Prasun Ghosh

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.

Minimally invasive kidney transplantation: perioperative considerations and key 6-month outcomes.

Background Minimally invasive approaches to kidney transplantation (KT) have been described recently. However, information concerning perioperative management in these patients is lacking. Accordingly, in the current study, we describe our perioperative management strategy in patients undergoing robotic KT with regional hypothermia and report its safety and efficacy. Further, we describe key 6-month outcomes in these patients. Methods Sixty-seven consecutive end-stage renal disease patients underwent live-donor robotic KT at a single tertiary care institution between January 2013 and June 2014. Outcomes including patient/graft survival, graft function, operative parameters, and perioperative complications are reported in patients with a minimum of 6-month follow-up (n = 54). Results All patients successfully underwent robotic KT with regional hypothermia using a modified intraoperative management protocol. None of the cases required conversion to open surgery (0%). Mean console, warm ischemia, and rewarming times were 130.8 minutes, 2.3 minutes and 42.9 minutes, respectively. Mean graft-surface temperature was 19.2°C with zero incidence of systemic hypothermia. Routine extraperitonealization of the graft insured against graft-torsion (0%) despite a transperitoneal approach to graft placement. There were no instances of graft vascular thromboses/stenoses/leaks (0%). Three patients (5.6%) developed clinical head-neck edema but were successfully extubated on table. There was no delayed graft function (0%). Mean 6-month serum creatinine was 1.2 mg/dL. Patient survival was 96.3% (n = 52), and death-censored graft survival was 100% at a median follow-up of 13.4 months. Conclusions Significant differences exist in intraoperative management of patients undergoing robotic KT and open KT. By tweaking fluid infusion rates and pneumatic pressures and maintaining core body temperature, optimal patient outcomes can be achieved. Pretransplant and posttransplant management is essentially the same.

Laparoscopic pyeloplasty using the postanastomotic dismemberment method: technique and results.

BACKGROUND AND PURPOSE Despite excellent results, widespread acceptance of the laparoscopic dismembered Anderson-Hynes pyeloplasty (AH) is hampered by its steep learning curve. Laparoscopic nondismembered pyeloplasty techniques, although simpler, have not matched the results of AH. We have been using a technical modification of AH to combine its excellent outcome with technical ease of nondismembered pyeloplasties. We describe the procedure and results of laparoscopic postanastomotic dismemberment (PAD) pyeloplasty for primary ureteropelvic junction (UPJ) obstruction. PATIENTS AND METHODS PAD technique involves an initial partial division of the dilated pelvis and ureteral spatulation without dismembering the UPJ. Both layers of ureteropelvic anastomosis are completed before dismemberment and pelvic reduction. Forty-one PAD procedures in 40 patients with UPJ obstruction and follow-up of at least 3 months were evaluated. Mean age was 37.2 years (range 2-82 years) with 22 patients younger than 15 years. The UPJ was dependent in 31 and had high insertion in 10 (24.4%). The stenotic segment was long (> or =1.5 cm) in 18 (43.9%). Crossing vessels and secondary calculi were observed in six (14.6%) and seven (17.1%) units. RESULTS Mean (+/- SD) blood loss, hospital stay, convalescence, and analgesia requirement were 68.1 +/- 37.6 mL, 3.8 +/- 1.1 days, 11.4 +/- 3.9 days, and 204.8 +/- 60.5 mg diclofenac, respectively. The mean operative time was 97.6 +/- 22.1 minutes. There was one intraoperative complication in the form of injury to a renal vein tributary, with no transfusions or conversions. Postoperative complications included pain after stent removal, persistent drainage, and pyelonephritis in 1, 2, and 4 patients, respectively. Mean follow-up was 19.5 months (range 3-58 months), with a success rate of 95.1%. Failures were not attributable to UPJ configuration, length of stenosis, or age. CONCLUSIONS The PAD technique has several practical advantages with a shorter operative time compared with other historical series of laparoscopic pyeloplasty (LP). It combines the ease of nondismembered LP with the excellent outcome of dismembered techniques.

ABO-incompatible renal transplantation in developing world - crossing the immunological (and mental) barrier

ABO incompatibility has been considered as an important immunological barrier for renal transplantation. With the advent of effective preconditioning protocols, it is now possible to do renal transplants across ABO barrier. We hereby present a single center retrospective analysis of all consecutive ABOi renal transplants performed from November 2011 to August 2014. Preconditioning protocol consisted of rituximab, plasmapheresis and intravenous immunoglobulin (IVIG) and maintenance immunosuppression consisted of tacrolimus, mycophenolate sodium, and prednisolone. The outcome of these ABOi transplants was compared with all other consecutive ABO-compatible (ABOc) renal transplants performed during same time. Twenty ABOi renal transplants were performed during the study period. Anti-blood group antibody titer varied from 1:2 to 1:512. Patient and graft survival was comparable between ABOi and ABOc groups. Biopsy proven acute rejection rate was 15% in ABOi group, which was similar to ABOc group (16.29%). There were no antibody-mediated rejections in ABOi group. The infection rate was also comparable. We conclude that the short-term outcome of ABOi and ABOc transplants is comparable. ABOi transplants should be promoted in developing countries to expand the donor pool.

Renal transplantation across ABO barrier

In India, patients without a compatible blood group donor are usually excluded from renal transplantation. For young patients, it is a difficult therapeutic choice to stay on long-term dialysis. We describe the case of a 19-year-old male patient who had blood group O +ve and had no compatible donor in the family. His mother was B +ve and was willing to donate. The patient had an initial anti-B antibody titer of 1:512 and underwent antibody depletion with plasmapheresis (11 sessions) and intravenous immunoglobulin (IVIG) 100 mg/kg after every plasmapheresis. He also received rituximab 500 mg for 3 days prior to transplant and was induced with basiliximab. At the time of transplant, his anti-B titers were <1:8. Post-operatively, he required four sessions of plasmapheresis and IVIG as his titers rebounded to 1:64. The titers then spontaneously subsided to <1:16 and have stayed at the same level for 6 months post-transplant. The patient continues to have normal renal function with a creatinine of 1.4 mg/dl% and has had no episodes of rejection.

Robot Assisted Renal Transplantation

Minimally invasive approach in the field of renal transplantation has largely been restricted to laparoscopic donor nephrectomy. Wound related complications do occur in recipients and may compromise graft outcome [1]. Laparoscopic renal transplantation has not been taken up except in a very few centers. The inherent difficulty of laparoscopic vascular suturing, risk of increasing warm and cold ischemia, necessity of incision to place the graft and air tight closure prior to commencing anastomosis are the reasons behind it [2]. We describe our robot assisted approach side stepping most of these drawbacks, with results equivalent to open surgery, and benefits of minimally invasive surgery to the patients.

MP29-07 ROBOTIC KIDNEY TRANSPLANTATION WITH REGIONAL HYPOTHERMIA: RESULTS FROM A PROSPECTIVE TWO-ARM NON-RANDOMIZED CONTROLLED TRIAL (IDEAL PHASE 2B)

INTRODUCTION AND OBJECTIVES: Minimally invasive approaches to kidney transplantation (KT) have recently been described. We recently developed and described a novel technique of robotic KT (RKT) which allows intra corporeal graft cooling. Here, we sought to assess the comparative effectiveness of robotic and open KT (OKT) by evaluating peri and post-operative outcomes. METHODS: During Jan-May 2013, a total of 83 patients with end stage renal disease underwent KT at a tertiary referral center. Sixty six patients met the selection criteria and were enrolled into this prospective two-arm non-randomized controlled trial (IDEAL Phase-2b). Primary outcome was post transplant graft function. Secondary outcomes measured included surgical and immunologic complications, and peri-operative parameters. All patients had a minimum follow up of 6 months. RESULTS: Twenty five and 41 patients underwent RKT and OKT, respectively. There were no significant baseline differences between the two groups. Mean serum creatinine at discharge was 1.3 and 1.4 mg/dl in RKT and OKT patients, respectively (p1⁄40.71). Post-operative pain and analgesic requirements were significantly less in patients undergoing RKT (p1⁄40.01) (Fig 1). No patient undergoing RKT required post transplant dialysis whereas 2 (4.8%) patients undergoing OKT did. The incidence of lymphocele was markedly reduced in patients undergoing RKT detected by per protocol non contrast CT done at 3months (0% vs. 23.8%; p1⁄40.05; Fig 1). There was 1 graft loss in the OKT group; and 1 patient death (1.5 months post transplant secondary to congestive heart failure) in the RKT group (Table 1). CONCLUSIONS: RKT with regional hypothermia is safe and easily reproducible. Early outcomes are equivalent to OKT; with a propensity towards lower complications, quicker graft function recovery and shorter patient convalescence.