Single‐port extraperitoneal robotic kidney transplantation: early experience of novel technique

Abstract

There has been an increased shift in the adoption of robotic surgical platforms across various surgical specialties over the last two decades including kidney transplantation (KT) given proven benefits with enhanced recovery, decreased morbidity, and similar functional outcomes compared to the open approach [1, 2]. However, robot-assisted KT (RAKT) is commonly performed via the transperitoneal approach compared to the open extraperitoneal (EP) approach. The novel purpose-built single-port (SP) robotic platform (Intuitive Surgical, Sunnyvale, CA, USA) has been widely adopted for various urological procedures since 2018 including initial pre-clinical reports of SP KT [3], as well as the initial clinical experience with SP KT and SP kidney autotransplantation in prior studies [4, 5]. Appreciating the potential benefits of regionalised surgical access possible with the EP approach, we have adopted it for KT in our practice since the early report. A retrospective review was performed to identify all patients who underwent SP EP-KT between August 2020 and January 2023. All patients aged >18 years with end-stage renal disease diagnosis were considered candidates for SP KT. Exclusion criteria for SP EP-KT included calcifications in the external iliac artery, prior transplant on the ipsilateral side, and large donor kidney (>14 cm). The primary outcome of this study was to demonstrate the safety and feasibility of the surgery defined as successful completion of the transplant procedure without any conversion, abortion of procedure, or postoperative graft loss. Secondary outcomes reported include perioperative outcomes including estimated blood loss (EBL), total operative time (OT), revascularisation time (RT), and postoperative renal function assessment. Patient clinical demographics and postoperative outcomes data were collected prospectively. All procedures were performed under general anaesthesia. The patient was placed supine, with the arms out and the bed slightly tilted to the left side and minimal Trendelenburg position. A 5-cm infra umbilical midline incision was made and extended through the subcutaneous tissue and abdominal fascia. After the rectus muscles were split in the midline, the EP space was created by reflecting the peritoneum using blunt dissection and electrocautery. After the development of an adequate EP space, the inner wound retractor ring for the large incision da Vinci Access Kit was placed through the incision into the EP space (Fig. 1A). The access port was assembled, the EP cavity was insufflated to a pressure of 12 mmHg, and the SP robot was docked towards the ipsilateral pelvis using the floating dock technique with the camera-up orientation [6] (Fig. 1B). In preparation for the anastomoses, the external iliac vessels were isolated, exposed, and cleared of the adventitia robotically. Vessel loupes were applied around the external iliac vessels to facilitate handling. Once an adequate length of the iliac vessels were obtained, the SP robot was undocked, and the donor graft wrapped in a modified sterile surgical glove was introduced into the EP space (Fig. 1C). Insufflation was re-initiated, and the robot was re-docked. Two robotic bulldog clamps were placed on the proximal and distal aspects of the external iliac vein. A venotomy was sharply made on the anterior aspect of the vein in between and flushed with heparinised saline. With the kidney oriented medially, the renal vein was then anastomosed in an end-to-side running fashion using expanded polytetrafluoroethylene CV5 sutures (Fig. 1D). We performed a similar external iliac arteriotomy for renal arterial anastomosis and the renal artery was anastomosed similarly to the venous anastomosis (Fig. 1E). The venous and arterial anastomoses were tested sequentially with the removal of the bulldog clamps. Once the vascular anastomoses were complete, the kidney was lateralised above the psoas. The bladder was distended with saline, and a cystotomy was sharply