Robot-assisted versus open kidney transplantation in patients who previously underwent an open kidney transplant

The safety of robot-assisted kidney transplantation (RAKT) in patients with end-stage renal disease (ESRD) who underwent an open kidney transplantation (OKT) in the past is unknown. We tested the hypothesis that intraoperative and postoperative complication rates are similar between RAKT and OKT in this patient population.

This was a multicenter retrospective cohort study including 78 patients with ESRD who received RAKT or OKT from living donor between 2015 and 2023 in 7 European academic centers. All patients had received an OKT in the past. The primary outcome was to assess perioperative safety in terms of intra- and postoperative complications, described using the Clavien-Dindo classification. Secondary outcomes included dialysis-free survival (DFS), surgical reintervention-free survival (RFS) and renal function at discharge. Kaplan Meier estimates and log-rank test were used to compare DFS and RFS according to the surgical approach.

Among 78 patients who previously underwent OKT, 29 (37%) patients subsequently underwent RAKT and 49 (63%) OKT. Patients' baseline characteristics were comparable between groups. The site of transplantation was the left iliac fossa in 24 (83%) and 30 (61%) patients undergoing RAKT and OKT, respectively (p = 0.07). Cold ischemia time was shorter in the RAKT group (60 vs. 114 min, p = 0.005), as was total vascular anastomosis time (33 vs. 38 min, p = 0.01). Estimated blood loss, rewarming time and intraoperative complications were similar in both groups. Early and late postoperative complications were similar in RAKT and OKT (respectively: 17% vs. 33%, p = 0.1; and 14% vs. 10%, p = 0.7). Over a median follow-up of 42 (IQR: 20-74) months, DFS was similar between RAKT and OKT, whereas RFS was higher in the RAKT group (100% vs. 84%, p = 0.02). Main limitations are represented by patient selection and the small sample size.

In selected patients undergoing kidney re-transplantation after a previous OKT, RAKT appears to be technically feasible and provides perioperative outcomes comparable to the open approach. In this challenging surgical setting, RAKT may represent a valuable option in experienced centres.