Three-dimensional Augmented Reality-guided Robotic-assisted Kidney Transplantation: Breaking the Limit of Atheromatic Plaques

Background: Robotic-assisted kidney transplantation (RAKT) has shown solid results as a minimally invasive alternative to the standard open approach (open kidney transplantation [OKT]). However, RAKT is still limited in those cases where the recipient's iliac vessels present atherosclerotic plaques, frequently found in elder patients and in those subjected to long-term hemodialysis. Unlike OKT, where the surgeon can palpate the arterial plaques, in minimally invasive surgery the haptic feedback is missing, making the vascular clamping and arteriotomy unsafe. Objective: To employ three-dimensional (3D) imaging reconstruction using augmented reality (AR) to intraoperatively locate the plaques during the crucial steps of kidney transplantation. Design, setting, and participants: Our study was conducted according to the Idea, Development, Exploration, Assessment, and Long-term follow-up (IDEAL) model for surgical innovation. Three-dimensional virtual models were obtained from high-accuracy computed tomography scan imaging and superimposed on the vessels during RAKT using the Da Vinci console software. Surgical procedure: Three-dimensional AR-guided robotic-assisted kidney transplantation. Measurements: The correspondence of virtual models with the real anatomy of patients was assessed comparing vessels' and plaques' measures. Results and limitations: We tested the possibility of using the AR in the setting of vas-cular surgery by checking the correspondence of the virtual models to the real vessels. During the accuracy assessment, we investigated the anatomy of the iliac plaques and the capacity of the virtual models to correctly represent them. Finally, we tested the effi-cacy of the virtual model superimposition on the real vessels with plaques during RAKT in the recipients of living donor grafts. The main limitation consists in training needed to correctly superimpose virtual models on the real field. Conclusions: The employment of 3D AR allowed surgeons to overcome one of the main limitations of RAKT, setting the foundation to expand its indications to patients with advanced atheromatic vascular disease. Patient summary: The use of three-dimensional augmented reality guidance during kidney transplantation (KT) has the potential to "navigate'' the surgeon during KT, allowing a safer procedure in patients with atheromatic vascular disease. (c) 2022 European Association of Urology. Published by Elsevier B.V. All rights reserved.