AUTHOR=Van Praet Charles , Lambert Edward , Desender Liesbeth , Van Parys Benjamin , Vanpeteghem Caroline , Decaestecker Karel 

TITLE=Total Intracorporeal Robot Kidney Autotransplantation: Case Report and Description of Surgical Technique

JOURNAL=Frontiers in Surgery

VOLUME=Volume 7 - 2020

YEAR=2020

URL=https://www.frontiersin.org/journals/surgery/articles/10.3389/fsurg.2020.00065

DOI=10.3389/fsurg.2020.00065

ISSN=2296-875X

ABSTRACT=Introduction and objectives
Kidney autotransplantation can be performed in patients with complex renal or ureteral pathology not suitable for in situ reconstruction, such as renal vasculature anomalies, patients with proximal or long complex ureteral strictures or complex oncological cases. Robot-assisted surgery allows for a high-quality vascular and ureteral anastomosis and faster patient recovery. Robot-assisted kidney autotransplantation (RAKAT) is performed in two phases: nephrectomy and pelvic transplantation. In-between, extraction of the kidney allows for vascular reconstruction or kidney modification on the bench and safe cold ischemia can be established. If no bench reconstruction is needed, total intracorporeal RAKAT (tiRAKAT) is feasible. One case report in Europe has been described, however, to our knowledge no surgical video is available.

Methods
A 58-year old woman suffered from right distal ureter stenosis following pelvic radiotherapy 10 years prior for cervical cancer. A JJ stent was placed, but she suffered from recurrent urinary tract infections and ultimately a nephrostomy was placed. Renogram demonstrated 43% relative right kidney function. As her bladder volume was low following radiotherapy, no Boari flap was possible and the patient refused life-long nephrostomy and nephrectomy. Therefore, tiRAKAT was performed, using the DaVinci Xi system.

Results
We describe our surgical technique including a video. Surgical time (skin-to-skin) was 5 hours and 45 minutes. Warm ischemia time was 4 minutes, cold ischemia 55 minutes and rewarming ischemia 15 minutes. The abdominal catheter and bladder catheter were removed on the first and second postoperative day, respectively. The JJ stent was removed after 4 weeks. The patient suffered from pulmonary embolism on the second postoperative day, for which therapeutic low molecular weight heparin was started. No further complications occurred during the first 90 postoperative days. At 3 months, overall kidney function remained stable, right kidney function dropped from 27 to 20,65 mL/min (-23,5%) on renal scintigraphy.

Conclusion
We demonstrated feasibility and, for the first time, a surgical video of tiRAKAT highlighting patient positioning, trocar placement and intracorporeal cold ischemia technique.