Transvaginal recovery of the kidney has recently been reported, in a donor who had previously undergone a hysterectomy, as a less-invasive approach to perform laparoscopic live-donor nephrectomy. Also, robotic-assisted laparoscopic kidney donation was suggested to enhance the surgeon's skills during renal dissection and to facilitate, in a different setting, the closure of the vaginal wall after a colpotomy. We report here the technique used for the first case of robotic-assisted laparoscopic live-donor nephrectomy with transvaginal extraction of the graft in a patient with the uterus in place. The procedure was carried out by a multidisciplinary team, including a gynecologist. Total operative time was 215 min with a robotic time of 95 min. Warm ischemia time was 3 min and 15 s. The kidney was pre-entrapped in a bag and extracted transvaginally. There was no intra- or postoperative complication. No infection was seen in the donor or in the recipient. The donor did not require postoperative analgesia and was discharged from the hospital 24 h after surgery. Our initial experience with the combination of robotic surgery and transvaginal extraction of the donated kidney appears to open a new opportunity to further minimize the trauma to selected donors.
Transvaginal extraction of laparoscopically removed intact kidneys has previously been described (1), and more recently the technique was also used in a living donor who had previously undergone a hysterectomy (2). Potential advantages of this new approach include less pain, shorter hospital stays and improved cosmesis. The surgical robot provides sharp three-dimensional images and extended range of motion for the instruments. It also allows the surgeon to operate under ideal ergonomic conditions. These features are capable of enhancing the safety of the dissection of the renal vessels (3) and, in the setting of a transvaginal extraction of the kidney, to make closure of the vaginal wall easier (4). The combination of the two techniques can offer the donor an almost scarless operation without compromising the quality of the graft and the safety of the procedure.
This article reports the technique of robotic-assisted laparoscopic donor nephrectomy with transvaginal extraction of the kidney that we used in our first patient with a normal genital anatomy, discusses the safety issues of this approach and examines potential advantages of the new procedure.
Patient and Methods
A 48-year-old grand multipara (past vaginal delivery of five children) with no previous abdominal surgery was assessed for left kidney donation to her 22-year-old son. The left kidney had one artery, with an early bifurcation, and one ante-aortic vein. The patient was moderately obese, with a body mass index of 31.6. Standard gynecological evaluation was completed with a transvaginal ultrasonography to assess pelvic organs, and pathology of the rectovaginal septum specifically looking for signs of infection, including pelvic inflammatory disease. The vaginal microflora was preoperatively sampled to rule out the presence of infection. Current policy at Pavia's San Matteo Hospital requires the Istitutional Review Board approval only for experimental clinical studies and for observational and epidemiological research (http://www.osm.it/sperclin/regolamentocomitato.htm). The proposed technical development of this report did not meet these criteria. Our Ethics Committee, informed of the nature of the proposed operation, advised for a specific informed consent and for a close monitoring of the outcome. The procedure was explained in full to the donor and to the recipient who were also informed of its innovative nature, of the expected outcomes and foreseeable potential risks (5). They were allowed 3-month time to think it over, having also been informed about the available alternatives, before written consent was given.
On June 7, 2010, the patient underwent a robotically assisted left-sided donor nephrectomy with transvaginal extraction of the graft. The patient was placed in a modified right flank position for laparoscopic nephrectomy with the legs fixed in stirrups and abducted to expose the genital area. The operating table was also slightly tilted to the right for better exposure of the left flank (Figure 1). The abdomen, the external genitalia and the vagina were prepped with povidone–iodine solution, and the operative field was draped to include access to these areas. The pneumoperitoneum was insufflated with a Veress needle and a 12-mm disposable trocar for the optics was introduced 4 cm laterally and superior to the umbilicus. One additional 12-mm trocar was placed at a point midway between the umbilicus and the anterior superior iliac spine. This was used to give passage to an 8-mm reusable robotic trocar and for the final introduction of the stapler to transect the renal vein. Another reusable 8-mm robotic trocar was inserted under the left subcostal space. A fourth 5-mm accessory trocar was placed at the umbilicus to be used by the assistant for retraction/aspiration. The pelvis was initially examined to confirm the intraperitoneal viability of a transvaginal delivery of the graft. Mobilization of the left colon to expose the anterior aspect of the left kidney and ureter was done with a pure laparoscopic technique. Thereafter, the motorized cart of the robotic system (da Vinci Si HD; Intuitive Surgical Inc., Sunnyvale, CA) was docked to the patient, and the procedure was continued with the operating surgeon sitting at the robotic console. The left ureter, renal artery and vein were isolated with the combined use of robotic bipolar Maryland forceps and a monopolar hook and by ligating the collaterals of the renal vein with intracorporeal knots and needle suturing. Then, the gynecologist performed a posterior colpotomy through a transvaginal approach. This was then enlarged after entering the peritoneum by sectioning the left uterosacral ligament, to the point that it would easily allow the passage of three fingers inside the peritoneal cavity (about 6 cm). After creation of the vaginal opening, the pneumoperitoneum was self-maintained by the small bowel and sigmoid loop that was filling the pelvis. A 15-mm endobag (Endocatch II; Covidien, Mansfield, MA) was then inserted transvaginally, and the left kidney was introduced into the bag after division of the ureter at the iliac crossing. The robot was disconnected from the patient, and the renal vessels were divided laparoscopically after clipping the artery (extra large size Hem-o-lok clip; Teleflex Medical, Research Triangle Park, NC)-–to preserve the vessel before its bifurcation—and by application of a laparoscopic linear stapler on the vein (ETS 45; Ethicon Endo-Surgery, Cincinnati, OH). The endobag was then closed by pulling the integrated purse string, and the kidney delivered transvaginally by pulling the endobag. The bag was then opened by the gynecologist, and the kidney removed from it by the surgeon in charge of the cold perfusion, with maximal care to avoid any contamination from the outside of the bag. It was then placed in iced solution where it was immediately flushed through its artery. Soon after extraction of the kidney, a nonabsorbable transfixion suture was placed laparoscopically at the stump of the renal artery and tied, to prevent slipping of the clips. The colpotomy was repaired transvaginally with interrupted full-thickness reabsorbable sutures and checked at the intraperitoneal site with the laparoscope. There was no need for additional vaginal suturing.
Cefazolin was administered to the recipient intravenously prior to skin incision as usual for anti-infective profilaxis in uncomplicated renal transplant. Donor operative times, occurrence of complications, postoperative pain and recovery time, as well as kidney graft function and possible donor and recipient complications were monitored and recorded.
Total operative time was 215 min with a robotic time of 95 min. Warm ischemia time was 3 min and 15 s. Estimated blood loss was less than 50 mL. There was no intra- or postoperative complication. No infection developed in the donor or in the recipient. The donor reported mild abdominal discomfort on the evening of the operation which did not require postoperative analgesia and was discharged from the hospital 24 h after surgery. She had some vaginal discharge for 5 days but no genital pain or discomfort. Serum creatinine and estimated glomerular filtration rate of the donor dropped from pre-operative values of 0.86 mg/dL and 109 mL/min to 1.14 mg/dL and 65 mL/min, respectively, on postoperative day 45. Her menses returned, as expected, 2 weeks after surgery and were regular with no additional discomfort. The transplanted kidney showed prompt function, and the recipient was able to leave the hospital within a week.
To date (2 months after the transplant), there has been no evidence of infection or rejection.
Several reports have demonstrated the feasibility of transvaginal NOTES (natural orifice transluminal endoscopic surgery) for a number of abdominal procedures, including nephrectomy (6,7). In most cases, hybrid techniques were adopted that combine flexible and rigid instruments, as well as small-size transabdominal trocars (8–11). However, current technological limitation mainly restricts the use of pure NOTES nephrectomy to the experimental setting (12) and the risk of recovering a graft of inferior quality has so far contraindicated its use for the removal of a kidney from a living donor. Nonetheless, transvaginal access for pelvic procedures has been used by gynecologists for decades with little related morbidity, (13) and the same path has also been successfully adopted by general surgeons for specimen extraction following a variety of laparoscopic operations (8–10,14). Recently, urologists from the Brady Urological Institute in Baltimore, MD, have reported the first successful laparoscopic live-donor nephrectomy with vaginal extraction of the kidney (2). The purpose of using transvaginal access for graft extraction is to reduce abdominal incision damage to a minimum, avoiding the 5-cm transverse suprapubic wound that usually concludes the laparoscopic live donor procedure. The procedure they described is similar to the one we have independently used, although the donated kidney was the right one and the patient was selected because she had previously undergone a hysterectomy, likely to facilitate the extraction of the graft. We have shown that the transvaginal route for intact kidney graft recovery can also be used in the presence of a normal-size uterus and intact genital anatomy. The donor of this initial report was purposefully selected as a grand multipara because the resulting laxity of the pelvic floor and vaginal walls was thought to facilitate the passage of the graft. The test of the three fingers introduced transvaginally into the peritoneum before extracting the kidney can be set as an easy and reliable maneuver to establish that the extent of the posterior colpotomy is sufficient to allow the safe passage of a normal-size kidney. In our patient, the colpotomy was the narrowest section of the graft's path. There was no need for the episiotomy to facilitate the extraction that was deemed necessary for the first patient reported by the Baltimore group (2). A normal-size uterus, in absence of pelvic adhesions, did not create an obstacle to the safe transvaginal extraction of the kidney. The passage of the long cylindrical tube of the endobag through the posterior colpotomy lifted upwards the fundus of the uterus, further facilitating the path of the graft. Nonetheless, we were concerned that the large metallic rim of the retrieval bag, if left wide open during the extraction phase, might snare the bowel or the fundus of the uterus. Therefore, after pulling the ring handle that detaches the plastic bag from the metallic ring and closes its neck, we fully retracted the rim inside the tube, before pulling the endobag to retrieve the kidney.
A pre-operative gynecological evaluation was performed to assess the distensibility of the vaginal walls, a necessary condition for the safe passage of the kidney. In addition, we felt advisable to perform a transvaginal ultrasonography to assess pelvic organs and their mobility. In particular, the free movement of the bowel in the recto-uterine pouch seen during respiration was used to exclude chronic pelvic inflammation. We believe that the presence of adhesions in the recto-uterine pouch would make the transvaginal route for kidney extraction troublesome and perhaps not advisable.
Ratner (15), in commenting on the Baltimore report in his editorial that appeared in the same issue of the American Journal of Transplantation, stressed the danger of potential contamination of the kidney and suggested routine microbiological surveillance whenever vaginal extraction is planned. We paid maximum attention to avoid contamination from the vaginal walls and external genitalia, with careful prepping of the area, use of a disposable bag to deliver the kidney and of a sterile no-touch technique to pass the graft to the surgeon for the cold perfusion. The preoperative Gram stain microscopic examination of the vaginal fluid in our patient showed normal vaginal bacteria (predominantly lactobacilli) and absence of clue cells suggestive of ongoing infection. In such a circumstance, we felt it unnecessary to sample again the vagina after prepping. We also found it interesting to read recent findings that showed how vaginally delivered infants acquire bacteria similar to the mother's vaginal environment, again mostly lactobacilli (16) and that, oppositely, caesarian-section infants harbor microorganisms commonly found on the skin, dominated by staphylococci. The latter are potentially more dangerous for the child's health. Although it would be too early to give up concerns on infection risks, the above observation might suggest that the microbiological consequences of these two different delivery modes are likely to be similar to vaginal extraction of a kidney graft as opposed to the suprapubic extraction that is usually adopted for the laparoscopic live-donor nephrectomy.
The use of the da Vinci robotic system has already been advocated to facilitate the preparation of the renal vessels, usually the most difficult and risky part of a laparoscopic live-donor nephrectomy (17). In the setting of a transvaginal extraction of the kidney, it might also be of value to simplify additional suturing at the vaginal closure site, although this was not necessary in our patient (4). In such circumstances, the robot should be re-docked to the patient, and the accessory umbilical port should be used for the robotic needle driver to perform the suturing. The initial patient position on the operative table with abducted legs that we used allowed the laparoscopic, robotic and gynecological approach without the need for repositioning throughout the procedure. After the colpotomy is performed, the pneumoperitoneum should generally be re-established. Although it was not necessary in our patient, because intestinal loops in the pelvis avoided gas loss, this could have been accomplished by using a moistened laparotomy sponge placed inside a surgical glove to facilitate occlusion of the vagina and yet allow the side passage of the endobag.
Pre-entrapment of the kidney inside the endobag and precreation of a wide posterior colpotomy allowed a quick recovery of the graft, keeping the warm ischemia time to a minimum, comparable to that of the standard laparoscopic extraction technique (18).
Patient outcome was extremely positive, with minimal abdominal discomfort, no vaginal pain and no need for postoperative analgesia. The postoperative course was uneventful, and the quick recovery time allowed discharge from the hospital on the first postoperative day.
We have shown that the technique of transvaginal extraction of the kidney after laparoscopic live-donor nephrectomy may also be used in women without a previous hysterectomy. Candidates for this operation should be carefully selected to maintain donor safety and graft viability. We believe that the use of a robotic-assisted technique might enhance the safety of the endoscopic phase of the procedure by facilitating the dissection of the renal vessels, and that it would make easier the intraperitoneal suturing of the vaginal wall, when necessary. Reduction of the parietal trauma to a minimum results in a cosmetic and functional outcome which is likely to be superior to that of the conventional laparoscopic techniques and might therefore be considered in appropriately selected instances. Future studies will be necessary to confirm the long-term safety of this modified technique for kidney donation.
The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.