Robot-assisted Versus Open Kidney Transplantation from Living Donor

Background and objective: Evidence comparing robot-assisted kidney transplantation (RAKT) with open kidney transplantation (OKT) from living donors in patients with end-stage kidney disease (ESKD) remains limited. We aimed to determine whether RAKT, compared with OKT, results in improved renal function at 1 mo after transplantation and whether it is associated with reduced perioperative complication rates and improved long-term outcomes, including dialysis-free, graft, reintervention-free, and overall survival. Methods: This is a multicenter retrospective study including patients with ESKD who received RAKT or OKT between June 2015 and December 2023 in seven European academic centers. Missing values of relevant baseline characteristics were estimated through multiple imputation of chained equations. Baseline patients' heterogeneity for age, sex, body mass index, American Society of Anesthesiologists score, Charlson comorbidity index, and preemptive status was balanced using 1:1 nearest neighbor propensity score matching, estimated using logistic regression without replacement. Uni- and multivariable logistic and Cox regression analyses for early postoperative complications and need for reintervention during follow-up, respectively, were performed based on clinical characteristics. Kaplan-Meier estimates and log-rank test were used to compare dialysis-free, graft, reintervention-free, and overall survival according to the surgical approach. Key findings and limitations: Overall, 733 patients were included. After propensity score matching, two cohorts of 306 patients each with similar baseline characteristics were obtained. The site of transplantation was the right iliac fossa in 240 (78%) and 204 (67%) patients undergoing OKT and RAKT, respectively. RAKT was associated with reduced total vascular anastomosis time (38 vs 32 min, p < 0.001), whereas OKT was associated with reduced surgical time (165 vs 209 min, p < 0.001) and rewarming time (38 vs 45 min, p < 0.001). Overall, early (<30 d) and Clavien-Dindo ≥3 postoperative complication rates were lower in the RAKT group (42% vs 29%, 37% vs 21%, and 12.7% vs 5%; p < 0.001). In the multivariable regression analysis, RAKT was predictive of a lower risk of both early postoperative complications (odds ratio 0.43, interquartile range [IQR]: 0.29-0.62, p < 0.001) and reintervention (hazard ratio 0.38, IQR: 0.22-0.66, p < 0.001), which was confirmed with the Kaplan-Meier estimates. Conclusions and clinical implications: In experienced centers and appropriately selected recipients, RAKT from a living donor can be adopted to reduce perioperative morbidity and reinterventions without compromising early renal function or long-term patient and graft survival. Further studies should define which subgroups benefit most from RAKT, and evaluate patient-reported outcomes and cost effectiveness.