Managing Angiomyolipoma with triple vessel in right donor kidney: An innovative approach in robot-assisted kidney transplant

Abstract

Introduction

Kidney transplantation remains the gold standard treatment for patients with end-stage renal disease. While open surgery has long been the traditional approach, robot-assisted kidney transplant (RAKT) has emerged as a viable alternative. One of the key challenges in RAKT is managing multiple vessel renal allografts. Successful transplantation of an angiomyolipoma (AML)-affected kidney has been reported after its excision on the bench. However, it is still often seen, as a relative contraindication to transplantation. In this video, we demonstrate our innovative technique and share the outcome of managing AML and triple vessel allograft in RAKT using an internal iliac artery autograft.

Materials and Methods

A 50-year-old male patient was planned for RAKT. Pre-operative workup of the donor revealed two renal arteries on the left side and three renal arteries on the right side. Also, there was a 3 × 3 cm mass in the right kidney, which, on computed tomography, was characteristic of AML. Radio-isotope renogram study revealed equal function of both kidneys, 54.2 and 45.2 mL/min on the right and left side, respectively. A decision was made to take the right kidney laparoscopically for transplantation and remove the mass at bench dissection. The surgery was divided into three distinct steps. Step 1 was the robotic retrieval of the internal iliac artery autograft from the recipient. Step 2 involved bench dissection, which included ex-vivo vascular reconstruction to anastomose three renal arteries with internal iliac artery autograft, and excision of AML with renorrhaphy. Two upper polar arteries were anastomosed in pantaloon fashion, and this pantaloon was then anastomosed end-to-end with the autograft. The lower polar artery was reimplanted in an end-to-side fashion on the autograft. Step 3 is the anastomosis of this autograft-allograft complex with the external iliac vessels of the recipient.

Results

By creating the autograft-allograft complex, we were able to fashion a single arterial ostium that subsequently led to a single arterial anastomosis with the external iliac artery. Cold and rewarm ischemia times were 100 and 36 min, respectively. The intra and postoperative courses for both donor and recipient were uneventful. Renal function remained stable in both, with no complications, throughout the follow-up of 20 months.

Conclusions

This innovative technique of using internal iliac artery autograft offers reduced rewarm ischemia in robot-assisted kidney transplant, the same as that of a single vessel, and eliminates the need for more than one intracorporeal arterial anastomosis. Incidental or asymptomatic small benign renal masses in donor kidneys can be considered for transplantation after being thoroughly evaluated for their suitability, rather than rejected outright.