Orthotopic Robot-assisted Kidney Transplantation: Surgical Technique and Preliminary Results.

BACKGROUND AND OBJECTIVE: Orthotopic kidney transplantation (KT) has been proposed as an option for patients ineligible for heterotopic KT. In this scenario, orthotopic robot-assisted KT (oRAKT) represents a novel, minimally invasive alternative to the open approach. Here we describe the largest oRAKT series of patients, with a focus on the surgical technique, perioperative surgical outcomes, and functional results. METHODS: We queried prospectively maintained databases from three referral centers to identify patients who underwent oRAKT and evaluated surgical and functional outcomes. KEY FINDINGS AND LIMITATIONS: Overall, 16 oRAKT procedures were performed between January 2020 and August 2023. These involved four donors after cardiovascular death, five donors after brain death, and seven living donors. All oRAKT procedures were carried out in the left renal fossa. The indication for oRAKT was extensive calcification of the external iliac vessels (100%), frequently associated with prior KT (31%). The median operative time was 295 min (interquartile range [IQR] 268-360) and the median rewarming time 48 min (IQR 40-54). Conversion to open surgery occurred in two cases (12%), and delayed graft function was observed in two cases (12%). Postoperative complications occurred in 11 patients (69%) and three (18%) experienced Clavien-Dindo grade >II complications. At median follow-up of 9 mo (IQR 7-17), 14 patients had a functioning graft and median creatinine of 1.49 mg/dl (IQR 1.36-1.72). CONCLUSIONS AND CLINICAL IMPLICATIONS: Although oRAKT is a challenging procedure, it represents a feasible option for individuals ineligible for heterotopic KT and yields favorable perioperative and mid-term functional outcomes. PATIENT SUMMARY: We evaluated outcomes of orthotopic robot-assisted kidney transplantation (KT), in which the native kidney is removed and the donor kidney is transplanted into its place, in patients who are not eligible for heterotopic KT, in which the native kidney is left in place and the donor kidney is transplanted into a new location. We found that robot-assisted surgery is a safe and feasible alternative to traditional open surgery for orthotopic KT.

Randomized clinical trial of non-antibiotic prophylaxis with d-Mannose plus Proanthocyanidins vs. Proanthocyanidins alone for urinary tract infections and asymptomatic bacteriuria in de novo kidney transplant recipients: The Manotras study.

BACKGROUND: Studies analyzing non-antibiotic alternatives in kidney transplant UTI's are lacking. d-Mannose, a simple sugar, inhibits bacterial attachment to the urothelium, as does Proanthocyanidins; both could act as a synergic strategy preventing UTI; nonetheless their efficacy and safety have not been evaluated in kidney transplant population yet. METHODS: This is a pilot prospective, double-blind randomized trial. Sixty de novo kidney transplant recipients were randomized (1:1) to receive a prophylactic strategy based on a 24-h prolonged release formulation of d-Mannose plus Proanthocyanidins vs. Proanthocyanidins (PAC) alone. The supplements were taken for the first 3 months after kidney transplant and then followed up for 3 months as well. The main objective of the study was to search if the addition of Mannose to PAC alone reduced the incidence of UTI and/or asymptomatic bacteriuria in the first 6 months post-transplantation. RESULTS: 27% of patients experienced one UTI episode (cystitis or pyelonephritis) while asymptomatic bacteriuria was very common (57%). Incidences according UTI type or AB were: 7% vs. 4% for cystitis episode (p 0.3), 4% vs. 5% for pyelonephritis (p 0.5) and 17% vs. 14% for asymptomatic bacteriuria (p 0.4) for patients in the Mannose+PAC group vs. PAC group respectively. The most frequent bacteria isolated in both groups was Escherichia coli (28% of all episodes), UTI or AB due to E. coli was not different according to study group (30% vs. 23% for Mannose+PAC vs. PAC alone p 0.37). CONCLUSIONS: Non-antibiotic therapy is an unmet need to prevent UTI after kidney transplantation; however, the use of d-Mannose plus PAC does not seem capable to prevent it.

[Kidney transplant pathology.] / Histología del trasplante.

Renal biopsy procedure is used prior to insertion and at follow-up on a daily basis. The main donor renal biopsy indication is for evaluation of renal graft with expanded criteria, which have demonstrated heir utility for renal transplant decisions.Other indications include evaluation of donors on acuterenal failure; indeterminate lesions evaluation on renal parenchyma or evaluation prior to clinical trial evaluation.How the renal biopsy is performed is also importanton its evaluation, and evaluation of glomerularlesions, tubule-interstitial and vascular lesions. All those determine renal graft evaluation, survival and chronic renal disease during follow-up. The main indication for renal biopsy on the recipientis the differential diagnosis of rejection when clinically suspicious or on patients with high- immunologicalrisk where subclinical reject is important. In high 0riskpatients, such as sensitized patients or living-donor recipients with ABO incompatibility, protocol biopsies are evaluated without guideline consensus. For that procedure,an automatic punch 16G needle is used, generally associated with low complication rates.

La utilización de las biopsias renales tanto preimplantacional como en el seguimiento de los pacientes trasplantados está dentro de la práctica habitual. La principal indicación para realizar la biopsia renal en el donante es para la valoración de los injertos de donantes con criterios expandidos, lo que ha demostrado su utilidad para decidir si un injerto es apto o no paraser trasplantado. Otras indicaciones incluyen la valoración de donantes con fracaso renal agudo, la valoración de lesiones dudosas a nivel del parénquima renal o como información basal necesaria en ensayos clínicos. La forma en que la biopsia de realiza tiene importancia en su valoración, y la valoración de las lesiones glomerulares, túbulointersticiales y vasculares del donante condicionan laevolución del injerto renal, tanto en la supervivencia del injerto, como en el daño renal crónico que presenten en el seguimiento.La principal indicación para realización de biopsias enel receptor es el despistaje de rechazo tanto cuando existe sospecha clínica o en los casos de alto riesgo inmunológico donde resulta fundamental el diagnóstico de rechazo subclínico.En los pacientes de alto riesgo, como son los pacientes sensibilizados o los receptores de trasplante de vivo ABO incompatible, se plantea la planificación de biopsias de protocolo, sin existir un claro consenso entre diferentes centros. Para el procedimiento se utiliza una pistola automática con una aguja de 16 Gauge,y se relaciona con un porcentaje muy bajo de complicaciones.

Histología del trasplante / Transplant histology

La utilización de las biopsias renales tantopreimplantacional como en el seguimiento de los pacientes trasplantados está dentro de la práctica habitual. La principal indicación para realizar la biopsia renal enel donante es para la valoración de los injertos de do-nantes con criterios expandidos, lo que ha demostradosu utilidad para decidir si un injerto es apto o no paraser trasplantado. Otras indicaciones incluyen la valoración de donantescon fracaso renal agudo, la valoración de lesiones dudosas a nivel del parénquima renal o como informaciónbasal necesaria en ensayos clínicos. La forma en que labiopsia de realiza tiene importancia en su valoración, y la valoración de las lesiones glomerulares, túbulointersticiales y vasculares del donante condicionan laevolución del injerto renal, tanto en la supervivencia delinjerto, como en el daño renal crónico que presenten enel seguimiento. La principal indicación para realización de biopsias enel receptor es el despistaje de rechazo tanto cuandoexiste sospecha clínica o en los casos de alto riesgoinmunológico donde resulta fundamental el diagnósticode rechazo subclínico. En los pacientes de alto riesgo, como son los pacientes sensibilizados o los receptores de trasplante devivo ABO incompatible, se plantea la planificación debiopsias de protocolo, sin existir un claro consenso entre diferentes centros. Para el procedimiento se utilizauna pistola automática con una aguja de 16 Gauge,y se relaciona con un porcentaje muy bajo de complicaciones.(AU)

Renal biopsy procedure is used prior toinsertion and at follow-up on a daily basis. The maindonor renal biopsy indication is for evaluation of renalgraft with expanded criteria, which have demonstratedtheir utility for renal transplant decisions. Other indications include evaluation of donors on acuterenal failure; indeterminate lesions evaluation on renalparenchyma or evaluation prior to clinical trial evaluation. How the renal biopsy is performed is also important on its evaluation, and evaluation of glomerularlesions, tubule-interstitial and vascular lesions. All thosedetermine renal graft evaluation, survival and chronicrenal disease during follow-up. The main indication for renal biopsy on the recipientis the differential diagnosis of rejection when clinically suspicious or on patients with high- immunologicalrisk where subclinical reject is important. In high0riskpatients, such as sensitized patients or living-donor recipients with ABO incompatibility, protocol biopsies areevaluated without guideline consensus. For that procedure, an automatic punch 16G needle is used, generally associated with low complication rates.(AU)

Oncological outcomes and prognostic factors after nephron-sparing surgery in renal cell carcinoma.

PURPOSE: To analyse the mid-term oncological results and to asses predictive factors for recurrence and survival after nephron-sparing surgery (NSS) for renal cell carcinoma. MATERIALS AND METHODS: This is a retrospective study that includes 198 Partial Nephrectomies performed at our institution for malignant renal tumours. Demographic information and pathological characteristics were obtained, and completed statistical analysis was performed to assess predictors for overall survival (OS) and overall recurrence in our sample. RESULTS: The presence of positive surgical margins (PSM) in the surgical specimen was reported in 13.6 %. At a median of follow-up of 56.1 months, the non-adjusted cancer-specific mortality, DSS and OS were 100, and 93.4 %, respectively. In the bivariate analysis regarding predictive factors for recurrence, bilaterality and NSS indication (elective or imperative) were statistically significant (p = 0.03 and p = 0.05 respectively). On multivariate analysis only bilaterality was a significant predictor of recurrence (p = 0.03), while high Fuhrman grade was for survival (p = 0.006). CONCLUSION: Our data suggest that patients with bilateral tumours have a higher incidence of local recurrence. Regarding overall survival, our data showed more risk of death at 5 years in those patients with high Fuhrman grade. No differences were found among PSM and negative surgical margins patients regarding oncological outcomes.