Transplantation rénale par voie cœlioscopique robot-assistée utilisant la voie sous-péritonéale avec plus d’un an de suivi : description de la technique et résultats

25 janvier 2018

Auteurs : F. Bruyère, B. Pradère, B. Faivre d’Arcier, J.-M. Boutin, M. Buchler, N. Brichart
Référence : Prog Urol, 2018, 1, 28, 48-54




 




Introduction


Since the 1950s and the first kidney transplant, few technical developments have marked this intervention. Kidney transplantation remains the standard treatment for kidney failure. The kidneys come either from cadaveric donors or from living donors which lead to the best results. Unfortunately, the shortage of organs makes unable to provide a kidney to all transplant candidates. In addition, a number of transplantation is burdened with complications that can lead to the destruction of the kidney and the return to kidney failure. The robot-assisted approach was developed strongly for prostate surgery but also for the removal of the kidneys in living donors [1]. In 2008 the first kidney transplant performed in open surgery with the help of a surgical robot has been published [2]. In 2010, a robotic transplantation with a transperitoneal approach was performed in an obese patient [3]. Finally the first series were reported in April 2014 according to a transperitoneal technique described one month previously [4, 5, 6, 7]. This procedure seems difficult, poorly reproducible and all the elements that will facilitate the technique are expected. We report our technique and perioperative outcomes used in patients with more than one year follow up. We hope that this technique will help to develop the robotic approach in renal transplantation.


Method


Patient selection


Patients attending a first renal transplantation were eligible to RART if they were not on peritoneal dialysis, in the absence of previous major abdominal surgery or polycystic kidney disease. Obese Patients were also included. The procedure was performed by the same surgeon (FB) who had a large experience in renal graft surgery (more than 400 cases) and in robotic surgery (more than 800 cases of prostate, bladder or kidney procedures). We here present all the results for patients who had their renal transplantation entirely performed with the robotic approach. We voluntarily excluded one patient who was early converted to open surgery, even if we'll explain the case.


Preparation of the patient


In the operating room under general anaesthesia, the patient was installed in the supine position with a block under the ipsilateral buttock. The two arms were positioned along the body. The robot came almost parallel to the patient through the right lower zone with an angle of 20° to the sick.


Installation


Appendix A.


All the procedure video is available on line (REF).


An open laparoscopy was performed to the umbilicus to introduce the 0° scope. After a intra peritoneal pressure of 12mmHg, two robotic ports of 8mm were set up to 6cm on either side of the umbilicus, the first on the pubic umbilic line, the second to make a diamond between the trocar and the middle of the incision for the Alexis port. A 10mm port was positioned between the upper and the umbilicus trocar for the assistant. Once the trocars were positioned, a 4cm incision was performed in the right iliac fossa, exactly where an incision could be made to perform the open surgery procedure to convert to open if necessary (Figure 1).


Figure 1
Figure 1. 

Alexi Trocart for the insertion of the graft.




Extra peritoneal dissection was performed without opening the peritoneum.


A Trendelenburg position associated with a slight left roll permit to rule out bowel loops.


The external iliac vessels were dissected and two vessel loops were placed on the iliac external artery and two on the iliac external vein.


The kidney was then implemented through the Alexis trocar with ice. A short peritoneal opening was performed with the help of the robotic intra peritoneal instruments (Figure 2).


Figure 2
Figure 2. 

Short peritoneal opening to have access to the vessels.




This incision allowed to catch the renal artery and the renal vein with the robotic port needle instrument. After a vessel clamping using bulldogs inserted by the assistant, the artery was opened with robotic uncurved scissors, an arterial anastomosis was performed first and then the venous using two running 3-0 Prolene sutures (Figure 3, Figure 4).


Figure 3
Figure 3. 

Arterial anastomosis.




Figure 4
Figure 4. 

Anastomosis aspect at the end of suturing.




A bulldog was left on the donor renal artery after iliac artery unclamping during the venous anastomosis. The total unclamping was then performed and haemostasis was checked. The external part of the kidney was verified by opening the cover of the Alexis trocar. A tunnel was formed between the peritoneal opening and another opening near the bladder previously filled slightly with sterile serum to facilitate the dissection. A uretero-vesical anastomosis according to the Lich-Gregoir technique was performed by two hemi-running sutures of 4-0 Vicryl, the ureter was intubated with a double J stent CH7. The ureter was under peritonised with sutures of 2-0 Vicryl. A drain was left in the Douglas area. The final aspect is shown on Figure 5.


Figure 5
Figure 5. 

Final aspect of an obese patient.




Immunosuppressive therapy: all patients included had a negative T-cell and B-cell cross match. They received all the induction therapy with 8 receiving an induction through an anti-RIL2 receptor antibody (basiliximab) and one patient receiving an induction therapy with polyclonal anti-thymocyte antibodies (thymoglobulin). Long-term immunosuppression included tacrolimus, mycophenolate mofetil and steroids for all patients.


Results


Eight patients were included in the study between October 2013 and November 2015. Patients characteristics are described in Table 1.


The average age was 58 years (range 39-75 years). The average body mass index was 28 (range 22-38) and four were obsess patients (BMI>30). Three left and five right cadavers kidneys were transplanted in the right iliac fossa. No patient was transfused during surgery and two were transfused postoperatively. The median blood loss was 220ml (range 100-700). One patient had bleeding in the hilum probably due to uncorrected pre transplantation injury. Median length of hospital stay was 14 days (range 10-30 days). Only one patient needed postoperative morphine, the pain visual analogic scale 12hours postoperatively was two (0-5). At one year follow up, no patient had a wound infection or incisional hernia. One patient was re-operated for ureteral anastomosis stricture. The operative and the postoperative parameters are described in Table 2. Two patients had Delayed Graft Function. The renal results are summarized in Table 3.


Discussion


This article is the first to relate the retroperitoneal technique of RART with a one year follow up. The technique seems reproducible despite initial technical difficulties. These initial results are promising but need to be improved. This technique seems technically more difficult than the conventional approach but may decrease postoperative complications. For example, the warm ischemia time which is a major factor for the success of the procedure remained slightly higher than the 60minutes cut off initially described in our open experience [8]. We have planned animal sessions to improve our skills but the access to these sessions are expensive and opens the discussion about training. The vessels anastomosis even not more complicated than a standard pelvic junction repair, needs to be performed as fast as possible to decrease the warm ischemia time. In total our mixed technique should be compared to the transperitoneal technique widely used in other teams. The only possible advantage is to reproduce the open technique with less potential intraperitoneal injuries and less potential rotation of the graft.


Abdominal hernia is a common complication that occur after renal transplantation [9]. This incidence can reach 8.1% in polycystic kidney patients [10]. As its management is difficult we prevented this complication in reducing the length of the incision. At this time, with more than 1 year follow up, no hernia appeared in our cohort. Furthermore, one obese recipients had already a hernia due to a nephrectomy performed with a lumbotomy access. Even if the esthetic remains poorly important for these patients, it can be of importance for young women waiting renal transplantation. Knowing our experience, few renal insufficient patients come to our departments asking for this approach. Obesity is a risk factor of postoperative complications and especially for postoperative hernia [11], this population is an interesting target for RART. Very few cases of robotic renal transplantation in obese patients have been already performed and published and remain a difficult surgery but maybe with lower complications [12].


Vascular stenosis, arterial or venous, can occur after renal transplantation with up to 15% frequency [13]. The causes are unknown but many have been evocated such as technical injury. With the robotic approach the suture is performed under 3D vision with magnificent view that may decrease the vascular injury. We had to deal with the wire that is strongly injured by the robotic instruments even if we tried to reduce as minimal its prehension during the continuous suture. We decided to change for the Gore-Tex wire that was less injured by the instruments.


Ureteral stenosis is a non-exceptional complication that was previously estimated to 6.5% of our renal transplantation [14]. In the multivariate analysis, only donor age (P =0.001) and abnormal graft revascularisation (P =0.035) were independent risk factors for ureteral stenosis after renal transplantation. The potential causes are infection, ureteral injury or ureteral ischemia. After one year follow up we had one case of ureteral stenosis that required a catheter placement under general anaesthesia. Unfortunately, we haven't removed yet the catheter to see if the stenosis is cured.


The complication rate can appear too high for such procedure. The initial experience of open renal transplantation was also associated with high complication rate and recent publications revealed up to 40% complication rates [15]. Therefore, our complication incidence seems acceptable. We hope to decrease postoperative complications with time and training. Especially we would like to advise our colleagues who want to start this program. The apparent long length of stay is due to the local management that was not changed by nephrologists who decided not to decrease the hospital stay for this initial experience. Even with high experience of robotic or renal transplantation, one should be accompanied with a senior or ideally with a surgeon experienced in this surgery. This adds few problems to begin the program: first, experienced teams are still rare and second, to schedule such program is impossible with kidney from cadavers. Ideally the living donors kidney allow to schedule the transplantation. We did not choose to start this option for two reasons. Ethically it can be blamed to start an experience with living kidneys that come from un-sick donors, with higher risks of wasting the human gesture. All the departments involved in robotic renal transplant use living donors grafts [16, 17] and kidneys were early removed. Secondly, we are engaged for 10 years in a robotic program to remove the kidney of living donors. Hence, it would be difficult to follow up with a RART considering that we perform the transplantation immediately after the removal of the kidney in the next operative room and we have only one robot. It can be argued that immediately after the issue of the kidney the robot is not usefull for the living donor and could be transferred to the next operative room. We currently work on this option.


Conclusion


This is the first cohort of Robot-assisted renal transplantation with more than one year follow-up. Even if few complications appeared, the results are promising. The technique needs to be improved and comparative studies should be perform to compare to the conventional approach.


Disclosure of interest


The authors declare that they have no competing interest.



Appendix A. Supplementary data


(29.75 Mo)
  




Table 1 - Initial characteristics of the patients.
Age years mean [range]  58 [39-74] 
Sex F/M  3/5 
BMI mean [range]  28 [22-45] 
% of patients with BMI>30  50% 
Previous abdominal surgery 
ASA score median [range]  2 [2-4] 
Previous time with dialysis [range] months  30 [3-63] 
Graft size mean [range] mm  109 [90-130] 
Origin of renal failure  Nephro-angiosclerosis, n =2
Focal and segmental glomerulosclerosis, n =1
IgA nephropathy, n =1
Polycystic kidney disease, n =1
Interstitial nephropathy, n =1
Nephropathy of undetermined origin, n =
Pre op Haemoglobin [mean] [range]  12.2 [10.9-15.3] 





Table 2 - Operative and postoperative parameters for all the eight patients.
Median Operative time [range] min  200 [149-245] 
Median Hospital stay [range] days  14 [10-30] 
Median length with drainage (days) [range]  4 [2-8] 
mean length of the incision for insertion of the graft [range] mm  60 [40-100) 
Warm ischemia time [range] minutes  63 [46-84] 
Mean Post op Haemoglobin (g/dL) [range]  9.6 [7.6-12.6] 
Transfusion rate (%)  1 (12.5) (postoperatively) 
Pain visual analogic scale 12hours postoperatively [range]  2 [0-5] 
Complications  1 post op conversion for bleeding 
Clavien Dindo III-IV  1 laparotomy for bowel injury suspicion (was a urinoma and had a ureteral catheter placed) 





Table 3 - Renal function for the eight patients.
Patient  DGF  Creatinin postoperative day 7  Creatinin at 3 months postoperatively  Creatinin at 1 year 
No  576  80  86 
Yes  639  119  102 
No  98  118  108 
No  331  104  86 
No  250  235  194 
Yes  500  150  159 
No  251  137  122 
No  376  151  140 



Légende :
DFG: delayed graft function.


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