Robotic kidney transplantation with intraoperative regional hypothermia.

OBJECTIVE: To describe a novel and reproducible technique of robotic kidney transplantation (RKT) that requires no repositioning, and permits intraoperative regional hypothermia. PATIENTS AND METHODS: A GelPOINT™ (Applied Medical, Santa Ranchero, CA, USA) access port was used for delivery of ice-slush and introduction of the graft kidney. The new RKT technique using ice-slush has been performed in 39 patients. RESULTS: At a mean follow-up of 3 months all of the grafts functioned. There was a marked reduction in pain and analgesic requirement compared with patients undergoing open KT, with a propensity towards quicker graft recovery and lower complication rate. CONCLUSION: RKT has been shown to be safe and feasible in patients undergoing living-donor related KT. A prospective trial is underway to assess outcomes definitively.

Case report: Renal cell carcinoma with metastasis to the myometrium.

Renal cell carcinoma (RCC) is well known for its ability to metastasize to different organs, but the involvement of gynecological organs is rare. Our case represents the first case of bilateral RCC with metastasis to the myometrium. The patient was a 60-year-old woman who underwent bilateral robotic partial nephrectomy surgeries for clear cell RCC, low-grade, low-stage with negative margins. Her 1-year postoperative computed tomography scan showed an enlarging necrotic uterine mass. She underwent a debulking excision, including hysterectomy, with pathology showing metastatic RCC to the uterus. The patient developed widespread metastatic disease, and died months later of metastatic RCC.

Robotic kidney transplantation with regional hypothermia: evolution of a novel procedure utilizing the IDEAL guidelines (IDEAL phase 0 and 1).

BACKGROUND: Surgical innovation is essential for progress of surgical science, but its implementation comes with potential harms during the learning phase. The Balliol Collaboration has recommended a set of guidelines (Innovation, Development, Exploration, Assessment, Long-term study [IDEAL]) that permit innovation while minimizing complications. OBJECTIVE: To utilize the IDEAL model of surgical innovation in the development of a novel surgical technique, robotic kidney transplantation (RKT) with regional hypothermia, and describe the process of discovery and development. DESIGN, SETTING, AND PARTICIPANTS: Phase 0 (simulation) studies included the establishment of techniques for pelvic cooling, graft placement in a robotic prostatectomy model, and simulation of the RKT procedure in a cadaveric model. Phase 1 (innovation) studies began in January 2013 and involved treatment of a highly selective small group of patients (n=7), using the principles utilized in the phase 0 studies, at a tertiary referral center. INTERVENTION: IDEAL model implementation in the development of RKT with regional hypothermia. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: For phase 0 studies, the outcomes evaluated included pelvic and body temperature measurements, and technical feasibility assessment. The primary outcome during phase 1 was post-transplant graft function. Other outcomes measured were operative and ischemic times, perioperative complications, and intracorporeal graft surface temperature. RESULTS AND LIMITATIONS: Phase 0 (simulation phase): Pelvic cooling to 15-20(o)C was achieved reproducibly. Using the surgical approach developed for robotic radical prostatectomy, vascular and ureterovesical anastomoses could be done without redocking the robot. Phase 1 (innovation phase): All patients underwent live-donor RKT in the lithotomy position. All grafts functioned immediately. Mean console, anastomotic, and warm ischemia times were 154 min, 29 min, and 2 min, respectively. One patient was re-explored on postoperative day 1. CONCLUSIONS: Adherence to the IDEAL guidelines put forth by the Balliol Collaboration provided a practical framework for the establishment of a novel surgical procedure, RKT with regional hypothermia, without exposing the initial patients to unacceptable risk. PATIENT SUMMARY: The IDEAL model allows safe introduction of new surgical techniques without compromising patient outcomes.

Robotic kidney transplantation with regional hypothermia: a step-by-step description of the Vattikuti Urology Institute-Medanta technique (IDEAL phase 2a).

BACKGROUND: We recently reported on preclinical and feasibility studies (Innovation, Development, Exploration, Assessment, Long-term study [IDEAL] phase 0-1) of the development of robotic kidney transplantation (RKT) with regional hypothermia. This paper presents the IDEAL phase 2a studies of technique development. OBJECTIVES: To describe the technique of RKT with regional hypothermia developed at two tertiary care institutions (Vattikuti Urology Institute and Medanta Hospital). We report on the safety profile and early graft function in these patients. DESIGN, SETTING, AND PARTICIPANTS: This is a prospective study of 50 consecutive patients who underwent live-donor RKT at Medanta Hospital following a 3-yr planning/simulation phase at the Vattikuti Urology Institute. Demographic details, and perioperative and postoperative outcomes are reported for the initial 25 recipients who have completed a minimum 6-mo follow-up. SURGICAL PROCEDURE: Positioning and port placement were similar to that used for robotic radical prostatectomy. Allograft cooling was achieved by ice slush delivered through a GelPOINT device. The accompanying video details the operative technique. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was posttransplant graft function. Secondary outcomes included technical success or failure and complication rates. RESULTS AND LIMITATIONS: Fifty patients underwent RKT successfully, 7 in the phase 1 and 43 in the phase 2 stages of the study. For the initial 25 patients, mean console, warm ischemia, arterial, and venous anastomotic times were 135, 2.4, 12, and 13.4 min, respectively. All grafts were cooled to 18-20 °C with no change in core body temperature. All grafts functioned immediately posttransplant and the mean serum creatinine level at discharge was 1.3mg/dl (range: 0.8-3.1mg/dl). No patient developed anastomotic leaks, wound complications, or wound infections. At 6-mo of follow-up, no patient had developed a lymphocele detected on CT scanning. Two patients underwent re-exploration, and one patient died of congestive heart failure (1.5 mo posttransplant). CONCLUSIONS: RKT with regional hypothermia is safe and reproducible when performed by a team skilled in robotic surgery. PATIENT SUMMARY: RKT is safe and effective when performed by surgeons experienced in robotic techniques.

Robot-assisted partial nephrectomy in patients with baseline chronic kidney disease: a multi-institutional propensity score-matched analysis.

BACKGROUND: Robot-assisted partial nephrectomy (RPN) in the setting of chronic kidney disease (CKD) presents additional challenges for the preservation of renal function. OBJECTIVE: To evaluate functional outcomes of RPN in patients with CKD relative to patients undergoing RPN without baseline CKD. DESIGN, SETTING, AND PARTICIPANTS: A total of 1197 consecutive patients who underwent RPN at five academic institutions between 2007 and 2012 were identified for this descriptive study. A total of 172 patients who underwent RPN with preexisting CKD (estimated glomerular filtration rate [eGFR] of 15-60 ml/min per 1.73 m(2)) were identified. Perioperative results of 121 patients were compared against propensity score-matched controls without CKD (eGFR ≥60 ml/min per 1.73 m(2)). INTERVENTION: RPN in patients with or without baseline CKD. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Descriptive statistics and propensity score-matched operative and functional outcomes. RESULTS AND LIMITATIONS: After propensity score matching, patients with baseline CKD had a lower percentage eGFR decrease at first follow-up (-5.1 vs -10.9), which remained significant at a mean follow-up of 12.6 mo (-2.8 vs -9.1, p<0.05), and they had less CKD upstaging (11.8% vs 33.1%). CKD patients were less likely to be discharged in the first two postoperative days (39.7% vs 56.2%, p=0.006) and had a higher rate of surgical complications (21.5% vs 10.7%, p=0.007). The retrospective analysis was the main limitation of this study. CONCLUSIONS: RPN in patients with baseline CKD is associated with a smaller decrease in renal function compared with patients without baseline CKD, but a higher risk of surgical complications and a longer hospital stay.

Robotic partial nephrectomy with cold ischemia and on-clamp tumor extraction: recapitulating the open approach.

We describe a reproducible technique for achieving cold ischemia with intraoperative tumor assessment during robotic partial nephrectomy (RPN) that recapitulates the open approach: intracorporeal cooling and extraction (ICE). A total of seven patients underwent the ICE modification of RPN by transperitoneal (n=5) and retroperitoneal (n=2) approaches. A Gelpoint access port was used for the camera and assistant ports. Following hilar clamping, ice slush was introduced through the Gelpoint via syringes and applied over the kidney surface. The excised tumor was immediately extracted through the Gelpoint, allowing gross margin assessment by pathology during the renorrhaphy. RPN was achieved in all cases with successful introduction of ice slush and tumor extraction while on clamp. Median RENAL nephrometry score was 8 (range: 6-10), and there was one solitary kidney. Mean cold ischemia time was 19.6 min (range: 8-37) and mean estimated blood loss was 296.4 ml (range: 50-1000). Renal parenchymal temperatures <16°C were achieved within 7 min of cold ischemia and there was no drop in core body temperature >0.5°C during any procedures. Intraoperative assessment of the excised tumor showed adequate gross margins in all cases and final pathology confirmed negative surgical margins.

Comparison of robotic and laparoscopic ultrasound probes for robotic partial nephrectomy.

OBJECTIVES: To evaluate and compare perioperative outcomes of robotic partial nephrectomy (RPN) using robotic and laparoscopic ultrasound probe for tumor identification. MATERIALS AND METHODS: Data from 75 consecutive RPN procedures using a laparoscopic ultrasound probe (January 2009- November 2010) and 75 consecutive RPN procedures using a robotic ultrasound probe (November 2010- November 2011) were collected. Perioperative outcomes of the two groups were retrospectively analyzed. RESULTS: A total of 72 patients underwent 75 consecutive RPN using the laparoscopic ultrasound probe followed by 73 patients who underwent 75 consecutive RPNs using the robotic ultrasound probe. Characteristics were similar between groups, and tumors had a similar complexity (mean nephrometry score 6.6 vs. 6.8, p=0.534), mean operating room time (234 vs. 218 min, p=0.095), mean console time (173 vs. 156 min, p=0.071), mean blood loss (171 mL vs. 164 mL, p=0.79), and positive tumor margin rates (1.2% vs. 2.2%, p=1) did not achieve significance. All patients are free of cancer recurrence after a mean follow up of 25.7 months in the laparoscopic probe group and of 10.2 months in the robotic probe group. CONCLUSIONS: Robotic ultrasound probes for tumor identification during RPN had comparable perioperative outcomes and surgical margin rates as a laparoscopic ultrasound probe, but with the advantage of surgeon autonomy.