.74, respectively). Hospital length of stay was also found to be similar both male (19 vs 24.5 days, p=0.85) and female groups (22 vs 14.5 days, p=0.29). Conclusion: Sarcopenia did not correlate with post-transplant outcomes or mortality after liver re-transplantation

Robot-assisted Transplant Ureteral Repair to treat transplant ureteral strictures in patients after Robot-assisted Kidney Transplant: a case series

OBJECTIVE: To describe the use of robotic-assisted transplant ureteral repair (RATUR) for treating transplant ureteral stricture (TUS) in 3 patients who had undergone robot assisted kidney transplant (RAKT). METHOD: We reviewed the medical records of 3 patients who experienced TUS after RAKT and who underwent RATUR between 2017 and 2020. The patients\u27 RAKT, post-transplant clinical course, endourological interventions, reoperation, and recovery were assessed. RESULTS: All patients diagnosed with TUS presented with deterioration of kidney function after RAKT. Method of diagnosis included ultrasound, antegrade ureterogram, and CT scan. All 3 patients had a short (\u3c1 \u3ecm) area of TUS and underwent RATUR. For 2 patients, distal strictures were bypassed with modified Lich-Gregoir ureteroneocystostomy reimplantation. One patient was treated with pyelo-ureterostomy to the contralateral native ureter. No intraoperative complications, conversions to open surgery, or significant operative blood loss requiring blood transfusion for any patient were observed. Also, no patients had urine leaks in the immediate or late postoperative period. After RATUR, 2 patients developed Clavien grade II complications with rectus hematoma or urinary tract infection. CONCLUSION: RATUR is a technically feasible operation for kidney transplant patients with TUS after RAKT. This procedure may provide the same benefits of open operation without promoting certain comorbidities that may occur from open surgical procedures

A comparison of robotic and open living donor kidney transplantation -The minimally invasive option and its outcomes

Background: Robotic assisted kidney transplantation (RAKT) has become a feasible option in field of transplantation. We have been routinely performing this technique in living donor kidney transplant with excellent outcomes. Here, we compare our results with our open living donor kidney transplants (OKT). Methods: From 2013 to 2016, a total of 96 OKTs and 25 RAKTs have been performed at a tertiary care center. Pre-operative characteristics, operative parameters and post-operative patient outcomes were analyzed. Results: The technique of RAKT included proper positioning, placement of a Gellpoint-port and 3 other ports followed by intraperitoneal kidney implantation. Two patients had to be converted to open because of technical complications, while one was aborted due to poor insufflation. The comparison between RAKT and OKT is outlined in Table 1. RAKT offered lower blood loss and cold ischemia time, while warm ischemia time was higher. There was no increased incidence of delayed graft function, while post-operative pain and return to ambulation was similar to OKT. There was lower incidence of wound related complications in RAKT. Patient and graft survival at 1 year was 100% for both. Conclusion: Robotic kidney transplantation offers minimally-invasive option with equivalent outcomes to open kidney transplants. In obese patients, it is technically easier to perform. We believe that beyond the learning curve, robotic kidney transplant can provide a minimally invasive option which will eventually reduce overall complications while maintaining great renal outcomes

Robotic assisted live donor kidney transplantation - Technique and outcomes

Background: Robotic assisted kidney transplantation (RAKT) is now a feasible minimally invasive option in place of open living donor kidney transplant (OKT). Here, we briefly describe and compare the technical aspects and outcomes. Methods: From Jan 2013 to Aug 2017, we compared a total of 94 OKTs and 27 RAKTs and analyzed their outcomes. Results: The technique of RAKT included Trendelenburg in a modified lithotomy position at 10 degrees, placement of a midline Gellpoint port, 2 other robotic and 1 assistant ports. This was followed by intraperitoneal kidney implantation. Of the 27 recipients, 2 patients were converted to open because of technical complications. RAKT offered lower blood loss and lower cold ischemia time, while warm ischemia time was higher. There was no increased incidence of delayed graft function, with similar post-operative pain and length of stay. There was lower incidence of wound related complications in RAKT. Patient and graft survival was 100% for both. We divided our first 13 and our next 14 RAKTs for comparison. With experience, our mean blood loss and cold ischemia times have decreased moderately, while warm ischemia times decreased significantly (p=0.029). The mean pain scores and days to ambulation were also much lower in the latter period. Conclusions: RAKT offers minimally invasive option with equivalent outcomes to open kidney transplants. In obese patients, it is technically easier to perform. It has a short learning curve with a trend towards lower pain and warm ischemia times. RAKT can provide a minimally invasive option with equal or better short term patient outcomes while maintaining excellent renal outcomes