Back again in Chicago, the AUA2023 included some exciting transplantation research presented by institutions from all over the globe. A few important themes were evident across the plenary, podium, moderated poster, and video abstract sessions—improving our ability to evaluate graft quality, improving graft and patient outcomes, and innovation and novel surgical techniques.

An interesting, first-in-human trial examining the use of photoacoustic imaging technology to assess renal graft quality was presented by Dr Alex Koven from the University of Toronto (PD31-04). They demonstrated that this novel imaging modality was able to quantify graft fibrosis, oxygenation, and blood flow. They found that the photoacoustic collagen score correlated very well with degree of tissue fibrosis seen on histopathology from biopsies taken preimplant—for both living and deceased donor grafts (r = 0.85). The group is currently correlating photoacoustic scores with short- and intermediate-term graft function, and if this promising diagnostic technology can provide surgeons predictive, preimplantation information about graft quality, it may become a valuable clinical tool.

We now know that the historical teaching that “opioids, when taken for postoperative pain, are not addictive” is absolutely false. Given the opioid crisis we have witnessed in recent years, we should continue to strive to reduce postoperative opioid use while minimizing patient morbidity. To this end, Dr Michael Gross from the Cleveland Clinic presented outcomes of a randomized, double-blinded trial examining the benefits of transversus abdominus plane (TAP) bupivacaine nerve blocks on pain after kidney transplantation (PD31-01). They randomized 128 open kidney transplant recipients and, similar to other recent trials, demonstrated TAP blocks decreased postoperative pain and opioid use over placebo. However, most interesting were the outcomes among the subgroup of recipients who had an anterior rectus sheath (ARS) incision. Almost 50% (20/41) of the recipients who had an ARS incision+TAP block required no opioids during their hospital stay. Even among the ARS+placebo group, 16.3% (7/43) did not require any opioids postoperatively.

Ureteral strictures in kidney transplant recipients, though relatively uncommon, can be difficult to manage and have been associated with poor graft outcomes. There is still much debate in the literature about the merits of endourological management for these transplant patients, and in particular which patients should go straight to open reimplantation and which might benefit from a minimally invasive approach. Dr Alejandra Bravo from Fundacio Puigvert presented a multicenter retrospective study examining all kidney transplant recipients with ureteral strictures managed primarily endoscopically between 2009 and 2021 (PD31-03). Not surprisingly, they found that shorter strictures presenting <3 months postoperatively had the highest success rate. What was unique about this study was that they also examined the morphology of the ureteral strictures and found that those that had a tapered or “duckbill” appearance had significantly lower risk of failing endoscopic management (RR 0.39, P = .04) compared to strictures with a flat, concave morphology (see Figure). These data suggest that based on antegrade/retrograde imaging studies, clinicians may be able to better counsel patients on recommended treatment options for these stricture patients.

Figure. Ureteral stricture radiologic morphology associated with endoscopic management success rate (PD31-03).

The plenary session involved a vibrant debate between current Urologic Society for Transplantation & Renal Surgery (USTRS) President Dr Jeffrey Veale and incoming President Dr Alberto Breda. Audience members heard the merits, advantages, and limitations of the robotic-assisted kidney transplantation (RAKT) technique compared to the traditional open surgical approach. While there was no clear winner between friends, momentum continues to build for this minimally invasive approach to kidney transplantation. Supplementing this ongoing debate, the group from University of California Irvine presented their recent systematic review and meta-analysis comparing RAKT to open kidney transplantation (PD31-02). They found that RAKT was associated with less postoperative pain, fewer blood transfusions, and fewer overall complications—driven largely by fewer surgical site complications. And despite significantly longer operating room times, ischemic times, and rewarming times for RAKT, they found no significant differences in delayed graft function, rejection rates, and 1-year and 3-year graft and recipient survival. So while kidney transplantation may not yet go the way of open radical prostatectomy, RAKT seems to be at minimum a safe option when performed at centers of excellence in carefully selected patients.

The annual USTRS meeting was again held during the Annual AUA Meeting with a robust agenda including a debate on laparoscopic vs robotic donor nephrectomy, a review of the state of kidney transplantation training, and an interesting talk on immune tolerance in kidney transplantation. The inaugural USTRS Kapoor Lecture, presented by Dr Nima Nassiri, was an exciting review of the early experiences with bladder autotransplantation in porcine, cadaveric, and brain-dead, heart-beating research donors at the University of Southern California. They demonstrated technical feasibility, and Dr Indy Gill and his team are moving toward the first-in-human clinical trial of bladder transplantation. Truly exciting times ahead.

The Kapoor Lecture was established by the USTRS in honor of 2-time former USTRS president Dr Anil Kapoor, who passed away earlier this year. He was a friend, colleague, and collaborator to many in the transplant community, having contributed much to both the kidney transplant and kidney cancer literature. He was taken from us far too early and will be missed but not forgotten.