Pankaj Chandak

Renal transplantation in identical twins in United States and United Kingdom.

Background. The primary aim was to review the graft and patient survival of all recipients of a living identical twin donor renal transplant in the United States and United Kingdom, between 1988 and 2004. The secondary aim was to assess their maintenance immunosuppression. Methods. Data of all the patients who underwent living identical twin donor renal transplantation in the United States and United Kingdom during 1988-2004 were retrieved from United Network for Organ Sharing and UK transplant, respectively. Further data were retrieved by sending letters to the individual transplant units in the United Kingdom. Results. There were 120 living identical twin donor renal transplants in the United States and 12 in the United Kingdom during the study period. Graft survival was 99.17%, 91.84%, and 88.96% in the US group at 1, 3, and 5 years, respectively, and 83.3%, 83.3%, and 75% in the UK group during the same follow-up period. Patient survival was 100%, 97.01%, and 97.01% in the US group at 1, 3, and 5 years, respectively, and 100% in the UK group during the same 5-year follow-up period. A large number of patients were on some form of immunosuppression. Conclusions. Graft and patient survival were good in both countries. These results are better than those published in the literature over the previous 20 years. Although phenotypic differences in monozygotic twins can exist, immunosuppression may be unnecessary in all these patients. Ideally, all identical twins who are currently on immunosuppression should undergo zygosity testing to establish whether they should continue the immunosuppression unless they need it for another reason.

How safe is hand-assisted laparoscopic donor nephrectomy?—Results of 200 live donor nephrectomies by two different techniques

BACKGROUND Despite the rapid introduction of laparoscopic living donor nephrectomy, doubts exist about safety compared with open surgery. Early series have often reported on selective donor groups. We present a consecutive, prospective analysis of morbidity following hand-assisted laparoscopic donor nephrectomy (HALDN) compared with historical controls undergoing open donation (ODN) in a total of 200 living donors at a single UK centre. METHODS The results of 144 consecutively performed HALDN donors were compared to 56 preceding ODN patients. Patients with multiple arteries, right-sided nephrectomies and obesity were included. Data on recovery and complications were collected prospectively and consecutively. RESULTS There were two (1.4%) major complications in the HALDN group and one in the ODN group (1.8%, P = 0.629). Additionally, there were 24 minor complications in 23 HADLN patients (16.7%), compared with 21 in 21 ODN patients (37.5%, P = 0.003). Time taken to return to normal activity and mean post-operative stay was significantly shorter for the HALDN group. There was no mortality in either group. CONCLUSIONS Contrary to concerns, we report a safe experience with HALDN with a low rate of major complications. Furthermore, our patients spend less time in hospital with an earlier return to normal activity compared with open donation.

Is laparoscopic donation safe for paediatric recipients? A study of 85 paediatric recipients comparing open and laparoscopic donor nephrectomy

INTRODUCTION The safety of adult laparoscopic donor nephrectomy remains controversial with respect to paediatric recipients with few data existing about its efficacy. Small studies have shown no difference in graft survival when compared with open techniques, but previous data from United Network for Organ Sharing suggests a higher incidence of rejection in laparoscopically procured kidneys. METHODS We examined the outcome in a total of 85 consecutive paediatric renal recipients, comparing 46 recipients of laparoscopically procured kidneys (performed over a 3-year period, 2004-07) to a historical control of 39 open donor recipients. Thirty-seven laparoscopic donors were by the hand-assisted technique. RESULTS Mean recipient age was 9.8 (SD 5.04) years in the laparoscopic group and 10.4 (SD 4.67) years in the open group (P = 0.617). Two patients had delayed graft function in the laparoscopic group (4.3%) and one (2.5%) in the open group (P = 0.562). At 1 year follow-up, there was 100% graft survival in the laparoscopic group compared to 92% (P = 0.093) in the open group. Incidence of biopsy-proven acute rejection within 1 year of transplant was 26% (16 episodes in 12 patients) in the laparoscopic group compared to 41% (29 episodes in 16 patients) in the open group (P = 0.219). There were no deaths in the laparoscopic group but there were three deaths (7.6%) in the open group (P = 0.093). CONCLUSIONS Our experience of laparoscopic kidney donation for paediatric recipients suggests excellent outcome with no difference in rejection rate or graft survival compared to open donation. Laparoscopic donation is the optimal method of kidney procurement for paediatric recipients.

Three-dimensional printing in robot-assisted radical prostatectomy - an Idea, Development, Exploration, Assessment, Long-term follow-up (IDEAL) Phase 2a study

The surgical management of prostate cancer has been shown to be determined by the anatomical location of the tumour and its associated intricate relationship to the neurovascular bundle and the prostatic capsule. Studies have shown an improvement in decision making about preservation or resection of neurovascular bundles during robotic assisted prostatectomy (RARP) [1,2] during which the surgeon lacks the tactile feedback of conventional open surgery. This article is protected by copyright. All rights reserved.

Successful excision of a suspected mycotic transplant renal artery patch aneurysm with renal allograft autotransplantation.

Aneurysm of the transplant renal artery has an incidence rate of less than 1% and is associated with graft loss and mortality (1). We report a case of a suspected mycotic transplant renal artery patch aneurysm developing in a patient with systemic infection and a functioning renal allograft treated with surgical excision, in situ reconstruction, and subsequent allograft auto transplantation with successful outcome.

A novel 3D-printed hybrid simulation model for robotic-assisted kidney transplantation (RAKT)

Robotic-assisted kidney transplantation (RAKT) offers key benefits for patients that have been demonstrated in several studies. A barrier to the wider uptake of RAKT is surgical skill acquisition. This is exacerbated by the challenges of modern surgery with reduced surgical training time, patient safety concerns and financial pressures. Simulation is a well-established method of developing surgical skill in a safe and controlled environment away from the patient. We have developed a 3D printed simulation model for the key step of the kidney transplant operation which is the vascular anastomosis. The model is anatomically accurate, based on the CT scans of patients and it incorporates deceased donor vascular tissue. Crucially, it was developed to be used in the robotic operating theatre with the operating robot to enhance its fidelity. It is portable and relatively inexpensive when compared with other forms of simulation such as virtual reality or animal lab training. It thus has the potential of being more accessible as a training tool for the safe acquisition of RAKT specific skills. We demonstrate this model here.

Insights in Transplanting Complex Paediatric Renal Recipients With Vascular Anomalies

Background Children with end-stage kidney disease may have coexisting iatrogenic or congenital vascular anomalies making transplantation difficult. We describe our approach in 5 recipients with vascular anomalies and significant comorbidities, including one case of blood group incompatibility. Methods Five children aged 3 to 17 years (median, 7 years), weighing 14 to 34 kg (median, 18 kg) kg of whom 4 had occluded inferior vena cava or iliac veins and 2 had previous complex vascular reconstructions before transplantation for midaortic syndrome and multiple aortic aneurysms, respectively underwent renal transplantation. To establish implant feasibility surgery was commenced in 2 recipients before the donor surgery. Results There was 4 (80%) of 5 patient survival after 1 death from sepsis (with a functioning graft) and 2 cases of delayed graft function. At the latest median follow-up of 19 months, there was 100% (death-censored) renal allograft survival with estimated glomerular filtration rates (mL/min per 1.73 m2) of 43 to 72 (median, 55). Conclusions We conclude that major vascular anomalies do not necessarily preclude transplantation in complex pediatric patients and that surgical exploration of the recipient before commencing the donor surgery is valuable where feasibility and safety are uncertain. In addition, we have developed a novel classification system of congenital vascular abnormalities and propose its use in complex pediatric transplantation.

Classification of abdominal vascular anomalies and use of 3D printing to support complex renal transplantation in children

Abstract Background Transplantation is the treatment of choice for paediatric renal recipients. However, there are increased challenges in small ( Methods We describe our management in five paediatric renal recipients with vascular anomalies (median age 7 years [IQR 4·5–13·0], median weight 18 kg [IQR 14·5–29·0]). We assessed the utility of 3D printing as a planning tool in four children with complex abnormalities (one retrospective case, three prospective cases) for whom implantation was uncertain as judged by conventional imaging. Surgically relevant donor and recipient anatomy was segmented from MRI or CT data (Mimics Medical v18.0, Materialise, Leuven, Belgium). The segmentation geometry derived from the extracted anatomical data was then exported in STL file format and physically fabricated with multimaterial, polyjet 3D printing technology (Objet500 Connex1, Objet-Stratasys). We assessed the value of models using questionnaires and geometric validation studies. Findings Four (80%) of five children survived after one death from sepsis (with a functioning graft). At the latest median follow-up of 19 months (IQR 10·5–83·0) renal allograft survival was 100% (death censored) with a median estimated glomerular filtration rate of 55 mL/min per 1·73 m 2 (IQR 45–66). We have previously classified these vascular anomolies on the basis of aortic and IVC patency (I=aorta patent, II=infrarenal segment occluded, III=suprarenal segment occluded, IV=all aorta occluded) and similarly for IVC patency (A–D). By independent questionnaire, all prospective 3D printed models were considered useful for preoperative planning, and thereby facilitated transplantation. In our retrospective proof of concept, Bland–Altman analysis found that the mean difference in vascular diameter between the printed model and segmentation geometry was −0·1 mm (95% CI −0·7 to 0·5), which was insignificant when compared with the measurement uncertainty (±0·4 mm) and the limits of surgical precision. All models showed geometrical consistency with preprinting designs and intraoperative anatomical correlation within surgical acceptance for crucial decision making. Interpretation Vascular anomalies do not necessarily preclude transplantation, and a classification system could guide management. Our feasibility study of patient-specific 3D printing suggests that cases classified as sufficiently complex can benefit from this technology. Patient-specific models provide the surgical team with the full, 3D, accessible, haptic, and spatial appreciation of anatomy that is crucial in surgical decision making and planning. This technology can inform the selection of suitable anastamosis sites in the presence of anomalies and the best surgical approach for implantation of an adult-sized kidney into a small child. Funding None.