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NEW HORIZON
Year : 2018  |  Volume : 10  |  Issue : 3  |  Page : 330-332  

Robotic-assisted dual kidney transplantation


Department of Urology, Aster Medcity, Kochi, Kerala, India

Date of Submission02-Feb-2018
Date of Acceptance09-May-2018
Date of Web Publication12-Jul-2018

Correspondence Address:
Dr. Sharma Himanshu
Department of Urology, Aster Medcity, Kochi, Kerala
India
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DOI: 10.4103/UA.UA_14_18

PMID: 30089995

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   Abstract 


Aim: The aim of this study was to report the feasibility of robotic-assisted dual kidney transplantation (DKT) in a marginal donor.
Materials and Methods: The case was a 53-year-old male, who with IgA nephropathy underwent a robotic-assisted robotic DKT.
Results: The total operating time was 265 min, total console time was 215 min, and anastomotic time was 39 min for both the kidneys, and blood loss was 220 ml. The total drain output was 150 ml on the 1st day. The drain was removed after 48 h and Foley catheter was removed after 5 days. Nadir creatinine was 1.1 mg/dl and time to nadir creatinine was 7 days. The patient received one unit of blood transfusion. Total postoperative hospital stay was 7 days and bilateral ureteric stents were removed after 14 days. At the end of 3 months, creatinine was 1.0 mg% and epidermal growth factor receptor was 82 ml/min/1.73 m2.
Conclusion: Robotic DKT offers solutions to the challenges faced in open DKT.

Keywords: Dual transplantation, kidney transplantation, minimally invasive kidney transplantation, robotic kidney transplantation, robotic surgery


How to cite this article:
Himanshu S, Ramaprasad M K, Vishnu R, Kishore T A. Robotic-assisted dual kidney transplantation. Urol Ann 2018;10:330-2

How to cite this URL:
Himanshu S, Ramaprasad M K, Vishnu R, Kishore T A. Robotic-assisted dual kidney transplantation. Urol Ann [serial online] 2018 [cited 2020 Oct 24];10:330-2. Available from: https://www.urologyannals.com/text.asp?2018/10/3/330/236520




   Introduction Top


Expanded criteria donors (ECDs) are defined as older than 60 or over 50 years with complicating comorbidities including hypertension, diabetes, cerebrovascular accident as a cause of death, or a terminal serum creatinine of 2.0 mg/dl or higher.[1],[2] In order to increase the utilization of deceased donor organs, the United Network of Organ Sharing has implemented new policies to use organs from ECDs.[1],[2] The first adult dual kidney transplantation (DKT) was performed in 1996 by Johnson et al.[3] The premise of transplanting both donor kidneys into a recipient is to increase the functional nephron mass.[3] The DKT involves longer surgical time and is prone to surgical complications due to the complexity of procedure. The original technique included bilateral Gibson incision and transplanting one kidney to each side.[3] Later on, surgical modifications such as unilateral placement of the kidney and en bloc transplantation had been described.[4],[5],[6],[7] In the past few years, robotic kidney transplantation is gaining popularity across the world.[8],[9] The first case of robotic-assisted DKT was reported by Frongia et al.[10] We report our initial case of robotic DKT and, to our knowledge, this is the second case reported so far.


   Materials and Methods Top


A 53-year-old patient with IgA nephropathy was on hemodialysis with a history of recent laparotomy for splenic trauma. The deceased donor was a 63-year-old diabetic patient who had a cerebrovascular accident and subsequent brainstem death. He was a known diabetic for 5 years with a creatinine of 1.5 mg% at the time of retrieval. The ports are placed in a similar fashion to robotic radical prostatectomy with cephalad displacement of the ports by 4 cm. The procedure started with incision of peritoneum at the level of umbilicus to iliac fossa on both sides. This enables to fashion a flap of peritoneum along with bladder [Figure 1]a and [Figure 1]b. Subsequently, iliac vessels were dissected and prepared for anastomosis. A Pfannenstiel incision was made and a GelPOINT ® (Applied Medical Resources Corp, Rancho Santa Margarita, CA, USA) was inserted through it [Figure 1]c. The graft was wrapped in a gauze jacket and placed through this incision [Figure 1]d. A marking stich was placed on the upper pole on the gauze jacket to orient the kidney while performing anastomosis. Initially, the left donor kidney was placed in the right iliac fossa [Figure 2]a. Arterial and venous anastomoses were performed using 6.0 Gortex suture (Gore-Tex CV-6; W.L. Gore and Associates Inc., Flagstaff, AZ, USA). A custom-made punch was utilized for arteriotomy. Once the clamps were released, the right donor kidney was placed inside and anastomosis was performed to the left external iliac vessels [Figure 2]b. The peritoneum was approximated to the anterior abdominal wall [Figure 2]c and an extraperitoneal drain was placed [Figure 2]d. The vascularity of both kidneys was confirmed by a Doppler scan using a robotic drop-down probe (Hitachi Aloka Medical America Inc., CT, USA). After the release of pneumoperitoneum, the position of the graft was verified by inserting the camera through the GelPOINT ®. Vesicoureteric anastomosis was completed through the Pfannenstiel incision using a 4.0 Polygalactin suture (Ethicon Inc., Cincinnati, OH, USA) and a 5-Fr 15-cm double J stent was placed. The detrusor layer was closed using 6” V-Loc 3-0 CV23 (Covidien Inc., New Haven, CT, USA). The Pfannenstiel incision and port sites were closed subsequently [Figure 2]d.
Figure 1: (a) Development of extraperitoneal space, (b) the extraperitoneal flap, (c) the GelPOINT® in situ, (d) graft in position with ice slush

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Figure 2: (a) Right allograft being anastomosed with left external iliac vessels, (b) left-sided graft being placed and anastomosed, (c) peritoneal flap after closure, (d) postoperative appearance

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   Results Top


The total operating time was 265 min, total console time was 215 min, and anastomotic time was 39 min for both the kidneys, and blood loss was 220 ml. The total drain output was 150 ml on the first day. The drain was removed after 48 h and Foley catheter was removed after 5 days. Nadir creatinine was 1.1 mg/dl and time to nadir creatinine was 7 days. The patient received one unit of blood transfusion. Total postoperative hospital stay was 7 days and bilateral ureteric stents were removed after 14 days. At the end of 3 months, creatinine was 1.0 mg% and epidermal growth factor receptor was 82 ml/min/1.73 m 2.


   Discussion Top


DKT recipients have comparable outcomes in terms of function, graft loss, and survival versus those in elderly patients with younger grafts.[11],[12] DKT carries a potentially higher risk of surgical complications because of the longer surgical procedure and multiple anastomosis involved.[11],[12],[13] Conventional technique described is that of bilateral Gibson incision and transplanting one kidney to each side. The drawbacks of this method are higher tissue dissection, a longer operative time, and increased chance of wound complications.[3] A midline extraperitoneal approach was described to minimize dissection, operative time, and wound dissection by Haider et al. in 2007.[4] Unilateral placement of both kidneys was described by Mason and Hefty in 1998.[5] The right kidney was placed superiorly, with renal artery anastomosed into the common iliac artery and renal vein into the inferior vena cava. With this method, both ureters were spatulated and joined to each other. This technique reduced trauma from the surgical procedure and operative time. Moreover, the contralateral side remained untouched for possible future transplant.[6],[7] The drawbacks of this technique include higher incidence of lymphoceles, high risk of hemorrhage, and increased risk of single graft loss.[14],[15]

The first ever robotic DKT was performed by Frongia et al. in 2014 which resulted in favorable outcome at 24 months.[10] They have utilized an epigastric incision to introduce the graft and reported 400 min operating time. In our case, we have employed a Pfannenstiel incision and a GelPOINT ® to introduce the graft. The GelPOINT ® allows in maintaining the pneumoperitoneum while introducing the graft. The Pfannenstiel incision enabled us to perform open technique to perform ureterovesical anastomosis. The ureterovesical anastomosis can be performed comfortably through the graft insertion incision as it is directly placed over the bladder. This reduces the operating time, duration of pneumoperitoneum, and Trendelenburg position.


   Conclusion Top


Robotic DKT offers solutions to the challenges faced in open DKT.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Harada KM, Mandia-Sampaio EL, de Sandes-Freitas TV, Felipe CR, Park SI, Pinheiro-Machado PG, et al. Risk factors associated with graft loss and patient survival after kidney transplantation. Transplant Proc 2009;41:3667-70.  Back to cited text no. 1
    
2.
Pascual J, Zamora J, Pirsch JD. A systematic review of kidney transplantation from expanded criteria donors. Am J Kidney Dis 2008;52:553-86.  Back to cited text no. 2
    
3.
Johnson LB, Kno PC, Dafoe DC, Schweitzer EJ, Alfrey EJ, Klassen DK, et al. Double adult renal allografts: A technique for expansion of the cadaveric kidney donor pool. Surgery 1996;120:580-3.  Back to cited text no. 3
    
4.
Haider HH, Illanes HG, Ciancio G, Miller J, Burke GW. Dual kidney transplantation using midline extraperitoneal approach: Description of a technique. Transplant Proc 2007;39:1118-9.  Back to cited text no. 4
    
5.
Masson D, Hefty T. A technique for the transplantation of 2 adult cadaver kidney grafts into 1 recipient. J Urol 1998;160:1779-80.  Back to cited text no. 5
    
6.
Ekser B, Baldan N, Margani G, Furian L, Frison L, Valente M, et al. Monolateral placement of both kidneys in dual kidney transplantation: Low surgical complication rate and short operating time. Transpl Int 2006;19:485-91.  Back to cited text no. 6
    
7.
Salehipour M, Bahador A, Nikeghbalian S, Kazemi K, Shamsaeifar AR, Ghaffaripour S, et al. En-bloc transplantation: An eligible technique for unilateral dual kidney transplantation. Int J Organ Transplant Med 2012;3:111-4.  Back to cited text no. 7
    
8.
Oberholzer J, Giulianotti P, Danielson KK, Spaggiari M, Bejarano-Pineda L, Bianco F, et al. Minimally invasive robotic kidney transplantation for obese patients previously denied access to transplantation. Am J Transplant 2013;13:721-8.  Back to cited text no. 8
    
9.
Abaza R, Ghani KR, Sood A, Ahlawat R, Kumar RK, Jeong W, et al. Robotic kidney transplantation with intraoperative regional hypothermia. BJU Int 2014;113:679-81.  Back to cited text no. 9
    
10.
Frongia M, Cadoni R, Solinas A. First robotic-assisted dual kidney transplant: Surgical technique and report of a case with 24-month follow-up. Transplant Direct 2015;1:e34.  Back to cited text no. 10
    
11.
Lee RS, Marsh CL, Miller EA, Kuhr CS. Intermediate outcomes of dual renal allografts. Transplant Proc 2003;35:854-5.  Back to cited text no. 11
    
12.
Bunnapradist S, Gritsch HA, Peng A, Jordan SC, Cho YW. Dual kidneys from marginal adult donors as a source for cadaveric renal transplantation in the United States. J Am Soc Nephrol 2003;14:1031-6.  Back to cited text no. 12
    
13.
Hassan A, Halawa A. Dual kidney transplant. Exp Clin Transplant 2015;13:500-9.  Back to cited text no. 13
    
14.
Boggi U, Barsotti M, Collini A, Bernini M, Vistoli F, Paleologo G, et al. Kidney transplantation from donors aged 65 years or more as single or dual grafts. Transplant Proc 2005;37:577-80.  Back to cited text no. 14
    
15.
Timsit MO, Rabant M, Snanoudj R, Cohen D, Salin A, Malek S, et al. Single graft loss in dual renal transplant recipients: Impact of graft placement on recipient outcomes. Transpl Int 2011;24:51-7.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2]



 

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