We thank Dr. Joon Seo Lim from the Scientific Publications Team at Asan Medical Center for his editorial assistance in preparing this manuscript.

This study got approval from the Institutional Review Board of Asan Medical Center (IRB number: 2021-0101).
1. Pretransplant preparation
<ol>
	<li>Patient selection
	<ol>
		<li>Include patients with end-stage renal disease who require kidney transplantation. 
		NOTE: RAKT may not be considered if a recipient is younger than eighteen years old.</li>
		<li>Exclude those with any kind of untreated malignancy or active infection.</li>
		<li>Ensure that the recipient is suitable for surgery with respect to cardiac and pulmonary function and appropriate for a minimally invasive approach.</li>
		<li>Do not consider RAKT if a patient has a history of major abdominal surgery or severe intraperitoneal adhesion. In addition, do not consider RAKT and recommend open kidney transplantation if there is severe calcification in the iliac arteries on computerized tomography.</li>
	</ol>
	</li>
	<li>Patient preparation
	<ol>
		<li>Begin the standard presurgical preparation. Administer laxative suppository tablets for bowel preparation. Ensure that the patient does not ingest anything orally from midnight of the day of the operation. Administer prophylactic first-generation cephalosporin just before a skin incision.</li>
		<li>Provide the maintenance immunosuppressants (e.g., calcineurin inhibitors, methylprednisolone, mycophenolate mofetil) from two days (conventional cases) or seven days (ABO-incompatible or human leukocyte antigen-incompatible cases) before the transplantation according to the protocol of the respective center.</li>
		<li>Prepare the induction immunosuppressants (i.e., anti-thymocyte globulin or basiliximab) that will be administered during the RAKT.</li>
	</ol>
	</li>
	<li>Equipment
	<ol>
		<li>Ensure the availability of a robotic system.</li>
		<li>Ensure the availability of standard laparoscopic equipment and robotic instruments (see the Table of Materials).</li>
		<li>Ensure the availability of 6/0 or 7/0 polytetrafluoroethylene (ePTFE) sutures for artery and vein anastomosis.</li>
		<li>Ensure the availability of 6/0 polydioxanone suture and 3/0 polyglactin adsorbable suture for neocystoureterostomy.</li>
		<li>Ensure the availability of a double-J stent.</li>
	</ol>
	</li>
</ol>
2. Surgical preparation
<ol>
	<li>Anesthesia
	<ol>
		<li>Evaluate the operative risk according to the American Society of Anesthesiologists&#39; classification of Physical Health.</li>
		<li>Induce general anesthesia and use rocuronium bromide as a muscle-relaxant.</li>
		<li>Insert a central venous line and an arterial line.</li>
		<li>Insert a foley catheter and fill the bladder with normal saline. Keep the foley catheter clamped until ureteroneocystostomy is performed.</li>
		<li>Perform arterial blood gas analyses at 1 h intervals during the transplantation.</li>
		<li>Reverse the anesthesia with sugammadex (2 mg/kg, intravenous) at the end of the surgery.</li>
	</ol>
	</li>
	<li>Operation field 
	NOTE: A schematic arrangement map of the operating room is shown in Figure 1.
	<ol>
		<li>Have the operator perform procedures from the robotic console.</li>
		<li>Have the first assistant stand on the left side of the patient. 
		NOTE: The first assistant will be in charge of performing irrigation and suction, supplying sutures and bulldog clamps, and helping with retraction.</li>
		<li>Have the second assistant stand on the right side of the patient&#39;s hip to exchange robotic instruments and help the first assistant.</li>
		<li>Have a scrub nurse stand on the left side of the patient&#39;s left leg.</li>
		<li>Place the patient in the left lateral decubitus position with the legs parted and the Trendelenburg position (20&#176;-30&#176;). Dock the robot between the legs.</li>
	</ol>
	</li>
	<li>Preparation of the kidney allograft (Figure 2)
	<ol>
		<li>Ensure that cold ischemia is started immediately after recovering the kidney from the living donor. Remove the perinephric fat tissue and perform meticulous ligation of the lymphatics around the hilum of kidney allograft on a back table.</li>
		<li>Measure the weight and size of the kidney allograft.</li>
		<li>Consider arterial reconstruction if there are multiple renal arteries such as side-to-side anastomosis, end-to-side anastomosis of the polar artery into the main renal artery, and polar artery anastomosis to the inferior epigastric artery.</li>
		<li>Consider venous extension with a gonadal vein of the recipient or an iliac vein of the deceased donor.</li>
		<li>Insert a 4.8-French, 12 cm double-J stent in the ureter using a guide-wire.</li>
		<li>Wrap the kidney allograft in an ice-packed gauze.</li>
	</ol>
	</li>
</ol>
3. Positioning of the robotic and gel ports (&#160;Figure 3)
<ol>
	<li>Establish and maintain a pneumoperitoneum at approximately 10 mmHg. 
	NOTE: Trocar positioning is for right-sided kidney transplantation.</li>
	<li>Introduce the 12 mm or 8 mm robotic camera port just above the umbilicus. 
	NOTE: The camera port should be placed at about 10-15 cm from the nearest boundary of the target anatomy.</li>
	<li>Place the 8 mm robotic port for Arm II on the right lateral side at 8-9 cm away from the camera port.</li>
	<li>Place another 8 mm robotic port for Arm III along the line between the umbilicus and anterior superior iliac spine at a distance of approximately 8-9 cm from the umbilicus.</li>
	<li>Place the other 8 mm robotic port for Arm IV at approximately 8-9 cm laterally to the port for Arm III. 
	NOTE: Ensure a distance of 2 cm between the ports and bony prominences.</li>
	<li>Place the gel port (6 cm Pfannenstiel incision) on the right suprapubic area (the target anatomy). Make two or three ports on the gel port for the first and second assistants.</li>
</ol>
4. Intraabdominal dissection and insertion of the kidney allograft (Video 1)
<ol>
	<li>Incise the peritoneum along the right paracolic gutter to make a pouch for the kidney allograft with monopolar curved scissors (Arm II), fenestrated bipolar forceps (Arm III), and Prograsp forceps (Arm IV) (see the Table of Materials).</li>
	<li>Dissect the right external iliac vessels along their entire length. Encircle each vessel with a vessel loop.</li>
	<li>Dissect the bladder for ureteroneocystostomy on the right corner of the bladder and separate it from the peritoneal incision for the kidney allograft.</li>
	<li>After opening a cap of the gel port, insert slushed ice followed by the kidney allograft wrapped in the ice-packed gauze through the 6 cm Pfannenstiel incision.</li>
	<li>Place the allograft on the peritoneal pouch lateral to the iliac vessels on the right side.</li>
</ol>
5. Vascular anastomosis and reperfusion (Video 1)
<ol>
	<li>Keep the allograft as cold as possible with either slushed ice or cold normal saline.</li>
	<li>Clamp the right external iliac vein distal and proximal to the anastomosis site with Bulldog clamps, manipulated by Prograsp forceps (Arm IV).</li>
	<li>Make a venotomy with Potts scissors in a linear or oblique fashion, considering the diameter of the renal vein.</li>
	<li>Anastomose the allograft renal vein to the right external iliac vein in an end-to-side continuous manner using a 6/0 ePTFE suture. Make a knot at the caudal end of veins, and suture the posterior wall intraluminally in a continuous manner. Afterwards, suture the anterior wall in a continuous manner. 
	NOTE: The anastomosis is performed with a large needle driver on Arm II and black diamond microforceps or Maryland forceps on Arm III for right-handed surgeons.</li>
	<li>Flush the lumen with heparinized normal saline (5 IU/mL) just before knotting the anastomosis using a silastic tube through the gel port.</li>
	<li>Clamp the allograft renal vein with a Bulldog clamp.</li>
	<li>Declamp the right external iliac vein.</li>
	<li>Clamp the right external iliac artery proximal and distal to the anastomosis site with Bulldog clamps.</li>
	<li>Make an arteriotomy with Potts scissors. Create a round hole with Potts scissors and without an arterial punch.</li>
	<li>Using the same method as vein anastomosis, anastomose the allograft renal artery to the right external iliac artery in an end-to-side continuous manner using a 6/0 ePTFE suture.</li>
	<li>Flush the lumen with heparinized normal saline just before knotting the anastomosis using a silastic tube through the gel port.</li>
	<li>Clamp the allograft renal artery with a Bulldog clamp.</li>
	<li>Declamp the right external iliac artery.</li>
	<li>Declamp the allograft renal vein and artery if there is no evident bleeding at the anastomosis sites.</li>
	<li>Remove the ice-packed gauze.</li>
	<li>Apply warm normal saline on the allograft with an irrigation tube through the gel port.</li>
</ol>
6. Ureteroneocystostomy and peritoneal covering (Video 1)
<ol>
	<li>Perform ureteroneocystostomy according to the Lich-Gregoir technique11.</li>
	<li>Put the distal end of the double-J stent into the bladder.</li>
	<li>Starting at the posterior corner, perform a continuous suture using a 6/0 polydioxanone suture and make a knot at the anterior corner. Then, perform a continuous suture from the anterior corner to the posterior corner.</li>
	<li>From the anterior corner to the posterior corner, close the detrusor muscle antireflux tunnel in an interrupted manner using a 4/0 polyglactin multifilament absorbable suture.</li>
	<li>Cover the kidney allograft with the incised peritoneum along the right paracolic gutter intermittently using polymer locking clips.</li>
</ol>
7. Wound closure
<ol>
	<li>Insert a closed-suction drain through the 8 mm robotic port for Arm II on the right lateral side and put the drain around the kidney allograft.</li>
	<li>Deflate the pneumoperitoneum by opening the gel port.</li>
	<li>Close the gel port and the camera port incisions layer by layer (peritoneum, muscles, subcutaneous layer, and skin). Close the 8 mm robotic port incisions only at the level of the subcutaneous layer and skin.</li>
</ol>

<ol>
	<li>Wolfe, R. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+mortality+in+all+patients+on+dialysis,+patients+on+dialysis+awaiting+transplantation,+and+recipients+of+a+first+cadaveric+transplant.">Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant.</a> New England Journal of Medicine. 341 (23), 1725-1730 (1999).</li><li>Hoznek, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+assisted+kidney+transplantation:+an+initial+experience.">Robotic assisted kidney transplantation: an initial experience.</a> Journal of Urology. 167 (4), 1604-1606 (2002).</li><li>Breda, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic-assisted+kidney+transplantation:+our+first+case.">Robotic-assisted kidney transplantation: our first case.</a> World Journal of Urology. 34 (3), 443-447 (2016).</li><li>Menon, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+kidney+transplantation+with+regional+hypothermia:+evolution+of+a+novel+procedure+utilizing+the+IDEAL+guidelines+(IDEAL+phase+0+and+1).">Robotic kidney transplantation with regional hypothermia: evolution of a novel procedure utilizing the IDEAL guidelines (IDEAL phase 0 and 1).</a> European Urology. 65 (5), 1001-1009 (2014).</li><li>Tzvetanov, I., D'Amico, G., Benedetti, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic-assisted+kidney+transplantation:+our+experience+and+literature+review.">Robotic-assisted kidney transplantation: our experience and literature review.</a> Current Transplantation Reports. 2 (2), 122-126 (2015).</li><li>Giulianotti, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+transabdominal+kidney+transplantation+in+a+morbidly+obese+patient.">Robotic transabdominal kidney transplantation in a morbidly obese patient.</a> American Journal of Transplantation. 10 (6), 1478-1482 (2010).</li><li>Oberholzer, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+robotic+kidney+transplantation+for+obese+patients+previously+denied+access+to+transplantation.">Minimally invasive robotic kidney transplantation for obese patients previously denied access to transplantation.</a> American Journal of Transplantation. 13 (3), 721-728 (2013).</li><li>Tzvetanov, I. G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+kidney+transplantation+in+the+obese+patient:+10-year+experience+from+a+single+center.">Robotic kidney transplantation in the obese patient: 10-year experience from a single center.</a> American Journal of Transplantation. 20 (2), 430-440 (2020).</li><li>Garcia-Roca, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Single+center+experience+with+robotic+kidney+transplantation+for+recipients+with+BMI+of+40+kg/m2+or+greater:+a+comparison+with+the+UNOS+registry.">Single center experience with robotic kidney transplantation for recipients with BMI of 40 kg/m2 or greater: a comparison with the UNOS registry.</a> Transplantation. 101 (1), 191-196 (2017).</li><li>Gallioli, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Learning+curve+in+robot-assisted+kidney+transplantation:+results+from+the+European+Robotic+Urological+Society+Working+Group.">Learning curve in robot-assisted kidney transplantation: results from the European Robotic Urological Society Working Group.</a> European Urology. 78 (2), 239-247 (2020).</li><li>Alberts, V. P., Idu, M. M., Legemate, D. A., Laguna Pes, M. P., Minnee, R. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ureterovesical+anastomotic+techniques+for+kidney+transplantation:+a+systematic+review+and+meta-analysis.">Ureterovesical anastomotic techniques for kidney transplantation: a systematic review and meta-analysis.</a> Transplant International. 27 (6), 593-605 (2014).</li><li>Modi, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Retroperitoneoscopic+living-donor+nephrectomy+and+laparoscopic+kidney+transplantation:+experience+of+initial+72+cases.">Retroperitoneoscopic living-donor nephrectomy and laparoscopic kidney transplantation: experience of initial 72 cases.</a> Transplantation. 95 (1), 100-105 (2013).</li><li>Oberholzer, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+robotic+kidney+transplantation+for+obese+patients+previously+denied+access+to+transplantation.">Minimally invasive robotic kidney transplantation for obese patients previously denied access to transplantation.</a> American Journal of Transplantation. 13 (3), 721-728 (2013).</li><li>Menon, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+kidney+transplantation+with+regional+hypothermia:+a+step-by-step+description+of+the+Vattikuti+Urology+Institute-Medanta+technique+(IDEAL+phase+2a).">Robotic kidney transplantation with regional hypothermia: a step-by-step description of the Vattikuti Urology Institute-Medanta technique (IDEAL phase 2a).</a> European Urology. 65 (5), 991-1000 (2014).</li><li>Tsai, M. K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+renal+transplantation+in+the+retroperitoneum.">Robot-assisted renal transplantation in the retroperitoneum.</a> Transplant International. 27 (5), 452-457 (2014).</li><li>Sood, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+kidney+transplantation:+perioperative+considerations+and+key+6-month+outcomes.">Minimally invasive kidney transplantation: perioperative considerations and key 6-month outcomes.</a> Transplantation. 99 (2), 316-323 (2015).</li><li>Modi, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+transplantation+following+transvaginal+insertion+of+the+kidney:+description+of+technique+and+outcome.">Laparoscopic transplantation following transvaginal insertion of the kidney: description of technique and outcome.</a> American Journal of Transplantation. 15 (7), 1915-1922 (2015).</li><li>Wagenaar, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive,+laparoscopic,+and+robotic-assisted+techniques+versus+open+techniques+for+kidney+transplant+recipients:+a+systematic+review.">Minimally invasive, laparoscopic, and robotic-assisted techniques versus open techniques for kidney transplant recipients: a systematic review.</a> European Urology. 72 (2), 205-217 (2017).</li><li>Gastrich, M. D., Barone, J., Bachmann, G., Anderson, M., Balica, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+surgery:+review+of+the+latest+advances,+risks,+and+outcomes.">Robotic surgery: review of the latest advances, risks, and outcomes.</a> Journal of Robotic Surgery. 5 (2), 79-97 (2011).</li><li>Modi, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+assisted+kidney+transplantation.">Robotic assisted kidney transplantation.</a> Indian Journal of Urology. 30 (3), 287-292 (2014).</li><li>Vignolini, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+University+of+Florence+technique+for+robot-assisted+kidney+transplantation:+3-year+experience.">The University of Florence technique for robot-assisted kidney transplantation: 3-year experience.</a> Frontiers in Surgery. 7, 583798 (2020).</li><li>Musquera, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+kidney+transplantation:+update+from+the+European+Robotic+Urology+Section+(ERUS)+series.">Robot-assisted kidney transplantation: update from the European Robotic Urology Section (ERUS) series.</a> BJU International. 127 (2), 222-228 (2021).</li><li>Breda, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+kidney+transplantation:+the+European+experience.">Robot-assisted kidney transplantation: the European experience.</a> European Urology. 73 (2), 273-281 (2018).</li><li>Siena, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+kidney+transplantation+with+regional+hypothermia+using+grafts+with+multiple+vessels+after+extracorporeal+vascular+reconstruction:+results+from+the+European+Association+of+Urology+Robotic+Urology+Section+Working+Group.">Robot-assisted kidney transplantation with regional hypothermia using grafts with multiple vessels after extracorporeal vascular reconstruction: results from the European Association of Urology Robotic Urology Section Working Group.</a> European Urology Focus. 4 (2), 175-184 (2018).</li><li>Prudhomme, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic-assisted+kidney+transplantation+in+obese+recipients+compared+to+non-obese+recipients:+the+European+experience.">Robotic-assisted kidney transplantation in obese recipients compared to non-obese recipients: the European experience.</a> World Journal of Urology. 39 (4), 1287-1298 (2020).</li><li>Vignolini, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Development+of+a+robot-assisted+kidney+transplantation+programme+from+deceased+donors+in+a+referral+academic+centre:+technical+nuances+and+preliminary+results.">Development of a robot-assisted kidney transplantation programme from deceased donors in a referral academic centre: technical nuances and preliminary results.</a> BJU International. 123 (3), 474-484 (2019).</li><li>Ahlawat, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+kidney+transplantation+with+regional+hypothermia+versus+open+kidney+transplantation+for+patients+with+end+stage+renal+disease:+an+ideal+stage+2B+study.">Robotic kidney transplantation with regional hypothermia versus open kidney transplantation for patients with end stage renal disease: an ideal stage 2B study.</a> Journal of Urology. 205 (2), 595-602 (2021).</li></ol>

The authors have no conflicts of financial and non-financial interests to disclose.

Although laparoscopic and robotic-assisted techniques have been widely applied for living donor nephrectomy, kidney transplantations are still mainly performed using conventional open techniques. Recently, however, a minimally invasive approach for kidney transplantation has been increasingly used. Compared with traditional open surgery, minimally invasive kidney transplantation has a lower risk of surgical site infection, incisional hernia, and wound dehiscence, as well as shorter hospitalization12</su...

Kidney transplantation contributes to prolonged survival and a better quality of life compared with peritoneal dialysis or hemodialysis1. Although the open approach is the standard procedure for kidney transplantation, robotic-assisted techniques have been recently adopted2,3,4. Specifically, robot-assisted kidney transplantation (RAKT) has several advantages over open kidney transplantation: minimal postoperative pain, better cosmesis, fewer wound infections, and shorter hospital stay5.&#160;Moreover, minimally invasive access and robotic technology enable surgeons to safely perform kidney transplants in morbidly obese patients6,7,8,9. However, due to its complexity, RAKT requires a learning curve to achieve sufficient reproducibility in the operation time, functional results, and safety10.
Allografts with multiple vessels usually require vascular reconstruction, which leads to extended cold and warm ischemic times. Despite the technical challenges of RAKT, a European multicenter study reported that RAKT using allografts with multiple vessels is technically feasible and leads to favorable functional results11. Although it is more common to place the kidney allograft in the pelvis medially during vascular anastomosis, according to previous reports4,5,6,7,8,9, the allograft was placed on the peritoneal pouch lateral to the iliac vessels in this protocol. Although it may be safe to put an allograft medially during anastomosis and flip it to the peritoneal pouch, this technique may not be familiar for inexperienced surgeons. Furthermore, it is more convenient to perform vascular anastomosis with the allograft in the peritoneal pouch and renal vessels in the proper position. This paper describes the step-by-step procedures for RAKT without flipping.

<table><tbody><tr><td>12 mm Fluorescence Endoscope, 30&amp;deg;</td><td>Intuitive Surgical</td><td>370893</td><td>robotic instrument</td></tr><tr><td>8 mm Blunt Obturator</td><td>Intuitive Surgical</td><td>420008</td><td>robotic instrument</td></tr><tr><td>8 mm Instrument Cannula</td><td>Intuitive Surgical</td><td>420002</td><td>robotic instrument</td></tr><tr><td>ATRAUMATIC ROBOTIC VESSEL CLIPS</td><td>RZ Medizintechnic GmbH</td><td>300-100-799</td><td></td></tr><tr><td>BARD INLAY OPTIMA URETERAL STENT</td><td>BARD Medical</td><td>78414</td><td>4.7 Fr./14 cm</td></tr><tr><td>Black Diamond Micro Forceps</td><td>Intuitive Surgical</td><td>420033</td><td>robotic instrument</td></tr><tr><td>COATED VICRYL 4-0</td><td>Ethicon Endo-Surgery, Inc.</td><td>W9437</td><td></td></tr><tr><td>Da Vinci Si, X, or Xi</td><td>Intuitive Surgical</td><td></td><td></td></tr><tr><td>Fenestrated bipolar forceps</td><td>Intuitive Surgical</td><td>470205</td><td>robotic instrument</td></tr><tr><td>GELPORT LAPAROSCOPIC SYSTEM</td><td>Applied Medical Resources Corporation</td><td>C8XX2</td><td>standard laparoscopic equipment</td></tr><tr><td>GORE-TEX SUTURE CV-6</td><td>W.L. Gore and Associates Inc.</td><td>6M02A</td><td></td></tr><tr><td>GORE-TEX SUTURE CV-7</td><td>W.L. Gore and Associates Inc.</td><td>7K02A</td><td></td></tr><tr><td>HEMO CLIP</td><td>WECK</td><td>523735</td><td></td></tr><tr><td>HEM-O-LOK CLIP</td><td>WECK</td><td>544220</td><td></td></tr><tr><td>Hot Shears (Monopolar Curved Scissors)</td><td>Intuitive Surgical</td><td>420179</td><td>robotic instrument</td></tr><tr><td>laparoscopic atraumatic grasping forceps</td><td></td><td></td><td>standard laparoscopic equipment</td></tr><tr><td>laparoscopic irrigation suction set</td><td></td><td></td><td>standard laparoscopic equipment</td></tr><tr><td>Large Clip Applier</td><td>Intuitive Surgical</td><td>420230</td><td>robotic instrument</td></tr><tr><td>Large Needle Driver</td><td>Intuitive Surgical</td><td>420006</td><td>robotic instrument</td></tr><tr><td>Maryland Bipolar Forceps</td><td>Intuitive Surgical</td><td>420172</td><td>robotic instrument</td></tr><tr><td>Medium-Large Clip Applier</td><td>Intuitive Surgical</td><td>420327</td><td>robotic instrument</td></tr><tr><td>OPEN END URETERAL CATHETER</td><td>Cook Incorporated</td><td>21305</td><td>heparin flushing</td></tr><tr><td>PDS II 6-0 (DOUBLE)</td><td>Ethicon Endo-Surgery, Inc.</td><td>Z1712H</td><td></td></tr><tr><td>Potts Scissors</td><td>Intuitive Surgical</td><td>420001</td><td>robotic instrument</td></tr><tr><td>ProGrasp Forceps</td><td>Intuitive Surgical</td><td>420093</td><td>robotic forceps</td></tr><tr><td>Small Clip Applier</td><td>Intuitive Surgical</td><td>420003</td><td>robotic instrument</td></tr><tr><td>VESSEL LOOP BLUE MAXI</td><td>ASPEN surgical</td><td>011012pbx</td><td></td></tr><tr><td>VESSEL LOOP RED MINI</td><td>ASPEN surgical</td><td>011001pbx</td><td></td></tr><tr><td>XCEL BLADELESS TROCAR</td><td>JOHNSON &amp;amp; JOHNSON</td><td>2B12LT</td><td>standard laparoscopic equipment</td></tr></tbody></table>

robot-assisted kidney transplantation

This paper describes robot-assisted kidney transplantation (RAKT) from a living donor. The robot is docked between the parted legs of the patient, placed in the supine Trendelenburg position. Kidney allografts are provided by a living donor. Before vascular anastomosis, the kidney allograft is prepared by inserting a double-J stent in the ureter, and the temperature for the anastomosis is lowered by wrapping it in an ice-packed gauze. A 12 mm or 8 mm port for the robotic camera and three 8 mm ports for robotic arms are placed. A peritoneal pouch is created for the kidney allograft by raising the peritoneal flaps on both sides over the psoas muscle before dissecting the iliac vessels and bladder. A 6 cm Pfannenstiel incision is made to insert the kidney into the peritoneal pouch, lateral to the right iliac vessels. 
After clamping the external iliac vein with Bulldogs clamps, a venotomy is performed, and the graft renal vein is anastomosed to the external iliac vein in an end-to-side continuous manner with a 6/0 polytetrafluoroethylene suture. After clamping the graft renal vein, the iliac vein is declamped. This is followed by clamping of the external iliac artery, arteriotomy, arterial anastomosis with a 6/0 polytetrafluoroethylene suture, clamping of the graft renal artery, and declamping of the external iliac artery. Reperfusion is then carried out, and ureteroneocystostomy is performed using the Lich-Gregoir technique. The peritoneum is closed at a few locations with polymer locking clips, and a closed-suction drain is placed through one of the working ports. After deflating the pneumoperitoneum, all incisions are closed.

We set up a routine clinical pathway for recipients who have RAKT at our center. Renal Doppler ultrasound is performed one day post-transplant and technetium-99m diethylenetriamine penta-acetic acid renal scan two days post-transplant. For venous thromboembolism prophylaxis, an intermittent pneumatic compression device is applied during the first 24 h after RAKT. Foley catheter is removed on the fourth postoperative day. On the fifth day, a closed-suction drain is removed after confirming no intra-abdominal complication ...

Watch this Scientific Journal Video about Robot-Assisted Kidney Transplantation at JoVE.com

Robot-Assisted Kidney Transplantation

This paper provides technical details for robot-assisted kidney transplantation from a living donor.

This paper describes robot-assisted kidney transplantation (RAKT) from a living donor. The robot is docked between the parted legs of the patient, placed ...

Research

JoVE Journal

Medicine

3.4K Views.  University of Ulsan College of Medicine. In dit protocol hebben we stapsgewijze procedures voorgesteld voor robotondersteunde niertransplantatie zonder om te draaien. Het is natuurlijker om vasculaire anastomose uit te voeren met een allograft in de peritoneale buidel en de niervaten in de juiste positie. Deze techniek kan worden toegepast op andere vaste orgaantransplantaties, zoals de lever en de alvleesklier.We hopen het nut van minimaal invasieve chirurgische benaderingen met behulp van het robotsysteem op het gebied van ...

Video: Robot-Assisted Kidney Transplantation

Murine Renal Transplantation Procedure

Renal orthotopic transplantation in mice is a technically challenging procedure. Although the first kidney transplants in mice were performed by Russell et al over 30 years ago (1) and refined by Zhang et al years later (2), few people in the world have mastered this procedure. In our laboratory we have successfully performed 1200 orthotopic kidney transplantations with &gt; 90% survival rate. The key points for success include stringent control of reperfusion injury, bleeding and thrombosis, both during the procedure and post-transplantation, and use of 10-0 instead of 11-0 suture for anastomoses.
Post-operative care and treatment of the recipient is extremely important to transplant success and evaluation. All renal graft recipients receive antibiotics in the form of an injection of penicillin immediately post-transplant and sulfatrim in the drinking water continually. Overall animal health is evaluated daily and whole blood creatinine analyses are performed routinely with a portable I-STAT machine to assess graft function.

Renal transplantation in mice is a technically challenging procedure that requires careful post-operative care and treatment for success.

Renal orthotopic transplantation in mice is a technically challenging procedure. Although the first kidney transplants in mice were performed by Russell ...

Biology

Mouse Kidney Transplantation: Models of Allograft Rejection

Rejection of the transplanted kidney in humans is still a major cause of morbidity and mortality. The mouse model of renal transplantation closely replicates both the technical and pathological processes that occur in human renal transplantation. Although mouse models of allogeneic rejection in organs other than the kidney exist, and are more technically feasible, there is evidence that different organs elicit disparate rejection modes and dynamics, for instance the time course of rejection in cardiac and renal allograft differs significantly in certain strain combinations. This model is an attractive tool for many reasons despite its technical challenges. As inbred mouse strain haplotypes are well characterized it is possible to choose donor and recipient combinations to model acute allograft rejection by transplanting across MHC class I and II loci. Conversely by transplanting between strains with similar haplotypes a chronic process can be elicited were the allograft kidney develops interstitial fibrosis and tubular atrophy. We have modified the surgical technique to reduce operating time and improve ease of surgery, however a learning curve still needs to be overcome in order to faithfully replicate the model. This study will provide key points in the surgical procedure and aid the process of establishing this technique.

Here, we present a protocol to study the immunology of rejection. The surgical model presented reports a short operating time and a concise technique. Depending on the donor-recipient strain combination, the transplanted kidney may develop acute cellular rejection or chronic allograft damage, defined by interstitial fibrosis and tubular atrophy.

Rejection of the transplanted kidney in humans is still a major cause of morbidity and mortality. The mouse model of renal transplantation closely ...

Murine Kidney Transplant Technique

The first mouse kidney transplant technique was published in 19731 by the Russell laboratory. Although it took some years for other labs to become proficient in and utilize this technique, it is now widely used by many laboratories around the world. A significant refinement to the original technique using the donor aorta to form the arterial anastomosis instead of the renal artery was developed and reported in 1993 by Kalina and Mottram 2 with a further advancement coming from the same laboratory in 1999 3. While one can become proficient in this model, a search of the literature reveals that many labs still experience a high proportion of graft loss due to arterial thrombosis. We describe here a technique that was devised in our laboratory that vastly reduces the arterial thrombus reported by others 4,5. This is achieved by forming a heel-and-toe cuff of the donor infra-renal aorta that facilitates a larger anastomosis and straighter blood flow into the kidney.

The goal of this manuscript is to describe the steps required to perform a kidney transplant in a mouse, paying particular attention to the details of the arterial anastomosis.

The first mouse kidney transplant technique was published in 19731 by the Russell laboratory. Although it took some years for other labs to become ...

Heterotopic Renal Autotransplantation in a Porcine Model: A Step-by-Step Protocol

Kidney transplantation is the treatment of choice for patients suffering from end-stage renal disease. It offers better life expectancy and higher quality of life when compared to dialysis. Although the last few decades have seen major improvements in patient outcomes following kidney transplantation, the increasing shortage of available organs represents a severe problem worldwide. To expand the donor pool, marginal kidney grafts recovered from extended criteria donors (ECD) or donated after circulatory death (DCD) are now accepted for transplantation. To further improve the postoperative outcome of these marginal grafts, research must focus on new therapeutic approaches such as alternative preservation techniques, immunomodulation, gene transfer, and stem cell administration.
Experimental studies in animal models are the final step before newly developed techniques can be translated into clinical practice. Porcine kidney transplantation is an excellent model of human transplantation and allows investigation of novel approaches. The major advantage of the porcine model is its anatomical and physiological similarity to the human body, which facilitates the rapid translation of new findings to clinical trials. This article offers a surgical step-by-step protocol for an autotransplantation model and highlights key factors to ensure experimental success. Adequate pre- and postoperative housing, attentive anesthesia, and consistent surgical techniques result in favorable postoperative outcomes. Resection of the contralateral native kidney provides the opportunity to assess post-transplant graft function. The placement of venous and urinary catheters and the use of metabolic cages allow further detailed evaluation. For long-term follow-up studies and investigation of alternative graft preservation techniques, autotransplantation models are superior to allotransplantation models, as they avoid the confounding bias posed by rejection and immunosuppressive medication.

Porcine models of organ transplantation provide an important platform to study mechanisms of organ preservation. This article describes a heterotopic porcine renal autotransplantation model, which allows investigating new approaches to improve the outcome of transplantation using marginal kidney grafts.

Kidney transplantation is the treatment of choice for patients suffering from end-stage renal disease. It offers better life expectancy and higher quality ...

A Modified Surgical Technique for Kidney Transplantation in Mice

Kidney transplantation in mice is a complicated and challenging surgery procedure. There are very few publications demonstrating the key steps of this operation. Therefore, this article introduces the technique and points out the surgical caveats associated with this operation. In addition, important modifications in comparison to the conventional procedure are demonstrated. Firstly, a patch of the abdominal aorta is cut and prepared so that the proximal bifurcations of the renal artery, including the ureteral artery are transected together with the donor kidney en bloc. This reduces the risk of a ureter necrosis and avoids the development of a urinary tract occlusion. Secondly, a new method of the vascular anastomosis is demonstrated that allows the operator to flexibly increase or decrease the size of the anastomosis after renal transplant reperfusion has already been initiated. This avoids the development of vessel strictures and intraabdominal bleeding. Thirdly, a technique that enables the anastomosis of the delicate donor ureter and the recipient bladder that does not cause a trauma is shown. Adopting this protocol can shorten the operation time and reduces the damage to the recipient's bladder, thereby significantly increasing the operation success rate for the recipient mice.

This protocol presents a new surgical technique of mouse kidney transplantation focusing on a modified arterial anastomosis strategy. A vascular suture technique including a simple and safer ureter-bladder anastomosis method is also presented. These modifications shorten the operation time and improve the success rate of the mouse kidney transplantation procedure.

Kidney transplantation in mice is a complicated and challenging surgery procedure. There are very few publications demonstrating the key steps of this ...

Immunology and Infection

Orthotopic Rat Kidney Transplantation: A Novel and Simplified Surgical Approach

Kidney transplantation offers increased survival rates and improved quality of life for patients with end-stage renal disease, as compared to any type of renal replacement therapy. Over the past few decades, the rat kidney transplantation model has been used to study the immunological phenomena of rejection and tolerance. This model has become an indispensable tool to test new immunomodulatory pharmaceuticals and regimens prior to proceeding with expensive preclinical large animal studies.
This protocol provides a detailed overview of how to reliably perform orthotopic kidney transplantation in rats. This protocol includes three distinctive steps that increase the probability of success: perfusion of the donor kidney by flushing through the portal vein and the use of a cuff system to anastomose the renal veins and ureters, thereby decreasing cold and warm ischemia times. Using this technique, we have achieved survival rates beyond 6 months with normal serum creatinine in animals with syngeneic or tolerant kidney transplants. Depending on the aim of the study, this model can be modified by pre- or posttransplant treatments to study the acute, chronic, cellular, or antibody-mediated rejection. It is a reproducible, reliable, and cost-effective animal model to study different aspects of kidney transplantation.

The purpose of this manuscript and protocol is to explain and demonstrate in detail the surgical procedure of orthotopic kidney transplantation in rats. This method is simplified to achieve the correct perfusion of the donor kidney and shorten the reperfusion time by using the venous and ureteral cuff anastomosis technique.

Kidney transplantation offers increased survival rates and improved quality of life for patients with end-stage renal disease, as compared to any type of ...

Robot-Assisted Radical Antegrade Modular Pancreatosplenectomy Including Resection and Reconstruction of the Spleno-Mesenteric Junction

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the spleno-mesenteric junction, for cancer of the body-tail of the pancreas. The patient is placed supine with the legs parted and a pneumoperitoneum is established and maintained at 10 mmHg. To use the surgical system, four 8 mm ports and one 12 mm port are required. The optic port is placed at the umbilicus. The other ports are placed, on either side, along the pararectal line and the anterior axillary line at the level of the umbilical line. The assistant port (12 mm) is placed along the right pararectal line. Dissection begins by detaching the gastrocolic ligament, thus opening the lesser sac, and by a wide mobilization of the splenic flexure of the colon. The superior mesenteric vein is identified along the inferior border of the pancreas. Lymph node number 8a is removed to permit clear visualization of the common hepatic artery. A tunnel is then created behind the neck of the pancreas. To permit safe resection and reconstruction of the spleno-mesenteric junction, further preemptive dissection is required before dividing the pancreatic neck to bring in clear view all relevant vascular pedicles. Next, the splenic artery is ligated and divided, and the pancreatic neck is divided, with selective ligature of the pancreatic duct. After vein resection and reconstruction, dissection proceeds to complete the clearance of peripancreatic arteries that are peeled off from all lympho-neural tissues. Both celiac ganglia are removed en-bloc with the specimen. The Gerota fascia covering the upper pole of the left kidney is also removed en-bloc with the specimen. Division of short gastric vessels and splenectomy complete the procedure. A drain is left near the pancreatic stump. The round ligament of the liver is mobilized to protect the vessels.

The robotic technique shown herein aims at faithfully reproducing the open procedure for radical treatment of cancer of the body-tail of the pancreas. The protocol also demonstrates the ability to master involvement of major peripancreatic vessels without conversion to open surgery.

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the ...

Orthotopic Kidney Auto-Transplantation in a Porcine Model Using 24 Hours Organ Preservation And Continuous Telemetry

In the present era of organ transplantation with critical organ shortage, various strategies are employed to expand the pool of available allografts for kidney transplantation (KT). Even though, the use of allografts from extended criteria donors (ECD) could partially ease the shortage of organ donors, ECD organs carry a potentially higher risk for inferior outcomes and postoperative complications. Dynamic organ preservation techniques, modulation of ischemia-reperfusion and preservation injury, and allograft therapies are in the spotlight of scientific interest in an effort to improve allograft utilization and patient outcomes in KT.
Preclinical animal experiments are playing an essential role in translational research, especially in the medical device and drug development. The major advantage of the porcine orthotopic auto-transplantation model over ex vivo or small animal studies lies within the surgical-anatomical and physiological similarities to the clinical setting. This allows the investigation of new therapeutic methods and techniques and ensures a facilitated clinical translation of the findings. This protocol provides a comprehensive and problem-oriented description of the porcine orthotopic kidney auto-transplantation model, using a preservation time of 24 hours and telemetry monitoring. The combination of sophisticated surgical techniques with highly standardized and state-of-the-art methods of anesthesia, animal housing, perioperative follow up, and monitoring ensure the reproducibility and success of this model.

Large animal models play an essential role in preclinical transplantation research. Due to its similarities to the clinical setup, the porcine model of orthotopic kidney auto-transplantation described in this article provides an excellent in vivo setting for the testing of organ preservation techniques and therapeutic interventions.

In the present era of organ transplantation with critical organ shortage, various strategies are employed to expand the pool of available allografts for ...

A Rat Orthotopic Renal Transplantation Model for Renal Allograft Rejection

Renal allograft rejection limits the long-term survival of patients after renal transplantation. Rat orthotopic renal transplantation is an essential model to investigate the mechanism of renal allograft rejection in pre-clinical studies and could aid in the development of novel approaches to improve the long-term survival of renal allografts. Donor kidney implantation in rat orthotopic renal transplantation is commonly performed by end-to-side anastomosis to recipients' aorta and inferior vena cava. In this model, the donor's kidney was implanted using end-to-end anastomosis to the recipients' renal artery and renal vein. The donor's ureter was anastomosed to the recipient's bladder in an end-to-side 'tunnel' method. This model contributes to better healing of ureter-bladder anastomosis and increases the recipients' survival by avoiding interference with blood supply and venous reflux of the lower body. This model can be used to investigate the mechanisms of acute and chronic immune and pathologic rejection of renal allografts. Here, the study describes the detailed protocols of this orthotopic renal transplantation between rats.

The rat orthotopic renal transplantation model contributes to investigating the mechanism of renal allograft rejection. The current model increases the recipients' survival without interference with blood supply and venous reflux of the lower body using an end-to-end anastomosis of kidney implantation and an end-to-side "tunnel" method of ureter-bladder anastomosis.

Renal allograft rejection limits the long-term survival of patients after renal transplantation. Rat orthotopic renal transplantation is an essential ...

Retzius-Sparing Robot-Assisted Radical Prostatectomy

The technique of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) and initial experience with it at a single center are provided. The technique is described step-by-step and further illustrated by a video to enhance reproducibility. Early oncological and functional results were evaluated. In total, 77 patients were included with a median follow-up of 11 months (range: 3-21 months). Fifty-one percent of patients had local high-risk or locally advanced prostate cancer. There were no intra-operative complications, and all high-grade complications (2.6%) were related to pelvic lymph node dissection performed concomitant with RS-RARP. Median operation time was 160 min (range: 122-265 min) and median hospital stay was 3 (range: 3-8) days. A positive surgical margin was reported in 42.9%. One-year biochemical recurrence-free survival was 90.1%. After 6 months, all patients were socially continent and after 1 year, 94.3% were fully continent. Of sexually active patients who underwent at least unilateral nerve-sparing, 43.3% were able to have sexual intercourse. This series underlines the surgical safety of performing RS-RARP by a standardized technique and confirms the beneficial effect on the early return of continence. The patient needs to be informed about the risk of a positive surgical margin.

Robot-assisted Retzius-sparing radical prostatectomy is a technique that enables to preserve urinary continence or facilitates recovery of urinary continence in the majority of patients. Patients must be informed about the risk of a positive surgical margin.

The technique of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) and initial experience with it at a single center are provided. The ...

Robot-Assisted Kidney Transplantation

Samenvatting

Meer video's verkennen