Robotics open the door for high-risk kidney transplants

Issue: May 2019

ByEnrico Benedetti, MD

At the University of Illinois Hospital at Chicago, we have been using robotic surgery to transplant high-risk kidney patients since 2010, when we did the first successful robotic kidney transplant in a morbidly obese patient.¹ Since then with more than 18 years of experience using the surgical robot technology, we have successfully performed more than 250 kidney transplant surgeries with obese patients.

High-risk surgery

A significant portion of patients needing a kidney transplant are overweight or obese. Up to half of dialysis patients are obese, defined as having a BMI of greater than 30 kg/m².² Patients with a BMI of greater than 40 kg/m² who have ESRD are often denied transplantation because of being overweight.

Obese patients often have diabetes and hypertension as a result of being overweight. Seventy percent of patients on dialysis with hypertension and 75% of patients on dialysis with diabetes survive fewer than 5 years on dialysis, as previous research has shown.³ Transplant centers may avoid accepting high-risk morbidly obese patients for kidney transplantation due to the increased risks associated with surgery, wound infection, graft survival and patient safety. We often evaluate these patients to see if they are a fit for robotic-assisted kidney transplantation.

Enrico Benedetti, MD, FACS, professor and Warren H. Cole Chair in Surgery at the University of Illinois Hospital at Chicago, is using robotics to successfully perform high-risk transplant surgery.

Robotic-assisted surgery makes a dramatic difference for obese patients because it significantly reduces the risk of wound infection and offers a safer, minimally invasive procedure with fewer complications.

Robotic surgical procedure

For these transplants, we have developed a new robotic technique that avoids any incision in the infection-prone lower abdomen and uses only a small incision above the belly button. In a traditional “open” kidney transplant procedure, a 6-inch to 8-inch incision is made in the right lower abdomen to implant the donor kidney, increasing the risk of the surgery. Of note, the risk of wound infection in patients with a BMI of greater than 40 kg/m² is estimated at 35%.⁴ Our surgical team uses a robotic surgical system to transplant the kidney through a 2.75-inch incision above the patient’s belly button, and four tiny incisions in the abdomen to accommodate the robotic laparoscopic instruments.

Robotic surgery for morbidly obese patients can be accomplished safely and allows minimally invasive access without the visual and technical limitations of laparoscopic surgery. Current laparoscopic cameras provide only a 2-D view and laparoscopic instruments have a limited degree of freedom. In contrast, robotic surgery provides a 3-D view and utilizes instruments with 360° range of motion, allowing surgeons to complete more complex procedures.

Our results during the last 9 years have shown that obese patients who received robotic-assisted kidney transplants had fewer wound complications than patients who received traditional open transplant surgery.⁵

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Longer waits, poorer outcomes

Minimally invasive robotic transplantation may reduce health disparities for obese patients with ESRD. Studies have shown that obese patients with kidney failure wait longer for transplants and consequently have poorer outcomes than non-obese patients. However, obese transplant patients who do not have surgical site infections have similar kidney transplant success rates as non-obese patients.

We looked at 28 obese patients in our program who received robotic kidney transplants at the University of Illinois Hospital at Chicago between June 2009 and December 2011. We followed the patients for 6 months after transplant and compared their outcomes with a group of 28 obese patients who received traditional open kidney transplantation at the hospital prior to 2009.

Results showed no surgical site infections in patients who had robotic kidney transplants, while 29% of patients in the control group developed an infection. Measurements of kidney function, graft and patient survival were comparable between the groups.⁶

High-risk patients

The robotic kidney transplant procedure provides one of the best applications for transplant surgery because it gives high-risk patients who are frequently bypassed for surgery an opportunity for a better quality of life. Without robotics, most of these patients would not be considered for transplantation. In addition, robotic surgery can also be used to remove living donor kidneys.

The program at the University of Illinois Hospital in Chicago has gained worldwide attention. It was the first designated Center of Excellence in Robotic Surgery in the United States in 2015, awarded by Surgical Review Corporation. In September 2017, our department of surgery hosted the Clinical Robotic Surgery Association’s (CRSA) Worldwide Annual Congress. The CRSA is the premier association for robotic minimally invasive surgeons and other health care professionals dedicated to the advancement of these surgical techniques, with the goal of strengthening the bridge between theory and practice for general robotic minimally invasive surgery. Traditional, open kidney transplantation has been performed with minimal changes for more than half a century. The development of robotic surgical systems has made a minimally invasive approach possible, even for complex and precise procedures such as kidney transplantation.

We have also employed a robotic surgical system to perform transabdominal renal transplantation in obese recipients with encouraging results in terms of decreased wound complications, graft function, and graft and patient survival. Other groups, applying different robotic approaches to kidney transplantation, have also reported benefit for non-obese patients.

With the evolution of the robotic surgical technology and intensive exchange of experience, the popularity of minimally invasive kidney transplantation is expected to increase in the near future.

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References:
1. Giulianotti P, et al. Am Jrnl of Transplantation. 2010;doi:10.1111/j.1600-6143.2010.03116.x.
2. www.cdc.gov/obesity/adult/defining.html
3. Ghaderian SB, et al. Journal of Renal Injury Prevention. 2015; doi:10.12861/jrip.2015.07.
4. Pierpont YN, et al. ISRN Obes. 2014;doi:10.1155/2014/638936.
5. Spaggiari M, et al. Clin Transplant. 2018;doi:10.1111/ctr.13404.
6. Oberholzer J, et al. Am Jrnl of Transplantation. 2013;doi:10.1111/ajt.12078.

For more information:
Enrico Benedetti, MD, is professor and head of surgery and the Warren H. Cole Chair in Transplant Surgery at the University of Illinois Hospital at Chicago. He has to his credit several successful surgical firsts, including the first robotic donor nephrectomy for a living-donor kidney transplant, the first combined living-donor liver and bowel transplant from an adult to an infant, the first robotic combined kidney and pancreas procurement for a living-donor transplant and the largest series of living-donor intestinal transplants in the world. For more information about UIC’s transplantation programs and robotic kidney transplantation in obese patients, call 312-996-6771.

Disclosure: Benedetti reports no relevant financial disclosures.

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