Robotic Transplant Nephrectomy for Failed Renal Allograft
Abstract and Introduction
Minimally invasive surgery for removal of a failed renal allograft has not previously been reported. Herein, we report the first robotic trans-abdominal transplant nephrectomy (TN). A 34-year-old male with Alport's syndrome lost function of his deceased donor allograft after 12 years and presented with fever, pain over his allograft and hematuria. The operation was performed intra-abdominally using the Da Vinci Robotic Surgical System with four trocars. The total operative time was 235 min and the estimated blood loss was less than 25 cm. There were no peri-operative complications observed and the patient was discharged to home less than 24 h postoperatively. The utilization of robotic technology facilitated the successful performance of a minimally invasive, trans-abdominal TN.
Transplant nephrectomy (TN) is an invasive procedure with the potential for significant morbidity and mortality due to comorbid patient conditions, chronic immunosuppression and technical complexity. TN is performed via the same oblique incision in the iliac fossa as the original transplant to gain access to the failed allograft. Re-opening this incision produces considerable pain and discomfort resulting in a substantial postoperative hospital stay and a prolonged recovery upon discharge. The presence of postsurgical scarring and dense inflammation make dissection and removal of the failed allograft technically demanding. In recent series of TN significant morbidity was reported in 10–40% of patients and was mostly attributed to hemorrhage or infection. However, significant injuries to surrounding structures such as the bladder, colon and iliac vessels have been reported as well. The overall mortality rate associated with TN ranged from 3% to 9% and was mostly attributed to septic complications following surgery. In summary, TN is an invasive procedure associated with significant potential morbidity and mortality risk as well as considerable patient discomfort.
Minimally invasive surgical techniques have improved patient outcomes in many fields of surgery. Transplant surgeons, however, have been slow adaptors of this new technology. At present, the only widely adopted minimally invasive transplant related procedure is laparoscopic donor nephrectomy. Some progressive transplant centers have performed robotic donor nephrectomies and even robotic renal transplants, but these centers are the exception and not the rule. Minimally invasive surgery has been shown to reduce patient discomfort allowing for earlier mobilization, hospital discharge and return to work. Robotic surgery provides a three-dimensional field of view and greater freedom of movement through the use of articulated instruments. This allows surgeons to perform highly complex tasks with better visualization and improved dexterity compared to standard laparoscopy. Because our center has extensive experience with robotic donor nephrectomy, we wished to explore the application of robotic techniques to TN in an attempt to decrease post-operative discomfort, hospital length of stay and the traditionally associated morbidity and mortality risk.
To our knowledge, this is the first report of a robotic trans-abdominal TN successfully performed in a patient with a failed renal allograft.