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YUO/YAU section: Robotic kidney transplantation
Update from the ERUS-RAKT Working Group
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Dr. Riccardo Campi Member, YAU Kidney Transplantation working group University of Florence Carregi Hospital Florence (IT)
riccardo.campi@ gmail.com
Dr. Angelo Territo Chairman, YAU Kidney Transplantation working group Dept. of Urology Fundació Puigvert Barcelona (ES)
territoangelo86@ gmail.com
Fig. 1: Overview of the currently most active urological centres performing robot-assisted kidney transplantation (RAKT)
On behalf of the ERUS-RAKT working group
In recent years, robot-assisted kidney transplantation (RAKT) has emerged as a feasible and safe alternative to the traditional open approach, offering the benefits of minimally-invasive surgery to both surgeons and recipients. [1,2]
After its inception and development [3-5], RAKT was progressively adopted in the living donor setting in selected referral transplant centres worldwide. [6] In 2016, the European Association of Urology (EAU) Robotic Urology Section (ERUS) RAKT working group, led by Dr. Alberto Breda, was founded, which developed into an international collaboration aimed at standardising the technique of RAKT. The aim was to assess the perioperative and functional outcomes of RAKT using standardised metrics as well as to expand the indications for minimally invasive kidney transplantation in Europe and beyond.
Active centres To date, the most active centres in the ERUS-RAKT consortium are located in Spain (Dept. of Urology of the Fundaciò Puigvert, Hospital Clinic and Bellvitge University Hospital in Barcelona), Italy (Dept. of Urological Robotic Surgery and Renal Transplantation of Careggi University Hospital in Florence), Belgium (Dept. of Urology of Ghent University Hospital), Germany (Dept. of Urology of University Saarland in Homburg/Saar) and France (Dept. of Urology and Renal Transplantation of the University Hospital of Rangueil in Toulouse) (see Fig. 1).
Fruitful collaboration and teamwork The fruitful collaboration between such European transplant centres led by urological teams is the result of strong determination and resilience of a group of pioneers aiming to advance the field of kidney transplantation by leveraging the benefits of minimally-invasive surgery. In this regard, the contributions of Dr. Alberto Breda (Barcelona), Prof. Karel Decaestecker (Ghent), Prof. Antonio Alcaraz and Dr. Mireia Musquera (Barcelona), Prof. Francesc Vigués Julià (Barcelona), Prof. Sergio Serni and Dr. Graziano Vignolini (Florence), Prof. Michael Stoeckle (Homburg), Prof. Paolo Fornara (Halle), Prof. Volkan Tugcu (Istanbul (TR)) and Dr. Nicolas Doumerc (Toulouse), among others, to both the clinical and scientific achievements of the ERUS-RAKT working group during the last five years, were invaluable.
Update on RAKT at EAU22 Despite being relatively ‘young,’ the ERUS-RAKT working group has achieved several goals and has provided a robust foundation for significant further research in this field.
In the lecture entitled Robotic kidney transplantation: Update for the ERUS-RAKT Working Group, to be presented at the 37th Annual EAU Congress in Amsterdam (NL) during Thematic session 12: Difficult cases in renal transplantation (Speaker: Dr. R. Campi), the mosaic of evidence built by the ERUS-RAKT group over the last years will be analysed comprehensively. Urologists and transplant surgeons will be given key insights to understand the contemporary role of robotics in the field of kidney transplantation. Platform for prospective data collection The scientific collaboration between the centres included in the ERUS-RAKT group was enabled by the early development of a project-specific web-based platform for prospective granular data collection from patients undergoing RAKT at each participating institution. Such a platform, developed and managed by a team of researchers at the University of Florence, allowed all group members to share data on RAKT using a standardised data collection process and established clinical end points. Thanks to this collaborative initiative, the ERUS-RAKT working group has published several key papers in peer-reviewed journals over the last years, exploring the feasibility and safety of RAKT in a variety of clinical scenarios.
Recent reports by the ERUS-RAKT working group After the first report detailing the early European experience with RAKT from living donors and proving the technical feasibility, safety and favourable perioperative and short-term functioning of RAKT in experienced hands [2] (with lower rates of symptomatic lymphoceles and wound infections as compared to previous experiences [7]), Territo et al. reported an update regarding the mid-term outcomes of patients who underwent RAKT with a minimum of 1-year follow-up. [8] In this work, optimum functional outcomes and a low rate of mid-term postoperative adverse events (such as incisional hernia, ureteral stenosis, and vascular complications) were reported. The latest update published by the group in 2021 (the largest European multicentre study on RAKT) confirmed that RAKT can achieve good surgical and functional results that are competitive with those of the gold standard’ open kidney transplantation in centres with a wide experience in open kidney transplantation and robotic urologic surgery. [6]
Notably, considering the lack of evidence on the learning curve of RAKT, another study by Gallioli et al. evaluated the number of procedures needed to achieve proficiency in RAKT from living donors based on a a-priori developed Trifecta. [9] The authors found that a minimum of 35 cases are necessary to reach reproducibility in terms of rewarming time, complications and functional results.
Outcomes of RAKT in challenging cases and new frontiers The ERUS-RAKT working group also analysed the outcomes of RAKT from living donors in selected and more challenging clinical scenarios. In this regard, Siena et al. reported no significant differences in terms of median vascular anastomosis and rewarming times between RAKT using grafts with multiple vessels and those with standard single-vessel anatomy [10], confirming the feasibility and safety of RAKT in these cases after proper ex-vivo vascular reconstruction on the bench table. Similarly, Prudhomme et al. explored the outcomes of RAKT among obese vs. non-obese recipients. They found that RAKT is safe in this challenging patient cohort if performed by experienced surgeons, and it can achieve good graft function in the short-mid-term follow-up. [11] Lastly, the group has confirmed the feasibility and safety of postoperative percutaneous diagnostic or therapeutic procedures (such as graft biopsy, placement of a nephrostomy tube or drainage of postoperative fluid collections) after RAKT [12] and has highlighted the potential added value of the robotic platform regarding the assessment of graft and ureteral reperfusion thanks to intraoperative fluorescence vascular imaging with indocyanine green. [13,14] In a seminal report, Vigues et al. reported for the first time the technical feasibility of robot-assisted orthotopic kidney transplantation, focusing on technical nuances and early postoperative outcomes. [15]
RAKT from deceased donors In more recent years, the ERUS-RAKT working group has further moved the field forward by assessing the impact of robotics in frontier areas of kidney transplantation with either single centre or multicentre studies. In particular, the group at Careggi University Hospital in Florence has pioneered a technique and a specific logistical framework to perform RAKT from deceased donors. [16,17] While being more challenging from a logistical standpoint, these reports highlight the feasibility and safety of RAKT in the broader and more complex setting of deceased donors, provided proper recipient selection, surgical team experience and excellent organisation of the kidney transplantation pathway are present. Further studies are needed to compare the outcomes of RAKT vs. open kidney transplantation, aiming to assess the benefits and limits of robotic surgery for kidney transplantation from deceased donors.
Novel cold ischemia device for RAKT To overcome the limitations of the traditional strategy to achieve regional hypothermia during RAKT, Dr. Breda, Dr. Territo and colleagues at Fundación Puigvert in Barcelona successfully developed a novel cold ischemia device according to the IDEAL recommendations [18] allowing the maintenance of a constant low graft temperature during the rewarming time. [19] While waiting for prospective multicentre studies validating the benefits of this device in larger cohorts of recipients, the study by Territo et al. provides a foundation for optimisation of surgeons’ learning curve and, most importantly, functional outcomes after RAKT from both living and deceased donors.
Intracorporeal versus extracorporeal RAKT After previous preliminary reports showed the technical feasibility of robot-assisted kidney autotransplantation (RAKAT) in experienced hands [20], Breda et al. recently compared the outcomes of intracorporeal versus extracorporeal RAKAT, showing similar postoperative functional outcomes and highlighting the promising role of this procedure for well-selected patients. [21]
Another major step toward the definition of the benefits of robotic surgery for kidney transplantation from living donors is represented by exploratory studies suggesting the non-inferiority of RAKT vs. open kidney transplantation regarding intraoperative, perioperative and functional outcomes [22] as well as postoperative systemic inflammatory responses. [23] Future projects Based on the robust evidence on RAKT discussed above, the ERUS-RAKT working group is designing prospective multicentre projects aiming to increase the quantity and quality of evidence supporting the benefits of robotics in this inspiring field. These projects will provide evidence on the best indications and cost effectiveness of RAKT and will hopefully achieve the following goals in the near future:
a) integration of augmented-reality technologies into pre and intra-operative planning of RAKT using grafts from both living and deceased donors; b) comparison of postoperative, functional and patient-reported outcomes after robotic vs. open kidney transplantation by means of prospective high-quality (ideally randomised) trials; c) definition of standardised modular training programmes for RAKT, taking advantage of step-by-step learning modules and specific simulators (as previously achieved for other urological procedures [24,25]) in order to increase the number of urologists offering minimally invasive kidney transplantation at a higher number of transplant centres in Europe. To reach this goal, the ORSI Academy in Belgium is now offering structured courses on RAKT (https:// invivox.com/sales-rep/orsi-academy); d) improvement of RAKT programmes from deceased donors (which require a complex logistical framework as compared to the living donor setting).
In conclusion, while several key goals have already been achieved by the ERUS-RAKT working group during the last years, further research is needed to expand the indications for RAKT in Europe and beyond. Harnessing the power of scientific collaboration between referral urological centres performing RAKT will be key to improve the quality of the evidence as well as patient outcomes and quality of life.
References
1. Wagenaar S, Nederhoed JH, Hoksbergen AWJ, et al.
Minimally Invasive, Laparoscopic, and Robotic-assisted
Techniques Versus Open Techniques for Kidney Transplant
Recipients: A Systematic Review. Eur Urol. 2017
Aug;72(2):205-217. doi: 10.1016/j.eururo.2017.02.020. 2. Breda A, Territo A. Can the robotic approach replace open surgery in kidney transplantation? World J Urol. 2021
Sep;39(9):3699-3700. doi: 10.1007/s00345-020-03312-x. 3. Giulianotti P, Gorodner V, Sbrana F, et al. Robotic transabdominal kidney transplantation in a morbidly obese patient. Am J Transplant. 2010 Jun;10(6):1478-82. doi: 10.1111/j.1600-6143.2010.03116.x. 4. Decaestecker K, Territo A, Campi R, et al. Robot-Assisted
Kidney Transplantation. In: Medical Robotics - New
Achievements. Edited by Serdar Küçük and Abdullah
Erdem Canda. IntechOpen, DOI: 10.5772/intechopen.90276.
Available from: https://www.intechopen.com/ chapters/70819
The complete reference list of this article is available from the EUT Editorial Office. Please send an e-mail to: EUT@uroweb.org with reference to the article “Robotic kidney transplantation as safe alternative” March/May issue 2022.
