Robotic Assisted Living Donor Nephrectomies: A Safe Alternative to Laparoscopic Technique for Kidney Transplant Donation.

OBJECTIVE: To review outcomes after laparoscopic, robotic-assisted living donor nephrectomy (RLDN) in the first, and largest series reported to date. SUMMARY OF BACKGROUND DATA: Introduction of minimal invasive, laparoscopic donor nephrectomy has increased live kidney donation, paving the way for further innovation to expand the donor pool with RLDN. METHODS: Retrospective chart review of 1084 consecutive RLDNs performed between 2000 and 2017. Patient demographics, surgical data, and complications were collected. RESULTS: Six patients underwent conversion to open procedures between 2002 and 2005, whereas the remainder were successfully completed robotically. Median donor age was 35.7 (17.4) years, with a median BMI of 28.6 (7.7) kg/m2. Nephrectomies were preferentially performed on the left side (95.2%). Multiple renal arteries were present in 24.1%. Median operative time was 159 (54) minutes, warm ischemia time 180 (90) seconds, estimated blood loss 50 (32) mL, and length of stay 3 (1) days. The median follow-up was 15 (28) months. Complications were reported in 216 patients (19.9%), of which 176 patients (81.5%) were minor (Clavien-Dindo class I and II). Duration of surgery, warm ischemia time, operative blood loss, conversion, and complication rates were not associated with increase in body mass index. CONCLUSION: RLDN is a safe technique and offers a reasonable alternative to conventional laparoscopic surgery, in particular in donors with higher body mass index and multiple arteries. It offers transplant surgeons a platform to develop skills in robotic-assisted surgery needed in the more advanced setting of minimal invasive recipient operations.

Disparities in living donation.

PURPOSE OF REVIEW: Living organ donation provides improved access to transplantation, thereby shortening transplant wait times and allowing for more deceased organ transplants. However, disparity in access to living donation has resulted in decreased rates of living donor transplants for some populations of patients. RECENT FINDINGS: Though there have been marked improvements in deceased donor equity, there are still challenges as it relates to gender, racial/ethnic, and socio-economic disparity. Improvements in living donation rates in Hispanic and Asian populations are tempered by challenges in African American rates of organ donation. Socio-economic disparity may drive gender disparities in organ donation resulting in disproportionate female living donors. Tailored approaches relating to language-specific interventions as well as directed educational efforts have helped mitigate disparity. Additionally, the use of apolipoprotein1 testing and modifications of glomerular filtration rate calculators may improve rates of African American donation. This review will evaluate recent data in living donor disparity as well as highlight successes in mitigating disparity. SUMMARY: Though there are still challenges in living donor disparity, many efforts at tailoring education and access as well as modifying living donor evaluation and identifying systemic policy changes may result in improvements in living donation rates.

Kidney Transplantation for Erdheim-Chester Disease.

Erdheim-Chester disease is a rare inflammatory disease that infiltrates skeletal and extra-skeletal tissue. Chronic kidney disease (CKD) in Erdheim-Chester disease is usually attributed to retroperitoneal lesions that lead to urologic obstruction and hydronephrosis. In this report, we describe a patient diagnosed with Erdheim-Chester disease who eventually developed end-stage kidney disease (ESKD). After complete remission of Erdheim-Chester disease by vemurafenib therapy and 2 years of hemodialysis, the patient underwent a deceased donor kidney transplantation with basiliximab induction and tacrolimus/mycophenolic acid maintenance. After conversion of mycophenolic acid to azathioprine due to cost, acute cellular rejection had occurred, and he was treated with steroid therapy. The patient remained in complete remission from Erdheim-Chester disease and dialysis-free 16 months after transplant. Kidney transplantation is another treatment option for those patients with Erdheim-Chester disease who suffer from renal failure in the setting of complete remission.

Single Center Experience With Robotic Kidney Transplantation for Recipients With BMI of 40 kg/m2 Or Greater: A Comparison With the UNOS Registry.

BACKGROUND: Obesity represents a barrier to kidney transplantation, but the increasing prevalence among renal failure patients has forced some centers to carefully consider such candidates. Morbidly obese patients may be at increased risk of delayed graft function, higher postoperative complications, and inferior graft outcomes. Nevertheless, mortality on the waiting list remains significantly higher than after transplant. We have applied minimally invasive surgery to perform kidney transplant in individuals with body mass index (BMI) of 40 kg/m or greater. We compared our results to the national United Network of Organ Sharing database. METHODS: The United Network of Organ Sharing registry was reviewed for adult living donor kidney transplant recipients with BMI of 40 kg/m or greater performed from September 2009 to December 2014. We compared transplants performed with robotic technique (RKT) versus patients performed with open surgery at all US centers including our own (open kidney transplant). Subgroup analysis in patients with BMI of 45 kg/m or greater was conducted. We compared outcomes including patient and graft survival, renal function, and technical complications. RESULTS: Robotic kidney transplantation group had a significantly higher mean BMI overall. The 1-year patient and graft survival rates were similar between groups. Renal function was also similar at 6, 12, and 36 months. Thrombosis caused 1.3% of the graft losses in open kidney transplant and 0% in the RKT group. Interestingly, 52.8% of the overall experience in patients with BMI of 45 kg/m or greater was performed with the robotic technique. CONCLUSIONS: Robotic surgery offers similar patient and graft survivals with comparable renal function to open technique. Robotic kidney transplantation permits transplantation in extreme BMI categories without additional technical complications. Further studies are required to establish the role of RKT for obese candidates but preliminary data are encouraging.

Hand-assisted robotic right donor nephrectomy in patient with total situs inversus: A case report.

Total situs inversus" is an infrequent congenital condition. The robot has been already proved as a safe and attractive approach for living donor nephrectomies. We report here the first right donor nephrectomy in a patient with total situs inversus that is performed using the Da Vinci platform.

Successful living donor intestinal transplantation in cross-match positive recipients: Initial experience.

Sensitized patients tend to have longer waiting times on the deceased donor list and are at increased risk of graft loss from acute or chronic rejection compared to non-sensitized candidates. Desensitization protocols are utilized to decrease the levels of alloantibodies and to convert an initial positive cross-match to prospective donors into a negative crossmatch. These procedures are mostly available in the setting of living donation. Due to the elective nature of the procedure, desensitization protocols can be extended until the desire result is obtained prior to transplantation. We present two cases of successful desensitization protocol applied to living donor intestinal transplant candidates that converted to negative cross-match to their donors. We present two cases of intestinal transplant candidates with a potential living donor to whom they are sensitized. Both cases underwent successful transplantation after desensitization protocol. No evidence of humoral rejection has occurred in either recipient. Living donor intestinal transplantation in sensitized recipients against the prospective donors provides the ability to implement a desensitization protocol to convert to negative cross-match.

Sleeve gastrectomy surgery in obese patients post-organ transplantation.

BACKGROUND: Among organ transplant recipients, a common side effect of immunosuppressive therapy is the development of obesity, which affects a third of the patients within 3 years after transplantation. Bariatric surgery represents a possible surgical option for weight loss among posttransplant patients. OBJECTIVES: The aim of this study was to examine percent excess weight loss (%EWL), and percent weight loss (%WL) and perioperative and postoperative complications in posttransplant obese patients after sleeve gastrectomy (SG) compared with nontransplant patients. We hypothesize that transplant patients who undergo SG will not significantly differ in their perioperative or postoperative complications or in their %EWL and %WL compared with nontransplant patients who undergo SG. The second aim was to evaluate the impact of SG on graft function and immunosuppressive therapy in transplant patients. SETTING: University hospital. METHODS: Among 500 consecutive patients who underwent SG from January 2008 to June 2014, 10 patients were organ transplant recipients. The following variables were compared between groups: patient demographic characteristics and co-morbidities, type of transplant surgery, date of transplant surgery, pretransplant body mass index (BMI), date of bariatric surgery, prebariatric surgery BMI, operative time, length of hospitalization, postoperative complications, and change in BMI, %EWL, and %WL. Data were also collected on renal, liver, and pancreas graft function parameters and changes in immunosuppressive medications. RESULTS: Six patients had a kidney transplant, 2 patients had a liver transplant, and 2 had a pancreas transplant. No significant differences were observed in %EWL or %WL at 6 and 12 months follow-up between transplant and nontransplant patients. No transplant patients were lost to follow-up at 6 and 12 months. Among nontransplant patients, 36.7% and 35.7% were lost to follow-up at 6 and 12 months, respectively. No postoperative complications were registered in the transplant group. SG did not negatively affect the graft function. CONCLUSION: Initials results found that there were no significant differences in %EWL or %WL at 6 and 12 months follow-up between transplant and nontransplant patients. There were also no perioperative and postoperative complications among transplant patients after SG.

Simultaneous Living Donor Kidney and Parathyroid Allotransplantation: First Case Report and Review of Literature.

BACKGROUND: Congenital hypoparathyroidism can be severely debilitating for patients, leading to renal failure at young age. Parathyroid transplantation may represent a permanent parathyroid replacement therapy. In patients already on immunosuppression for other organ transplant, there is little additional risk involved with parathyroid allotransplantation. METHODS: Robotic assisted transaxillary single parathyroidectomy is performed on a living donor also donating a kidney to her sibling. RESULTS: Recipient total serum PTH levels became detectable after 3 days from the procedure and maintained for 9 months after transplant with minimal calcium supplementation after the procedure. Literature review and previous results are summarized. CONCLUSIONS: Obtaining a parathyroid gland and a kidney from the same donor reduces the exposure to different HLA antigens. The combined procedure using minimally invasive surgery is safe, with the additional cosmetic advantage and convenience for the willing donor. In the setting of need for immunosuppression, additional transplantation to treat the cause is safe and justified in the recipients.

Five-year follow-up of patients with type 1 diabetes transplanted with allogeneic islets: the UIC experience.

This report summarizes a 5-year phase 1/2 allogeneic islet transplantation clinical trial conducted at the University of Illinois at Chicago (UIC). Ten patients were enrolled in this single center, open label, and prospective trial in which patients received 1-3 transplants. The first four subjects underwent islet transplantation with the Edmonton immunosuppressive regimen and the remaining six subjects received the UIC immunosuppressive protocol (Edmonton plus etanercept and exenatide). All 10 patients achieved insulin independence after 1-3 transplants. At 5 years of follow-up, 6 of the initial 10 patients were free of exogenous insulin. During the follow-up period, 7 of the 10 patients maintained positive C-peptide levels and a composite hypoglycemic score of 0. Most patients maintained HbA1c levels <6.0 % (42.1 mmol/mol) and a significantly improved ß-score. In conclusion, this study demonstrated long-term islet graft function without using T cell depleting induction, with an encouraging outcome that includes 60 % of patients remaining insulin independent after 5 years of initial transplantation.

Concurrent hepatic artery and portal vein thrombosis after orthotopic liver transplantation with preserved allografts.

In contrast to early HAT, late HAT has an insidious clinical presentation. Nevertheless, biliary and vascular reconstructions in this late setting are unlikely to improve outcome. Patent portal flow makes an important contribution to the viability of liver in case of late HAT while the allograft reconstitutes intrahepatic arterial flow through neovascularization. Concurrent HAT with PVT without immediate graft necrosis is extremely rare, and allograft and patient survival are seemingly impossible without retransplantation. In fact, hepatopetal arterial and portal venous neovascularization are known albeit obscure phenomena that can preserve posttransplant hepatic function under the extenuating circumstances of complete interruption of blood flow to the graft. We describe two such cases that developed combined HAT and PVT more than six months after OLT with perfect preservation of graft function. The survival of allografts in our cases was due to extensive hepatopetal arterial and portal venous collateralization. Simultaneous HAT and PVT after OLT are rare events and almost uniformly fatal, if they occur early. Due to paucity of such cases, however, underlying mechanisms and etiology remain elusive, and despite radiological diagnosis of these complications, there is no way to predict these events in the wake of stable graft function.

Robotic-assisted kidney transplantation.

Robotic-assisted surgery has enabled organ transplantation in a minimally invasive fashion. Kidney transplantation is the best treatment of patients with chronic renal failure. Robotic surgery has reduced the difficulties associated with kidney transplantation for obese patients. Benefits such as reduced recovery period and reduced number of wound complications and surgical site infections have been attained with the robotic surgical approach. We believe that robotic-assisted surgery has expanded the ability to complete complex surgical procedures in a minimally invasive fashion. However, advanced training and experience are required in all surgeons who are interested in pursuing this technique.

State of the art of robotic surgery in organ transplantation.

Within the last two decades the application of minimally invasive surgical technologies has shown significant benefits when it comes to complex surgical procedures. Lower rates of complications and higher patient satisfaction are commonly reported. Until recently these benefits were inaccessible for patients with solid organ transplantation, because conventional laparoscopy was seen as nonapplicable in such technically demanding procedures. The introduction of the da Vinci Robotic Surgical System, with its inherent advantages, has expanded the ability to complete solid organ transplantation in a minimally invasive fashion. Robotic applications in kidney, pancreas, and liver transplantation have been reported. The initial results showed the viability of this technique in the field. The most extensive experience has been described in kidney transplantation. Over 700 donor nephrectomies and more than 70 renal transplants have been performed successfully with the robotic system. The proven advantage of the robotic technique, especially in obese kidney recipients, is a significantly lower rate of surgical site infection, which in these highly immunosuppressed patients is reflected in superior outcomes. The first results in pancreas transplantation and living donor hepatectomy are very promising; however, larger series are needed in order to address the value of the robotic surgery in these areas of solid organ transplantation.

Las complicaciones biliares en el trasplante hepático de donante vivo no afectan los resultados a largo plazo / The biliary complications in live donor liver transplant do not affect the long-term results

Introducción El trasplante hepático de donante vivo (THDV) es un tratamiento eficiente para pacientes con hepatopatía crónica terminal, a pesar de la elevada incidencia de complicaciones biliares. El objetivo es evaluar los resultados y el impacto a largo plazo de las complicaciones biliares tras el THDV. Pacientes y métodos Desde 2000 hasta 2010, se llevaron a cabo 70 THDV usando el hígado derecho como injerto. Se recogieron prospectivamente y analizaron retrospectivamente las complicaciones biliares (fugas y estenosis) de estos 70 receptores de THDV. Resultados Un total de 39 pacientes (55,7%) presentaron algún tipo de complicación biliar. Veintinueve presentaron una fuga y, de ellos, 14 desarrollaron posteriormente una estenosis. Además, 10 pacientes más presentaron una estenosis sin una fuga previa. La mediana de tiempo hasta la aparición de una estenosis fue de casi un año. Los pacientes con una fuga biliar previa presentaron una mayor probabilidad de desarrollar una estenosis (58 vs. 29,5% a 5 años, p = 0,05). Con una mediana de seguimiento de 80 meses, el 70,8% de los pacientes fueron tratados satisfactoriamente mediante radiología intervencionista. Tras excluir la mortalidad inicial, no hubo diferencias de supervivencia en función de las complicaciones biliares. Se observó una disminución de las complicaciones biliares en los segundos 35 pacientes en comparación con los primeros. Conclusiones El THDV está asociado a una incidencia elevada de complicaciones biliares. Sin embargo, los resultados a largo plazo de los pacientes no se ven afectados. Tras un tiempo de seguimiento mediano de casi 7 años, la supervivencia en función de la aparición de complicaciones biliares permaneció sin diferencias (AU)

Introduction Living donor liver transplantation (LDLT) is an effective treatment for patients with terminal chronic liver disease, despite the high incidence of biliary complications. The objective is to evaluate the results and long-term impact of biliary complications after THDV. Patients and methods From 2000 to 2010, 70 right lobe LDLT were performed. Biliary complications (leakage and stenosis) of the 70 LDLT recipients were collected prospectively and analyzed retrospectively. Results A total of 39 patients (55.7%) had some type of biliary complication. Twenty nine presented a leak, and of these, 14 subsequently developed a stricture. In addition, 10 patients had a stenosis without prior leakage. The median time to onset of stenosis was almost a year. Patients with previous biliary leakage were more likely to develop stenosis (58% vs. 29.5% at 5 years, P=.05). With a median follow up of 80 months, 70.8% of patients were successfully treated by interventional radiology. After excluding early mortality, there were no differences in survival according to biliary complications. A decrease of biliary complications was observed in the last 35 patients compared with the first 35.ConclusionsLDLT is associated with a high incidence of biliary complications. However, long-term outcome of patients is not affected. After a median follow-up time of nearly seven years, no differences were found in survival according to the presence of biliary complications (AU)

[The biliary complications in live donor liver transplant do not affect the long-term results]. / Las complicaciones biliares en el trasplante hepático de donante vivo no afectan los resultados a largo plazo.

INTRODUCTION: Living donor liver transplantation (LDLT) is an effective treatment for patients with terminal chronic liver disease, despite the high incidence of biliary complications. The objective is to evaluate the results and long-term impact of biliary complications after THDV. PATIENTS AND METHODS: From 2000 to 2010, 70 right lobe LDLT were performed. Biliary complications (leakage and stenosis) of the 70 LDLT recipients were collected prospectively and analyzed retrospectively. RESULTS: A total of 39 patients (55.7%) had some type of biliary complication. Twenty nine presented a leak, and of these, 14 subsequently developed a stricture. In addition, 10 patients had a stenosis without prior leakage. The median time to onset of stenosis was almost a year. Patients with previous biliary leakage were more likely to develop stenosis (58% vs. 29.5% at 5 years, P=.05). With a median follow up of 80 months, 70.8% of patients were successfully treated by interventional radiology. After excluding early mortality, there were no differences in survival according to biliary complications. A decrease of biliary complications was observed in the last 35 patients compared with the first 35. CONCLUSIONS: LDLT is associated with a high incidence of biliary complications. However, long-term outcome of patients is not affected. After a median follow-up time of nearly seven years, no differences were found in survival according to the presence of biliary complications.

Renal artery aneurysm in robotic donor nephrectomy: a case report.

OBJECTIVES: With the current disparity between donor organ availability and recipient need, creative techniques help optimize the use of available organs. We present a case of a woman, who was worked-up as a kidney donor, who was incidentally found to have a saccular aneurysm on her renal artery. The patient was asymptomatic, normotensive, and had normal renal function. MATERIALS AND METHODS: We performed a laparoscopic robotic donor nephrectomy, repaired the aneurysm on the back table, and transplanted the organ into the recipient. RESULTS: The donor underwent a successful robotic nephrectomy, successfully eradicating any risk of aneurysmal complications; the recipient received an anatomically normal organ with excellent function. CONCLUSIONS: An altruistic act by the donor identified a potentially fatal lesion, which was not only remedied, but the intended donation proceeded when a creative approach was used.

Pancreatic islet cell transplantation: an update for interventional radiologists.

Pancreatic islet cell transplantation is a promising cellular-based therapy for type 1 diabetes mellitus. This procedure involves portal venous injection of islet cells and affords 1-year insulin independence in as many as 80% of recipients. Although transplant surgeons represent historical drivers of islet therapy, requirement for image guidance and transcatheter techniques has fostered collaboration with interventional radiologists, who are positioned to play a significant role in clinical performance of islet transplantation and in basic science research in this field. This review article aims to familiarize interventional radiologists with islet cell transplantation patient selection, procedure technique, clinical outcomes, and future clinical and research avenues.

Preservation of pancreas graft function after complete venous thrombosis: report of four cases treated conservatively.

BACKGROUND: Pancreas graft thrombosis is the most common cause of technical graft failure, with an incidence of up to 20% is some series. In most instances, vascular thrombosis of the graft will require immediate removal to avoid further abdominal complications. We present a total of four cases of complete venous thrombosis with preservation of function that were managed conservatively, resulting in long-term graft function. METHODS: Retrospective analysis of our case series over 10 years was carried out, obtaining patients with complete graft thrombosis by Doppler ultrasound. We included in the study only those patients who remained asymptomatic with preserved graft function. The clinical status of the patients, radiological findings, and therapeutic approach are evaluated. Patient and graft outcomes are analyzed. RESULTS: Retrospective evaluation of 227 transplants, a total of four patients were found to have complete thrombosis of the graft, remaining asymptomatic and preserving function without complications. Graft thrombosis was found on routine Doppler ultrasound evaluation of the transplanted organs at a median time of 19 days (range, 11-28 days), angiographic confirmation was obtained in all cases. The clinical condition and the presence of collateral flow allowed for conservative treatment. Median hospital stay was 29 days (range, 16-38 days), with a median follow-up of 106 months (range, 24-110 months), all patients are alive with a functioning graft. CONCLUSIONS: In rare instances with complete thrombosis of the pancreas transplant in absence of clinical manifestations, the grafts can be closely monitored and treated with systemic anticoagulation, allowing long-term patient and graft survival.

A prospective evaluation of ultrasonography for the diagnosis of penetrating torso injury.

BACKGROUND: Ultrasound (US) is commonly used for the diagnosis of hemoperitoneum after blunt abdominal trauma, but the value of US as an aid for identification of operative lesions after penetrating trauma is not well documented. The purpose of this investigation was to determine the accuracy of US for the evaluation of penetrating torso trauma and to assess the impact of this information on patient management. METHODS: We conducted a prospective cohort observational study of consecutive penetrating torso patients at a Level I trauma center. RESULTS: During the 6-month trial period, 177 victims of penetrating torso trauma were assessed by our trauma teams. Ninety-two patients had stab wounds, 84 patients had gunshot wounds, and 1 patient had a puncture wound. All 28 patients with positive US examination had an exploratory laparotomy or thoracotomy (one patient had more than one procedure), resulting in 26 therapeutic operations. There were 149 negative US examinations, but in this group, 36 patients underwent laparotomy or thoracotomy, and 28 had therapeutic operations. The overall accuracy of the US examination was therefore 85%, the sensitivity was 48%, and the specificity was 98%. There were only three patients who had their initial management altered by a positive US examination. CONCLUSION: The US examination lacks sensitivity to be used alone in determining operative intervention after gunshot or stab wounds. Rarely does US information contribute to the management of patients with penetrating abdominal injuries.