Toward Precision Kidney Transplantation: Implementation of a Robot-Assisted Kidney Transplantation Program through Definition of a Standardized Training Curriculum Integrating 3D Models and Augmented-Reality

Kidney transplantation (KT) is the treatment of choice for patients with end-stage renal disease, providing a better survival rate and quality of life compared to dialysis. Despite the progress in the medical management of patients undergoing KT, from a purely surgical standpoint KT has resisted innovations during the last 50 years. Recently, robot-assisted KT (RAKT) has been proposed as an alternative approach to open surgery, especially due to its potential benefits for both surgeons and the fragile and immunocompromised recipients. It was not until 2014 that the role of RAKT has found value thanks to the pioneering Vattikuti Urology Institute-Medanta collaboration that conceptualized and developed a new surgical technique for RAKT following the Idea, Development, Exploration, Assessment, Long-term follow-up (IDEAL) recommendations for introducing surgical innovations into real-life practice. During the last years, mirroring the Vattikuti-Medanta technique, several Centers developed RAKT programs worldwide, providing increasing evidence on the safety and feasibility of this procedure in a variety of clinical scenarios. The PhD research project reported in this Thesis, entitled “Toward precision kidney transplantation: implementation of a robot-assisted kidney transplantation program through definition of a standardized training curriculum integrating 3D models and augmented-reality", had three main objectives: 1. to implement the existing RAKT program from living and deceased donors at Careggi University Hospital (Florence, Italy) through the standardization of the surgical technique and the analysis of the risk-benefit ratio of RAKT as compared to the gold standard open kidney transplantation; 2. to develop a 3D-printed model for vascular anastomoses during RAKT, aiming to provide a foundation for future modular training programs in RAKT; 3. to integrate 3D-models and augmented-reality into preoperative and intraoperative surgical planning, aiming to improve the technical finesse of RAKT (especially from deceased donors), toward the concept of “precision surgery”. Specifically, the key steps of the project were: 1. Observation and modular surgical training in the operating theatres of Careggi University Hospital aiming to progressively acquire the technical and non-technical skills for multiorgan procurement surgery, kidney transplantation surgery, and robotic urologic surgery. This phase of the project allowed us to identify and categorize the main steps of all surgical interventions related to both kidney donation and transplantation (in particular, RAKT); 2. Definition of the structured, step-by-step University of Florence techniques for both robot-assisted living donor nephrectomy and robot-assisted kidney transplantation from living and deceased donors. The conceptualization of these techniques allowed us to further standardize the surgical pathway for minimally-invasive kidney donation and transplantation at Careggi University Hospital. 3. Review of the current evidence on RAKT, aiming to define its indications, limits and challenges; 4. Prospective assessment of the intraoperative, perioperative and functional outcomes of RAKT in the challenging clinical scenario of deceased donors, as well as obese recipients; 5. Prospective evaluation of the learning curve of RAKT through the European Association of Urology (EAU) Robotic Urology Section (ERUS) – RAKT working group; 6. Review of the current evidence on the learning curve of both open kidney transplantation and RAKT; 7. Development of a novel, entirely three-dimensional (3D)-printed hyper-accuracy simulator for vascular anastomoses during RAKT, aiming to provide novice surgeons wishing to start their experience in RAKT a reliable model for dry-lab exercises before structured modular training programs on animal models and patients; 8. Integration of 3D cognitive surgery and augmented reality to improve preoperative and intraoperative decision-making during RAKT, breaking the limit of atheromatic plaques (especially in the setting of deceased donors) and increasing the technical finesse of RAKT toward the paradigm of “precision surgery”; 9. Design and conduction of multicenter collaborative research projects on RAKT, leveraging the power of the ERUS-RAKT and EAU-Young Academic Urologists (YAU) kidney transplantation working groups; 10. Exploration of the role of urologists for kidney transplantation across European countries, with special emphasis on their value for RAKT programs.