The aim of the study is to report the European experience on surgical variations and technical innovations in robot-assisted kidney transplantation (RAKT).
The patient is placed in the lithotomy and Trendelenburg (20°-30°) position. On the bench table, a double-J ureteral stent is inserted, and the graft is wrapped in a gauze filled with ice slush to lower its temperature once in the abdominal cavity. The anterior wall of the artery is shortened to avoid its kinking after kidney rotation into the peritoneal pocket. The positioning of the ports resembles the W-shaped scheme for robot-assisted radical prostatectomy. The difference is represented by the port for arm 3, to be placed on the intersection between the line joining the pubis to arm 4 and the umbilicus–anterior superior iliac spine line. After dissection of the exterior iliac vessels, a transverse incision of the peritoneum is done above the level of the appendix for graft retroperitonealization. The GelPOINT® is placed through a periumbilical or Pfannenstiel incision; the graft is inserted into the abdominal cavity. In selected cases, the graft may be inserted transvaginally. The AirSeal® system might be used to maintain the pneumoperitoneum at 8mmHg.
The venotomy is performed using the cold scissors. The graft renal vein is anastomosed in an end-to-side continuous fashion to the external iliac vein using a 6/0 Gore-Tex® CV-6, as for the arterial anastomosis. The arteriotomy is performed at 1 o’clock to reduce the risk of arterial kinking, and eventually regularized with an arterial punch. The first knot at the caudal angle of the arterial anastomosis is tied after passing the needle through the graft artery in outside-inside fashion to start the suture. A double graft artery may be anastomosed on the bench or separately. Just prior to knot the anastomoses, the lumen is flushed with heparinized solution via a ureteral catheter.
Once the graft has been rotated for retroperitonealization, vascularization of the graft can be evaluated with the FireFly™ fluorescence and, particularly, vascularization of the ureter, which is crucial to low the risk of ureteral stenosis. Ureteroneocystotomy is performed according to the Lich-Gregoir technique.
Intraoperative complications occurred in 8/183 (4.4%). Postoperative Clavien-Dindo grade III/IV complications were reported in 11/183 (6%) cases, the majority during the first ten RAKTs in each Center (7/11, 64%). Three graft losses occurred during the first ten procedures, all because of arterial thrombosis; none were reported after 10 surgeries (3/183; 1.6%; p=0.02).
Mean eGFR on postoperative days 7, 30 and at 1 year were 54 (±22), 57(±21), 58(±18) ml/min/1.73 m2, respectively.
Robot-assisted kidney transplantation is a safe and feasible surgery which innovations and technical variations are permitting to expand its indications.