Robot-Assisted Renal Transplantation Using Indocyanine Green and the Firefly System for Graft Perfusion Evaluation

Abstract

Objective:

After robot-assisted renal transplantation, graft perfusion evaluation is usually confirmed by visual cues. We sought to describe an extra tool for graft perfusion evaluation after robot-assisted renal transplantation by incorporating indocyanine green (ICG) and the Firefly^® system in the procedure.

Materials and Methods:

After side docking the Da Vinci X robot, the left external iliac vessels were dissected and looped. A deceased-donor right kidney was prepared in an ice bag and introduced inside the recipient through an Alexis^® system. A common practice at our institution was to invert kidneys to have the renal pelvis on the anterior part, therefore, right kidneys are transplanted in the left fossa and vice versa. This allows easier access to the pelvis in case of long-term urinary complications. After passing the vein under the external iliac artery, a terminolateral venovenous anastomosis was performed by two running sutures of Gore-Tex 5-0 after double clamping the external iliac vein with a robotic bulldog clamp. The passage of the vein underneath the artery is another common practice at our institution to leave the anterior part of the artery free, this facilitates the arterial anastomosis. The arterioarterial anastomosis was then performed in a method similar to the venous anastomosis. An ureterobladder reimplantation was performed in a classic Lich Gregoire technique with two running sutures of Vicryl 4-0, after retrograde placement of a Double-J stent. ICG and the Firefly system were used once the transplantation was complete to evaluate graft perfusion.

Results:

Three patients underwent robotic renal transplantation using the Firefly system. Mean operative time was 168 minutes, warm ischemia in the recipient was 68 minutes, and peroperative blood loss was 103 mL. The recipients recovered a normal urine output on average after 1.7 days. Serum creatinine improved progressively and normalized on average on day 14. The patient was discharged on average on day 14. Only one patient presented a Clavien II complication. The other two patients did not present complications. The Firefly system allowed adequate graft perfusion evaluation for all three patients.

Conclusions:

Robot-assisted renal transplantation using ICG and the Firefly system allowed an adequate graft perfusion evaluation in three simple cases. Larger studies are needed to evaluate the Firefly system in robotic renal transplantation in complex cases wherein visual cues are not enough such as grafts with multiple arteries requiring reconstruction on bench, or a small polar artery requiring a separate anastomosis.

No competing financial interests exist.

Runtime of video: 9 mins 18 secs