Robot-assisted kidney transplantation: an update

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ABSTRACT

Renal transplantation has become the gold-standard treatment for the majority of patients with established renal failure. Recent decades have seen significant progress in immunosuppressive therapies and advances in post-transplant management of recipients, resulting in improved graft and patient outcomes. However, the open technique of allograft implantation has stood the test of time, remaining largely unchanged. In a world where major advances in surgery have been facilitated by innovations in the fields of biotechnology and medical instrumentation, minimally invasive options have been introduced for the recipient undergoing kidney transplantation. In this review we present the evolution of minimally invasive kidney transplantation, with a specific focus on robot-assisted kidney transplant and the benefits it offers to specific patient groups. We also discuss the ethical concerns that must be addressed by transplant teams considering developing or referring to robotic programs.

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Most cited references 80

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Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant.

R Wolfe, V. B. Ashby, E Milford … (1999)

The extent to which renal allotransplantation - as compared with long-term dialysis - improves survival among patients with end-stage renal disease is controversial, because those selected for transplantation may have a lower base-line risk of death. In an attempt to distinguish the effects of patient selection from those of transplantation itself, we conducted a longitudinal study of mortality in 228,552 patients who were receiving long-term dialysis for end-stage renal disease. Of these patients, 46,164 were placed on a waiting list for transplantation, 23,275 of whom received a first cadaveric transplant between 1991 and 1997. The relative risk of death and survival were assessed with time-dependent nonproportional-hazards analysis, with adjustment for age, race, sex, cause of end-stage renal disease, geographic region, time from first treatment for end-stage renal disease to placement on the waiting list, and year of initial placement on the list. Among the various subgroups, the standardized mortality ratio for the patients on dialysis who were awaiting transplantation (annual death rate, 6.3 per 100 patient-years) was 38 to 58 percent lower than that for all patients on dialysis (annual death rate, 16.1 per 100 patient-years). The relative risk of death during the first 2 weeks after transplantation was 2.8 times as high as that for patients on dialysis who had equal lengths of follow-up since placement on the waiting list, but at 18 months the risk was much lower (relative risk, 0.32; 95 percent confidence interval, 0.30 to 0.35; P<0.001). The likelihood of survival became equal in the two groups within 5 to 673 days after transplantation in all the subgroups of patients we examined. The long-term mortality rate was 48 to 82 percent lower among transplant recipients (annual death rate, 3.8 per 100 patient-years) than patients on the waiting list, with relatively larger benefits among patients who were 20 to 39 years old, white patients, and younger patients with diabetes. Among patients with end-stage renal disease, healthier patients are placed on the waiting list for transplantation, and long-term survival is better among those on the waiting list who eventually undergo transplantation.

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Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial.

Surya S A Y Biere, Mark I van Berge Henegouwen, Kirsten W. Maas … (2012)

Surgical resection is regarded as the only curative option for resectable oesophageal cancer, but pulmonary complications occurring in more than half of patients after open oesophagectomy are a great concern. We assessed whether minimally invasive oesophagectomy reduces morbidity compared with open oesophagectomy. We did a multicentre, open-label, randomised controlled trial at five study centres in three countries between June 1, 2009, and March 31, 2011. Patients aged 18-75 years with resectable cancer of the oesophagus or gastro-oesophageal junction were randomly assigned via a computer-generated randomisation sequence to receive either open transthoracic or minimally invasive transthoracic oesophagectomy. Randomisation was stratified by centre. Patients, and investigators undertaking interventions, assessing outcomes, and analysing data, were not masked to group assignment. The primary outcome was pulmonary infection within the first 2 weeks after surgery and during the whole stay in hospital. Analysis was by intention to treat. This trial is registered with the Netherlands Trial Register, NTR TC 2452. We randomly assigned 56 patients to the open oesophagectomy group and 59 to the minimally invasive oesophagectomy group. 16 (29%) patients in the open oesophagectomy group had pulmonary infection in the first 2 weeks compared with five (9%) in the minimally invasive group (relative risk [RR] 0·30, 95% CI 0·12-0·76; p=0·005). 19 (34%) patients in the open oesophagectomy group had pulmonary infection in-hospital compared with seven (12%) in the minimally invasive group (0·35, 0·16-0·78; p=0·005). For in-hospital mortality, one patient in the open oesophagectomy group died from anastomotic leakage and two in the minimally invasive group from aspiration and mediastinitis after anastomotic leakage. These findings provide evidence for the short-term benefits of minimally invasive oesophagectomy for patients with resectable oesophageal cancer. Digestive Surgery Foundation of the Unit of Digestive Surgery of the VU University Medical Centre. Copyright © 2012 Elsevier Ltd. All rights reserved.

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No surgical innovation without evaluation: the IDEAL recommendations.

Peter McCulloch, Douglas G. Altman, W Campbell … (2009)

Surgery and other invasive therapies are complex interventions, the assessment of which is challenged by factors that depend on operator, team, and setting, such as learning curves, quality variations, and perception of equipoise. We propose recommendations for the assessment of surgery based on a five-stage description of the surgical development process. We also encourage the widespread use of prospective databases and registries. Reports of new techniques should be registered as a professional duty, anonymously if necessary when outcomes are adverse. Case series studies should be replaced by prospective development studies for early technical modifications and by prospective research databases for later pre-trial evaluation. Protocols for these studies should be registered publicly. Statistical process control techniques can be useful in both early and late assessment. Randomised trials should be used whenever possible to investigate efficacy, but adequate pre-trial data are essential to allow power calculations, clarify the definition and indications of the intervention, and develop quality measures. Difficulties in doing randomised clinical trials should be addressed by measures to evaluate learning curves and alleviate equipoise problems. Alternative prospective designs, such as interrupted time series studies, should be used when randomised trials are not feasible. Established procedures should be monitored with prospective databases to analyse outcome variations and to identify late and rare events. Achievement of improved design, conduct, and reporting of surgical research will need concerted action by editors, funders of health care and research, regulatory bodies, and professional societies.

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Author and article information

Contributors

Harry V M Spiers:

ORCID: https://orcid.org/0000-0001-7308-2711

Videha Sharma

Alexander Woywodt

Rajesh Sivaprakasam

Titus Augustine

Journal

Journal ID (nlm-ta): Clin Kidney J

Journal ID (iso-abbrev): Clin Kidney J

Journal ID (publisher-id): ckj

Title: Clinical Kidney Journal

Publisher: Oxford University Press

ISSN (Print): 2048-8505

ISSN (Electronic): 2048-8513

Publication date Collection: April 2022

Publication date (Electronic): 15 November 2021

Publication date PMC-release: 15 November 2021

Volume: 15

Issue: 4

Pages: 635-643

Affiliations

Department of Transplantation, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust , Cambridge, UK

Department of Surgery, University of Cambridge , Cambridge, UK

Department of Renal and Pancreas Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust , Manchester, UK

Faculty of Biology, Medicine and Health, Centre for Health Informatics, Division of Informatics, Imaging and Data Science, University of Manchester , Manchester, UK

Department of Renal Medicine , Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK

Department of Transplant and Robotic Surgery , Royal London Hospital, Barts Health NHS Trust, London, UK

Department of Renal and Pancreas Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust , Manchester, UK

Faculty of Biology, Medicine and Health, Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester , Manchester, UK

Author notes

Correspondence to: Harry V.M. Spiers; E-mail: harry.spiers@ 123456addenbrookes.nhs.uk

Author information

Harry V M Spiers https://orcid.org/0000-0001-7308-2711

Article

Publisher ID: sfab214

DOI: 10.1093/ckj/sfab214

PMC ID: 8967665

PubMed ID: 35371439

SO-VID: 699d23f0-231c-47bd-8afa-8280a20e6da2

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License ( https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@ 123456oup.com

History

Date received : 22 February 2021

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Pages: 9

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Robot-assisted kidney transplantation: an update

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Karger: Nephrology

Most cited references 80

Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant.

Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial.

No surgical innovation without evaluation: the IDEAL recommendations.

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Cited by 4

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