In case of RAKT, a double-J stent is routinely placed at the time of bench surgery to facilitate subsequent ureterovesical anastomosis. The graft is finally placed in a gauze jacket filled with ice, with the renal artery fixed to the gauze with a landmark stich. In case of right-sided grafts, an inferior vena cava patch is performed to increase the length of the graft renal vein. During bench surgery, the anterior margin of the graft vein is reshaped by cutting away a slice of venous tissue to improve visualisation of its posterior margin during the subsequent venous anastomosis. In this specific case, the aortic patch was removed by the surgeon during bench surgery. (C) External and intraoperative view of the graft before and after its introduction into the peritoneal cavity during RAKT. A Pfannenstiel incision is used to introduce the graft through the GelPoint device or the Alexis system. Pneumoperitoneum pressure was set at 8–10 mmHg and maintained constant through the use of the Airseal system. ] using either the da Vinci Si or the Xi robotic platform in a four-arm configuration, with a 0° lens and a 20° Trendelenburg tilt. In particular, there must be no recipient-related contraindications for RAKT (currently represented by recipient age <18 yr, absolute contraindication for robotic surgery, multiple previous major abdominal surgeries, and severe atherosclerotic plaques at the level of iliac vessels), the robotic transplant team and operating room staff must be available (even during the night or the weekends), the robotic operating room must be available, the cold ischaemia time (CIT) must be <20 h to allow a safe graft reperfusion within a <24 h time frame, and finally, no graft-related contraindications for RAKT must be seen at the time of bench surgery (ie, mainly complex vascular anatomy requiring complex ex situ reconstruction and potentially multiple anastomoses). If one or more criteria are not respected, then open kidney transplantation (OKT) is performed. Once the kidney offer has been received, the kidney has been evaluated for its suitability for transplantation by the Regional Transplant Authority (RTA Centro Regionale Allocazione Organi e Tessuti ), and selection of the potential recipient has been finalised, specific criteria must be met to perform robot-assisted kidney transplantation (RAKT). 1 Flowchart showing the decision-making strategy regarding selection of the open versus robotic surgical approach for kidney transplantation from donors after brain death (DBDs) at our centre. 1): (1) absence of recipient-related contraindications for RAKT (currently represented by recipient age <18 yr, absolute contraindication for robotic surgery, multiple previous major abdominal surgeries, and severe atherosclerotic plaques at the level of iliac vessels), (2) availability of the robotic transplant team (mainly according to the surgeon on call assistant surgeons and operating room staff are always available, if needed), (3) availability of the robotic operating room (during weekdays, nights, and weekends), (4) CIT <20 h to achieve graft reperfusion within a <24 h time frame, and (5) no graft-related contraindications for RAKT during bench surgery (mainly complex vascular anatomy requiring complex ex situ reconstruction and potentially multiple anastomoses).įig. Nowadays, after the evaluation of graft suitability for transplantation by the Regional Transplant Authority and selection of the potential recipient, all the following criteria must be met to perform RAKT ( Fig. The study is limited by its nonrandomised nature and the small sample size. At the multivariable analysis, donor- and/or recipient-related factors, but not the surgical approach, were independent predictors of DGF, trifecta, and suboptimal graft function at the last follow-up. A higher proportion of patients undergoing OKT experienced DGF yet, at a median follow-up of 31 mo (interquartile range 19–44), there was no difference between the groups regarding the dialysis-free and overall survival. The median second warm ischaemic time, ureterovesical anastomosis time, postoperative complication rate, and eGFR trajectories did not differ significantly between the groups. The OKT and RAKT cohorts were comparable regarding all graft-related characteristics, while they differed regarding a few donor- and recipient-related factors. The yearly proportion of RAKT ranged between 10% and 18% during the study period. Overall, 138 patients were included (117 OKTs and 21 RAKTs).
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