# Robot-assisted Kidney Transplantation from Deceased Donor: The European Experience

## TL;DR

Robot-assisted kidney transplants from deceased donors are safe and effective, offering a viable option for patients with end-stage kidney disease.

## Contribution

The study reports outcomes of deceased donor robotic-assisted kidney transplantation across seven European centers, highlighting its feasibility and safety.

## Key findings

- DD-RAKT is feasible and safe at experienced centers, with a graft survival rate of 92.6%.
- Major postoperative complications occurred in 16% of patients, and 27% experienced delayed graft function.
- Recipient selection and organ matching are key to achieving optimal outcomes in DD-RAKT.

## Abstract

In the context of deceased donors, robotic-assisted kidney transplantation presents satisfactory results and provides a viable way of expanding transplantation access to patients with end-stage renal disease considered at risk of open kidney transplantation. A careful selection of potential recipients is of utmost importance.

In the context of deceased donors (DDs), robotic-assisted kidney transplantation (RAKT) is underutilized due to specific logistical and technical challenges. The aim of this study was to report the outcomes of DD-RAKT performed in centers involved in the European Association of Urology Robotic Urology Section (ERUS)-RAKT working group.

This retrospective analysis is based on a prospectively collected multicenter database including data on DD-RAKT performed at seven referral ERUS-RAKT European centers from July 2015 to April 2024. Intraoperative, perioperative, and midterm functional outcomes after DD-RAKT were assessed. The decision-making strategy regarding the selection of a robotic versus an open surgical approach for kidney transplantation was also reported across the included centers.

A total of 67 patients with a median age of 36 yr (interquartile range [IQR]: 24–58) underwent DD-RAKT. Most donors were donors after brain death (80.6%), followed by donors after uncontrolled circulatory death (10.4%); there were 26 “expanded criteria” donors (39%). The median cold ischemia time was 14.8 h (IQR: 11.0–19.0). Eight patients (11.9%) had orthotopic DD-RAKT, while 59 patients (88.1%) had heterotopic DD-RAKT. The median operative time and the median rewarming time were 220 min (IQR: 180.0–252.0) and 50 min (IQR: 42–60), respectively. The major postoperative surgical complications (Clavien-Dindo ≥3) occurred in 11 patients (16%). Eighteen patients (27%) experienced delayed graft function. At a median follow-up of 27.1 mo (IQR: 9.5–59.4), graft survival rate was 92.6% and patient survival rate was 97.0%. The last median estimated glomerular filtration rate was 55.0 ml/min/1.73 m2 (IQR: 41.5–70.0). The main study limitations are its retrospective nature and the lack of a comparator group.

DD-RAKT is feasible and safe at experienced centers, providing a viable way of expanding transplantation access to patients with end-stage kidney disease. Notwithstanding the logistical barriers for DD-RAKT, careful recipient selection and organ matching are key factors to achieve the best perioperative and functional outcomes.

Robotic kidney transplantation using grafts from deceased donors is technically feasible and safe in well-selected recipients at experienced referral centers, showing favorable intra- and postoperative outcomes. While robotic kidney transplantation from deceased donors may be challenging to implement in clinical practice due to organizational and logistical barriers (which may vary across hospitals and countries), careful recipient selection is essential to ensure the best perioperative and functional outcomes.