Transplantation/Vascular Surgery: Emergence of robotic donor nephrectomy

Christopher L. Marsh

The emergence of robot-assisted laparoscopic donor nephrectomy (RLDN) and new findings regarding renal transplant patients' cancer risk highlight the discussions of transplantation/vascular surgery discussions at this year's AUA meeting.  The transplantation/vascular surgery take-home messages were presented by Christopher L. Marsh, MD of Scripps Center for Organ Transplantation, La Jolla, CA.

Robot-assisted laparoscopic donor nephrectomy (RLDN) is beginning to be rolled out, but long-term data are needed to confirm its feasibility. Compared to standard laparoscopic donor nephrectomy, RLDN required longer operation time and warm ischemia time but had shorter hospital stays. Complication rates were similar.

Kidney transplant recipients show higher risk of cancers such as kidney and bladder cancer.

Transvaginal natural orifice transluminal endoscopic surgery-assisted living donor nephrectomy is a feasible and reproducible alternative to laparoscopic live donor nephrectomy in select cases. The approaches were similar in cold/hot ischemia time, operation time, and length of stay.

Kidneys from older donors (>70 years of age) appear to be feasible for transplantation. Age of donor did not affect graft loss. In donations from donors under age 70 years, average serum creatinine was significantly lower up until 36 months. Cumulative graft survival at 1, 3, and 4 years was lower for kidneys from older donors.

Renal transplant recipients who required percutaneous nephrostomy had similar graft survival as the general transplant population (11.9 vs. 10.5 years). At 63%, distal ureteral stricture was the most common indication.

Robot-assisted re-do ureteroneocystostomy can be performed with acceptable results (despite lengthy operative time) and is linked to early recovery, with all patients discharged on the first day with Foley catheter for 1 week.

Continue to the next page for more take-home messages

• Cystoscopy with bladder washout with 6 liters of saline appears to be an effective method to decrease frequency of urinary tract infections in renal transplant recipients.

• To reduce postoperative lymphoceles in renal transplants, two easy strategies-placement of a retroperitoneal drain and FloSeal hemostatic matrix-both show promise.

• A literature review identified 56 studies exploring small renal masses in transplant allograft kidneys and showed that the current management of small renal masses in transplant kidney tumors mirrors management of renal masses in the average population.

• Patients with nonmuscle-invasive bladder cancer after renal transplantation could be treated with mitomycin C or bacillus Calmette-Guérin (BCG) vaccine depending on risk level. Adjuvant BCG reduced risk as did change to mTOR inhibitors, while having multiple tumors increased risk. For muscle-invasive bladder cancer, radical cystectomy with ileal conduit is the treatment of choice.

• Renal transplants may benefit from monitoring of insertion-deletion allele polymorphism, N-glycans hybrid m/z 2033, and major proteins mediating HIF-1 signaling.

• In several separate animal models of kidney transplantation, researchers found various protective results in infusion with carbon monoxide releasing molecule, sildenafil (Viagra), and tricostatin A.

More AUA take-home messages

Sexual Function/Dysfunction: Mixed results with CCH in Peyronie's

Bladder Cancer: Androgen receptor activation a potential therapeutic traget

Kidney Cancer: Cytoreductive nephrectomy appears to be protective