Minimally invasive surgical techniques for kidney transplantation

Abstract

Description of the condition Kidney transplantation is the best treatment for patients with end-stage kidney disease (ESKD). It prolongs life ( Wolfe 1999 ) and increases the quality of life for these patients (Dew 1997 ; Dobbels 2007). Every year about 79,000 kidney transplants are performed worldwide, of which 3000 are performed in the UK. Despite that, there remains a discrepancy between available organs for transplantation and patients on the waiting list because of increasing demand. Description of the intervention Minimally invasive surgery (MIS) has been a key innovation in surgery over the last 20 years, improving outcomes and becoming the standard of care in many areas. Within kidney transplantation, it has transformed the living donor nephrectomy operation, significantly improving outcomes. However, kidney transplantation has not changed significantly since it was first performed over 50 years ago until recently. MIS techniques are methods developed to access body cavities, organs and tissues using smaller skin incisions. They have been shown to improve outcomes for many surgical procedures by reducing post-operative morbidity (Gandaglia 2014) and by promoting a faster return to normal function after surgery (Nicholson 2010). These techniques include small incision open surgery, laparoscopic surgery and robotic surgery. Small incision open surgery has variously been described as mini-incision kidney transplantation and minimal access kidney transplantation. This involves open transplantation with an incision limited to 10 cm or less. The first reported series used an 8 cm incision (Oyen 2006) followed by 10 cm (Park 2008) and a 5 cm incision (Kacar 2013) with the kidney placed in the retroperitoneal space and all three anastomoses performed. An 8 cm incision with anastomoses performed with the kidney extracorporeal, then placed inside the abdomen, has also been reported (Brockschmidt 2014). Laparoscopic surgery for kidney implantation also uses a reduced incision of about 7 cm for insertion of the kidney with an additional 3 to 4 ports for laparoscopic instruments (Rosales 2010 ; Modi 2011 ; Modi 2012 ; Modi 2013). The main differences with open surgery being the anastomoses are all performed intracorporeally with laparoscopic instruments. An alternative technique using the vagina to insert the kidney has also been described (Modi 2015). Robotic-assisted kidney transplantation is the latest development of minimally invasive surgery for kidney transplantation (MIKT). This procedure uses a small incision of about 7 cm to introduce the kidney with 4 or 5 laparoscopic ports. The key differences from laparoscopic transplantation are that the laparoscopic instruments are controlled remotely from a console by the surgeon and the instruments design allows for an improved range of movement. This process has itself evolved from when it was first reported with a small open incision to the side of the lower abdomen followed by the robot being used to complete the anastomoses through this incision (Hoznek 2002) to retroperitoneal placement of the kidney through a similar incision but the anastomoses were completed transabdominally using the robot arms (Tsai 2014). A transabdominal technique has been developed (Abaza 2014 ; Boggi 2011 ; Giulianotti 2010) and standardised (Menon 2014a ; Menon 2014b ,; Sood 2014 ; Sood 2016). Variations of this technique are now being used worldwide (Breda 2016 ; Doumerc 2015 ; Frongia 2015 ; Tugcu 2016). How the intervention might work Patients with ESKD are more vulnerable to the stresses of surgery due to chronic uraemia and multiple systemic illnesses with multiple studies demonstrating increased complications and mortality in this group of patients undergoing surgery (Bechtel 2008 ; Drolet 2010 ; Gajdos 2013 ; Labrousse 1999 ; Schneider 2009). Kidney transplantation is conventionally performed with a large abdominal incision which is painful and at risk of complications and it poses a significant challenge to the body's homeostatic mechanisms. Minimally invasive surgery reduces the incision size which aids faster recovery with less pain. This has been demonstrated in donor nephrectomy surgery (Nicholson 2010 ; Wilson 2011). These benefits may also be relevant to ESKD patients undergoing transplantation. Why it is important to do this review A key issue arising from MIKT is the effect on the kidney allograft. Some MIKT techniques prolong the re-warming time due to the anastomoses. Results suggest that this may reduce the eGFR in the early post-transplant period when compared to open kidney transplant with no difference in function at 1 and 2 year follow-up (Modi 2013). The long-term consequences for the graft beyond this period are unknown. There is some evidence that prolonged anastomosis time is associated with an increased rate of delayed graft function and longer hospital stay in deceased donor kidney transplants (Marzouk 2013), this may raise concerns with regard to MIKT from living donors. The effects of pneumoperitoneum on the transplant kidney have also been questioned with suggestions that higher intra-abdominal pressures may reduce allograft perfusion during surgery with negative consequences for the allograft based on experience with other studies of both human (Koivusalo 1998) and animal (Lindberg 2003) models. There is now some limited evidence regarding the effects of patient positioning and pneumoperitoneum on the outcome for MIKT (Parikh 2013). Other important concerns for surgeons are issues with developing the appropriate skill sets required with minimally invasive surgery. It is not known how transferable skills from open surgery are to laparoscopic and robotic surgery. The learning curve is an area of interest and has been investigated in other specialties (Lucereau 2016) and might present a challenge to the transplant surgeon. Robotic surgery also has additional costs associated with acquiring equipment, skills and training. The machines are a scarce item in great demand which creates issues with access to them that may have implications for the transplant surgeon. MIKT promises to offer significant benefits to kidney transplant recipients. A reduction in surgical site infections has already been noted in obese patients undergoing robotic MIKT (Oberholzer 2013) and further evidence suggests that morbidly obese patients derive equivalent benefit and complications from robotic surgery compared to open kidney transplantation (Garcia-Roca 2016). Smaller incisions with reduced analgesia requirement are a key benefit which may affect length of stay and associated co-morbidity, hospital costs and the patient experience.