Volume 65, Issue 5, Pages (May 2014)

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Volume 65, Issue 5, Pages 991-1000 (May 2014) Robotic Kidney Transplantation with Regional Hypothermia: A Step-by-step Description of the Vattikuti Urology Institute–Medanta Technique (IDEAL Phase 2a) Mani Menon, Akshay Sood, Mahendra Bhandari, Vijay Kher, Prasun Ghosh, Ronney Abaza, Wooju Jeong, Khurshid R. Ghani, Ramesh K. Kumar, Pranjal Modi, Rajesh Ahlawat European Urology Volume 65, Issue 5, Pages 991-1000 (May 2014) DOI: 10.1016/j.eururo.2013.12.006 Copyright © 2013 European Association of Urology Terms and Conditions

Fig. 1 (a) GelSeal cap with a 12-mm camera-port (C) and a 10-mm assistant port, for the 5-mm suction (A). (b) Diagrammatic illustration of port placement for robotic kidney transplantation with regional hypothermia. European Urology 2014 65, 991-1000DOI: (10.1016/j.eururo.2013.12.006) Copyright © 2013 European Association of Urology Terms and Conditions

Fig. 2 (a) Skeletonized iliac vessel bed. (b) Bladder preparation: detrusor flaps created for subsequent ureteroneocystostomy (modified Lich-Gregoir technique). European Urology 2014 65, 991-1000DOI: (10.1016/j.eururo.2013.12.006) Copyright © 2013 European Association of Urology Terms and Conditions

Fig. 3 (a) Multiple modified Toomey syringes (nozzles cut off) being readied for rapid delivery of ice slush. (b) Graft kidney wrapped in a gauze jacket filled with ice slush. (c) Pelvic bed lined with ice slush to achieve pelvic-bed cooling before introduction of the graft kidney. (d) Additional ice slush delivered onto the graft kidney immediately after its introduction, to achieve uniform cooling. European Urology 2014 65, 991-1000DOI: (10.1016/j.eururo.2013.12.006) Copyright © 2013 European Association of Urology Terms and Conditions

Fig. 4 (a) External iliac vein clamped with a robotic bulldog clamp. (b) End-to-side venous anastomosis. European Urology 2014 65, 991-1000DOI: (10.1016/j.eururo.2013.12.006) Copyright © 2013 European Association of Urology Terms and Conditions

Fig. 5 (a) Linear arteriotomy converted to circular arteriotomy using a 3.6-mm aortic punch. (b) End-to-side arterial anastomosis. European Urology 2014 65, 991-1000DOI: (10.1016/j.eururo.2013.12.006) Copyright © 2013 European Association of Urology Terms and Conditions

Fig. 6 (a) Ureteroneocystostomy. (b) Inferior epigastric artery being flushed with heparinized saline using a 5F ureteric catheter. (c) Lower-pole accessory artery anastomosis to the inferior epigastric artery using 6-0 prolene sutures. European Urology 2014 65, 991-1000DOI: (10.1016/j.eururo.2013.12.006) Copyright © 2013 European Association of Urology Terms and Conditions

Fig. 7 Technical modifications done during phases 1 and 2a of procedure development plotted against case timeline. European Urology 2014 65, 991-1000DOI: (10.1016/j.eururo.2013.12.006) Copyright © 2013 European Association of Urology Terms and Conditions

Fig. 8 (a) Box plots of console, warm ischemia, rewarming, iliac vessel bed preparation, and arterial, venous, and ureterovesical anastomoses times (the upper and the lower bars represent the 75th and the 25th percentiles, respectively). (b) Fall in serum creatinine level in patients undergoing robotic kidney transplantation with regional hypothermia. Bars represent standard error of means. POD=postoperative day. European Urology 2014 65, 991-1000DOI: (10.1016/j.eururo.2013.12.006) Copyright © 2013 European Association of Urology Terms and Conditions