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MP72-10 ROBOTIC KIDNEY TRANSPLANTATION WITH REGIONAL HYPOTHERMIA: EVOLUTION OF A NOVEL PROCEDURE UTILIZING THE IDEAL GUIDELINES (IDEAL PHASE 0 AND 1)
THE JOURNAL OF UROLOGYâ
Vol. 191, No. 4S, Supplement, Tuesday, May 20, 2014
e827
MP72-10 ROBOTIC KIDNEY TRANSPLANTATION WITH REGIONAL HYPOTHERMIA: EVOLUTION OF A NOVEL PROCEDURE UTILIZING THE IDEAL GUIDELINES (IDEAL PHASE 0 AND 1) Wooju Jeong*, Detroit, MI; Ronney Abaza, Columbus, OH; Akshay Sood, Detroit, MI; Rajesh Ahlawat, New Delhi, India; Mahendra Bhandari, Khurshid Ghani, Detroit, MI; Vijay Kher, New Delhi, India; Ramesh Kumar, Mani Menon, Detroit, MI INTRODUCTION AND OBJECTIVES: Surgical innovation is essential for progress of surgical science, but its implementation comes with potential harms during the learning phase. The Balliol Collaboration has recommended a set of guidelines (IDEAL) that permit innovation while minimizing complications. We sought to utilize the IDEAL model of surgical innovation in development of a novel surgical technique; robotic kidney transplantation (RKT) with regional hypothermia. Here, we describe the process of discovery and development. METHODS: Phase-0 (simulation) studies included the establishment of techniques for pelvic cooling, and graft placement in a robotic prostatectomy model; and simulation of the RKT procedure in a cadaveric model. Phase-1 (innovation) studies involved treatment of a highly select small group of patients (n¼7) using the principles utilized in the phase-0 studies, at a tertiary referral center (see Fig 1a for the Evolution Timeline). For phase0 studies the outcomes assessed included; pelvic and body temperature measurements, and technical feasibility. Primary outcome during phase-1 was post transplant graft function. Other outcomes measured were operative and ischemic times, peri-operative complications and intracorporeal graft surface temperature. RESULTS: Phase-0: Pelvic cooling to 15-20oC was achieved reproducibly with no alterations in the body temperature (Fig 1b). Using the surgical approach developed for robotic radical prostatectomy, vascular and uretero-vesical anastomoses could be done without redocking the robot. Phase-1: All patients underwent live donor RKT successfully in the lithotomy position. All grafts functioned immediately (Fig 1c). Mean console, anastomotic and warm ischemia times were 154 minutes, 29 minutes and 2 minutes, respectively (Fig 1d). Mean intracorporeal graft surface temperature was 22oc, measured just before reperfusion of the graft. One patient was re-explored on postoperative day 1. CONCLUSIONS: Adherence to the IDEAL guidelines put forth by the Balliol Collaboration provided a practical framework for the establishment of a novel surgical procedure, RKT with regional hypothermia, without exposing the initial patients to unacceptable risk.
Source of Funding: NONE
MP72-11 ILIAC VESSEL CALCIFICATION IN RENAL ALLOGRAFT RECIPIENT - PROGNOSTIC SIGNIFICANCE DURING TRANSPLANT Ankush Jairath*, Jigish Vyas, Arvind Ganpule, Shashikant Mishra, Ravindra Sabnis, Mahesh Desai, Nadiad, India INTRODUCTION AND OBJECTIVES: To study the significance of calcified iliac vessels found during the screening of patients being evaluated for renal transplant. METHODS: We undertook mean 9.4 months follow up of 12 (male 11, female 1) out of 190 (4.7%) patients who had moderate to severe calcification during the screening for renal transplantation. Mean age group was 57.4 years. Out of 12, 7 patients were diabetic, 5 were smokers. Besides examination, plain X ray, Doppler study and if required pre dialysis CT angiography helped us to decide the side of the transplant. Out of 12, 10 had a live related transplant and 2 had a cadaver transplant. One patient required orthotropic renal transplant. RESULTS: During transplant, two patients had poor perfusion of the graft required revision, one of them had dissection of external iliac artery and required a PTFE (Polytetrafluoroethylene) graft interposition. Three patients had delayed graft functions post-transplant, two recovered completely. Two patients required post-transplant angioplasty of the anastomotic site after diagnosing critical stenosis. One patient had gangrene of the distal penis after transplant required partial penectomy. Out of the 12 patients there was one graft loss and one mortality on 3rd week due to associated cardiac complications. Mean creatinine after mean 9.4 months of follow up was 1.35 mg/dl.
Vol. 191, No. 4S, Supplement, Tuesday, May 20, 2014
e827
MP72-10 ROBOTIC KIDNEY TRANSPLANTATION WITH REGIONAL HYPOTHERMIA: EVOLUTION OF A NOVEL PROCEDURE UTILIZING THE IDEAL GUIDELINES (IDEAL PHASE 0 AND 1) Wooju Jeong*, Detroit, MI; Ronney Abaza, Columbus, OH; Akshay Sood, Detroit, MI; Rajesh Ahlawat, New Delhi, India; Mahendra Bhandari, Khurshid Ghani, Detroit, MI; Vijay Kher, New Delhi, India; Ramesh Kumar, Mani Menon, Detroit, MI INTRODUCTION AND OBJECTIVES: Surgical innovation is essential for progress of surgical science, but its implementation comes with potential harms during the learning phase. The Balliol Collaboration has recommended a set of guidelines (IDEAL) that permit innovation while minimizing complications. We sought to utilize the IDEAL model of surgical innovation in development of a novel surgical technique; robotic kidney transplantation (RKT) with regional hypothermia. Here, we describe the process of discovery and development. METHODS: Phase-0 (simulation) studies included the establishment of techniques for pelvic cooling, and graft placement in a robotic prostatectomy model; and simulation of the RKT procedure in a cadaveric model. Phase-1 (innovation) studies involved treatment of a highly select small group of patients (n¼7) using the principles utilized in the phase-0 studies, at a tertiary referral center (see Fig 1a for the Evolution Timeline). For phase0 studies the outcomes assessed included; pelvic and body temperature measurements, and technical feasibility. Primary outcome during phase-1 was post transplant graft function. Other outcomes measured were operative and ischemic times, peri-operative complications and intracorporeal graft surface temperature. RESULTS: Phase-0: Pelvic cooling to 15-20oC was achieved reproducibly with no alterations in the body temperature (Fig 1b). Using the surgical approach developed for robotic radical prostatectomy, vascular and uretero-vesical anastomoses could be done without redocking the robot. Phase-1: All patients underwent live donor RKT successfully in the lithotomy position. All grafts functioned immediately (Fig 1c). Mean console, anastomotic and warm ischemia times were 154 minutes, 29 minutes and 2 minutes, respectively (Fig 1d). Mean intracorporeal graft surface temperature was 22oc, measured just before reperfusion of the graft. One patient was re-explored on postoperative day 1. CONCLUSIONS: Adherence to the IDEAL guidelines put forth by the Balliol Collaboration provided a practical framework for the establishment of a novel surgical procedure, RKT with regional hypothermia, without exposing the initial patients to unacceptable risk.
Source of Funding: NONE
MP72-11 ILIAC VESSEL CALCIFICATION IN RENAL ALLOGRAFT RECIPIENT - PROGNOSTIC SIGNIFICANCE DURING TRANSPLANT Ankush Jairath*, Jigish Vyas, Arvind Ganpule, Shashikant Mishra, Ravindra Sabnis, Mahesh Desai, Nadiad, India INTRODUCTION AND OBJECTIVES: To study the significance of calcified iliac vessels found during the screening of patients being evaluated for renal transplant. METHODS: We undertook mean 9.4 months follow up of 12 (male 11, female 1) out of 190 (4.7%) patients who had moderate to severe calcification during the screening for renal transplantation. Mean age group was 57.4 years. Out of 12, 7 patients were diabetic, 5 were smokers. Besides examination, plain X ray, Doppler study and if required pre dialysis CT angiography helped us to decide the side of the transplant. Out of 12, 10 had a live related transplant and 2 had a cadaver transplant. One patient required orthotropic renal transplant. RESULTS: During transplant, two patients had poor perfusion of the graft required revision, one of them had dissection of external iliac artery and required a PTFE (Polytetrafluoroethylene) graft interposition. Three patients had delayed graft functions post-transplant, two recovered completely. Two patients required post-transplant angioplasty of the anastomotic site after diagnosing critical stenosis. One patient had gangrene of the distal penis after transplant required partial penectomy. Out of the 12 patients there was one graft loss and one mortality on 3rd week due to associated cardiac complications. Mean creatinine after mean 9.4 months of follow up was 1.35 mg/dl.