Robot-Assisted Living Donor Kidney Surgery

Surgeons with the Penn Transplant Institute are performing robotic surgery for living kidney donors. 

At Penn Medicine, robotic-assisted surgery has been a mainstay of surgical practice for more than a decade. The living donor robotic-assisted program is under the direction of Ronald F. Parsons, MD, Surgical Director of Kidney and Pancreas Transplantation at the Penn Transplant Institute.

For kidney recipients, living donor kidney transplantation (LDKT) is the best treatment option for end stage renal disease. Among the many benefits LDKT provides are reductions in waiting list time, improved surgical outcomes and survival, less time on dialysis, and enhanced long-term kidney function.

However, considering the altruistic nature of living donation from healthy individuals, the safety and post-surgical well-being of living kidney donors is of equivalent importance. For these reasons, the Penn Transplant Institute (PTI) performs robot-assisted kidney nephrectomy, a safe, effective, and minimally invasive surgery for the living donor community.

The advantages of robotic surgery have been well documented over time, and include reduction in blood loss, decreased postoperative pain, and faster recovery. Robotic surgery allows for lower abdominal incision, and reduces the risk of hernia and infection. In addition, robotic LDKT has proven to have equivalent perioperative outcomes and safety by comparison to laparoscopic kidney donation in experienced centers. [1]

In addition, although optimal graft function is thought to be achieved with a donor–recipient pair of normal BMI, recent studies suggest that robotic surgery may allow for donation from overweight or obese individuals, [2] a population for whom donorship had previously been linked to a higher risk of intraoperative and postoperative complications.

References

1. Reese PP, Boudville N, Garg AX. Living kidney donation: outcomes, ethics, and uncertainty. Lancet Lond Engl 2015;385:2003–2013.
2. Spaggiari M, Garcia-Roca R, Tulla, K, Okoye, O, et al. Robotic Assisted Living Donor Nephrectomies | A Safe Alternative to Laparoscopic Technique for Kidney Transplant Donation. Ann Surg 2022;275:591-595.

Case Study 

Mr. K, a healthy 36-year-old man completed a thorough medical and psychosocial evaluation and was found suitable for voluntary kidney donation. Following a consultation during which the risks and benefits of nephrectomy for donation were discussed, including potential for infection, bleeding, hernia, pain, injury to surrounding structures, and other potentially serious problems, as well as the risk of kidney failure and death, he provided informed consent.

Procedure Details — The procedure followed standard steps, briefly discussed here. Mr. K was brought to the operating room and prepared for surgery in the standard fashion, with particular regard to patient safety and identification. After opening of the peritoneum under direct vision and the establishment of pneumoperitoneum with CO2, the working ports were placed under direct vision and the robot was docked. Mr. K’s left colon was then visualized, released from its lateral attachments and rotated medially to reveal the left kidney and ureter.

Because the gonadal vein, ureter, and renal artery are removed with the donor kidney for transplantation, a series of procedures then took place to free these structures, including en bloc dissection of the gonadal vein and ureter, followed by hilar venous and arterial dissection. The anterior surface of the renal vein was cleared of investing tissue. The gonadal and adrenal veins were identified, dissected free, then ligated and divided near their insertions into the left renal vein.

The ureter and lower pole of the kidney were then elevated and the retroperitoneal tissues cleared to the lumbar vein, which was dissected, clipped and divided. The anterior and inferior aspects of the renal artery at its origin were cleared of lymphatics and the renal vein then circumferentially cleared of extraneous tissue. A plane was created between the left adrenal gland and the upper pole of the kidney with the harmonic scalpel and the upper pole attachments were released. The kidney was then mobilized, separated from the adjacent adrenal gland, and delivered through the hand port.

After close inspection, the kidney was found to be of good quality with no procurement injury, and was packaged in a sterile fashion for transport to the recipient’s operating room. The transection sites were then inspected to ensure their closure, the colon was replaced in its natural position, and the ports retracted. The wound sites were then irrigated and closed following standard procedures to ensure patient safety.

Mr. K tolerated the procedure well without apparent complications and following extubation, was transferred to the post-anesthesia care unit. He stayed overnight on the surgical floor, and following discharge on post-op day two, was followed closely by the living donor team, including check-in phone calls after leaving the hospital, and an in person postoperative visit two weeks after surgery. His recovery was uneventful, and he returned to work from his home office a month after surgery.

Kidney Paired Donation at Penn Medicine

Home to kidney, liver, lung, heart, pancreas, uterine and hand transplantation programs, the Penn Transplant Institute is now a leader in the effort to increase kidney paired donation for kidney transplantation. In partnership with the National Kidney Registry (NKR), a consortium of 72 transplant centers nationwide, the Penn Transplant Institute took part in a kidney exchange over a 40-day period that ultimately involved 28 donors and 28 recipients. The Living Donor Kidney Program at Penn Medicine is one of a select group of US centers designated as a Donor Care Network Center of Excellence within the NKR.

The US Department of Health and Human Services has awarded the Penn Transplant Institute’s Kidney Transplant program a Silver Level Award. Penn is one of the few programs in the nation to receive this distinction, and the only transplant center in the region so awarded.

In addition to its partnership with the NKR, the Penn Transplant Institute is a member of the United Network for Organ Sharing (UNOS). We also participate in other registries such as the Alliance for Paired Donation and the UNOS Paired Donation Program, which maximize the chance at finding a match and achieving transplant with a living donor.

Penn Faculty Team

Transplant Surgery

• James Francis Markmann, MD, PhD
  Vice President of Transplant Services
• Ronald F. Parsons, MD
  Surgical Director, Kidney and Pancreas Transplant Programs
• Samir Abu-Gazala, MD
  Surgical Director, Living Donor Kidney Transplant
• Peter L. Abt, MD
  Professor of Surgery at the Hospital of the University of Pennsylvania and the Children's Hospital of Philadelphia
• Matthew H. Levine, MD, PhD
  Associate Professor of Surgery
• Ali Naji, MD, PhD
  J. William White Professor of Surgical Research
• Elizabeth Marie Sonnenberg, MD, MHSP
  Assistant Professor of Surgery

Transplant Nephrology

• Roy D. Bloom, MD
  Medical Director, Kidney/Pancreas Transplant Program, Hospital of the University of Pennsylvania
  Professor of Medicine at the Hospital of the University of Pennsylvania
• Behdad David Besharatian, MD
  Assistant Professor of Clinical Medicine
• Melissa B. Bleicher, MD
  Assistant Medical Director, Penn Kidney Transplant Program, Post-Transplant Operations, University of Pennsylvania
  Director, Transplant Adolescent Transition Program, University of Pennsylvania
  Associate Professor of Clinical Medicine
• Simin Goral, MD
  Director, Polycystic Kidney Disease Clinic
  Transplant Nephrology Fellowship Director
  Professor of Medicine at the Hospital of the University of Pennsylvania
• Mary Ann C. Lim, MD
  Associate Professor of Clinical Medicine
• Peter Reese, MD, MSCE
  Professor of Medicine
  Professor of Biostatistics and Epidemiology
  Professor of Medical Ethics and Health Policy
• Amanda Leonberg-Yoo, MD
  Medical Director, Living Donor Kidney Transplant Program
  Assistant Professor of Clinical Medicine
• Gail Eastman, MSN, CRNP

Published on: January 24, 2024