Mixed reality imaging in the preoperative planning of high-risk pediatric renal transplants: proof of concept case report

Abstract

Background: Pediatric renal transplants can be technically challenging because of disparity in the recipient vessels and body cavity, and the adult donor vessels and organ mass respectively. Innovative technologies utilizing spatial reconstruction may be beneficial in preoperative planning for these patients. We present a case where three-dimensional (3D) reconstruction, and a mixed reality system were employed in preoperative planning as proof of concept. Methods: The recipient is an 18-year-old male patient with end-stage renal failure from Alport syndrome and steroid-resistant nephrotic syndrome. His small and slender stature (36.7 kg, 161.3 cm) and severe thoracoabdominal scoliosis (Cobb angle of >60°) raised concerns of potential limitations in space for retroperitoneal implantation and challenges in alignment with potentially tortuous and size-matched iliac vessels for vascular anastomoses. A computed tomography scan was hence performed for preoperative planning. The donor's (the mother) computed tomography scan of the kidneys was superimposed with that of the recipient utilizing Synapse 3D (Fujifilm Holdings America Corp.). Real-time holographic visualization was also accomplished utilizing HoloLens 2 (Microsoft Corp.). Results: Preoperative visualization of the 3D images and video confirmed that there was sufficient domain for a retroperitoneal implantation and planning of vascular anastomoses to the right common iliac artery and vein which were respectively 6 to 7 mm and 10 mm in caliber and relatively straight at the proposed site of anastomoses. The renal transplants proceeded as planned with a warm ischemic time of 44 minutes. There was brisk urine output on-table and preserved vascular patency and satisfactory waveforms on postoperative doppler ultrasound. Serum creatinine normalized by postoperative day 4. Conclusions: A combination of modern technologies (3D reconstruction and HoloLens2) are useful adjuncts in preoperative planning and performance of high-risk pediatric renal transplants. This technology may be also considered in the training, education, and intraoperative assistance of young pediatric renal transplant surgeons.