Introduction

Kidney autotransplantation (KAT) is a useful alternative for renal salvage in select patients who failed other surgical and medical management. While the open approach has a high success rate, there is an increased morbidity associated with it. In recent years, there has been a successful shift towards minimally invasive laparoscopic and robotic approach.^1,2 The novel da Vinci Single-port (SP) robotic platform expanded the feasibility of multiquadrant urological surgeries due to the ability to rotate its surgical axis through a single incision. We have earlier published our minimally invasive series of SP KAT for various etiologies.³

Methods

We have successfully completed a series of 12 SP KATs between 2020-2022 at our institution. The various indications included complex ureteral strictures, recurrent nephrolithiasis due to metabolic stone disease, iatrogenic ureteral injury, chronic visceral pain, and left renal vein occlusion due to nutcracker phenomenon.

The video abstract of one of the KAT cases presented at AUA2023 was awarded the best video of its session. In this video, we demonstrated the safety and feasibility of our minimally invasive SP KAT approach in a 58-year-old male patient with complete ureteral avulsion. The additional difficulty in this particular patient is the lack of a viable ureter that required extensive back bench dissection of the renal pelvis (Figure 1, C) and Boari flap reconstruction for the bladder to reach the renal pelvis.

Figure 1. Operative images. A, Periumbilical 5-cm vertical incision used for the single-port kidney autotransplantation. B, Patient positioning in 45-degree bumped position with the ipsilateral side up and single-port robot docked in a floating dock technique. C, Kidney back bench preparation demonstrating renal pelvis without any viable ureter. D, Animation demonstrating the kidney transplantation technique with venous anastomosis. E, Intraoperative arterial vascular anastomosis using 6-0 GORE-TEX suture. F, Post-surgery CT images demonstrating the autotransplant kidney with the Boari flap.

The video demonstrates our technique in detail including (1) robotic nephrectomy, (2) kidney benching, (3) dissection of iliac vessels and kidney placement, (4) vascular anastomosis, and (5) Boari flap ureteral reconstruction.

The patient was placed in a supine position with ipsilateral torso tilted to 45 degrees. A single 4-5–cm periumbilical incision was utilized for surgery and the peritoneum was entered in an open fashion (Figure 1, A). The Alexis wound retractor and GelPOINT access platform with the 25-mm multichannel cannula, 12-mm AirSeal are inserted through the incision and the robot is docked in a floating dock technique previously described (Figure 1, B).⁴ The donor nephrectomy was performed in a standard fashion.

The SP robot is redirected to the ipsilateral pelvis using the same periumbilical incision for dissection of iliac vessels for later transplant. The extracorporeal kidney benching was performed at the same time while the iliac vessels are prepared robotically. The vascular anastomosis, the renal vein first and later the artery, were performed using 6-0 GORE-TEX sutures in an end-to-side running fashion (Figure 1, D-E). The patient demonstrated in the video in particular had a complete ureteral avulsion that required Boari flap ureteral reimplant. We used a tubularized U-shaped flap from the posterolateral bladder that is subsequently anastomosed to the widely spatulated ureteropelvic junction.

Results

The surgery was completed without any complications or conversion. Total warm and cold ischemia times were 6 and 209 minutes, respectively. Total revascularization time was 65 minutes. Estimated blood loss was 500 cc. The patient was discharged on postoperative day 3. The latest follow-up was 1 year from surgery with relative preservation of renal function and no sign of obstruction (Figure 1, F).

In our overall initial series, all cases were completed with relative preservation of renal function (Figure 2) and no conversion to open surgical approach. The patients who reported significant visceral pain preoperatively had near-complete resolution of pain scores at follow-up appointment.

Figure 2. Median stable renal function (creatinine) response in our initial consecutive single-port kidney autotransplantation patient series (N=12). POD indicates postoperative day.

Discussion

Different minimally invasive approaches have been incorporated in KAT to decrease patient’s morbidity. Modifications included laparoscopic nephrectomy with open Gibson reimplantation and, more recently, multiport robotic KAT.⁵

Multiport robotic KAT, although feasible, required different ports, patient repositioning and redraping for the nephrectomy, and later kidney transplantation. Kaouk et al earlier presented our initial successful experience with kidney transplantation using the SP robotic platform and early outcomes in both preclinical^6,7 and clinical phases.⁸

Extrapolating the knowledge from our SP kidney transplantation, we studied the feasibility of the approach for KAT using the purpose-built da Vinci SP robotic platform with successful completion of surgery without conversion or loss of graft function.³ The SP robot with 360-degree anatomical access and multiquadrant approachability gave a unique opportunity to perform the surgery without need for patient repositioning or additional ports.

Limitations of our SP KAT series include small case volume, heterogeneity of patient population, and surgeon expertise. KAT is an uncommon procedure and increased inclusion of SP robotic platform in urology practice can help multi-institutional collaboration and external validation of our institutional results.

Conclusions

SP KAT is a safe, efficient, multiquadrant robotic surgery. It is associated with reduced surgical morbidity, without loss of the graft function.

Disclosures: None.