Establishing a Robot-Assisted Kidney Transplant Program: Independent Evaluation of the Learning Curve and Surgical...

Robot-assisted kidney transplantation (RAKT) is a technically challenging procedure and there has been limited reporting of its learning curve (LC), mostly by a single surgical working group. The aim of the current study was to perform an independent analysis of LC and describe our modifications in the technique of RAKT. All consecutive cases performed at our center from April 2016 to March 2020 were reviewed. LC was analyzed by using the cumulative summation method for total anastomosis time (technical outcome) and serum creatinine at days 7 and 30 (functional outcome). Patient safety was assessed by using Shewhart control charts, and a comparison of safety outcomes before and after achieving LC was done by using Chi-square or Fischer exact test as appropriate. A descriptive review of technical modifications made during our experience was conducted. Ninety patients underwent robot-assisted renal transplant during the study period. LC was crossed at 24 cases (total anastomosis time) and 15 to 25 cases (serum creatinine). Shewhart control charts showed that total anastomosis time remained below alert/alarm line in 94.4%/98.9% cases, with the alert line being crossed a significantly greater number of times before the LC. Serum creatinine values remained below alert/alarm line in 85.5%/90% cases at day 7 and 92.2%/96.7% cases at day 30, with no difference made due to LC. Key technical modifications included arterial and ureteric spatulation at bench, use of polypropylene 5 to 0 holding stitch in graft vessels to facilitate intraoperative handling, keeping anterior arterial wall smaller to visualize posterior arterial wall anastomosis, and leaving a small amount of fatty tissue on the supero-lateral surface of the kidney for handling after jacket removal. Our LC of RAKT was crossed at 24 cases (technical outcome) and 15 to 25 cases (functional outcome). We have also detailed valuable technical modifications in the procedure.