Kidney transplantation (KT) is the gold standard treatment for patients with end-stage renal disease due to an established long-term survival benefit as compared to dialysis.¹ However, it is associated with a not trivial risk of perioperative morbidity, especially if considering that KT candidates are immunocompromised and frail patients at higher risk of developing postoperative sequelae.² Following the results achieved by minimally invasive surgery in other fields, the robot-assisted approach has been introduced in KT aiming at reducing perioperative morbidity while improving surgical outcomes. Since the first robot-assisted kidney transplantation (RAKT) was reported in 2002, the surgical technique has been refined and standardized over the years through an extensive collaboration of highly experienced centers and surgeons in robotic surgery and KT. In this regard, the Robotic Urology Section of the European Association of Urology Working Group has led to a constant growth of scientific evidence on surgical and functional outcomes of the procedure, improving its wider distribution in Europe.³

To date, RAKT showed comparable surgical (ie, rewarming time and time of vascular and ureteral anastomosis; see Figure) and functional outcomes to the open approach.⁴ Notably, several multicenter studies provided evidence regarding the optimal long-term functional outcomes of the graft after RAKT, and in a retrospective matched-pair analysis including 126 and 378 robotic and open KTs Ahlawat et al reported no statistically significant difference in terms of delayed graft function (0% vs 2.4%, P = .08), graft rejection (16.2% vs 18.6% at 36 months, P = .6), and graft (95.2% vs 96.3% at 36 months, P = .2) and overall survival (94.5% vs 98.1% at 36 months, P = .3) between the 2 procedures.^5,6 The robot-assisted approach has been also associated with several potential benefits as compared to the traditional open technique, including a lower rate of early and late postoperative complications, namely, wound infection, incisional hernia, and symptomatic lymphocele, as well as reduced postoperative pain.⁴ Furthermore, RAKT has been demonstrated to be effective in challenging cases such as obese patients in whom the open approach may also have a potentially detrimental effect. In particular, patients with a high BMI are those in whom the open approach may be strongly limited due to a restricted surgical field and technical difficulties in performing a safe and accurate vascular anastomosis as well as a higher predisposition to wound infection and incisional hernia. In such patients, RAKT showed no statistically significant differences in intra- and postoperative outcomes in patients with mild (25<BMI<30) or severe obesity (BMI ≥30) as compared to fit patients.⁷ Similarly, RAKT has been reported to be feasible in grafts with multiple vessels since no statistically significant difference emerged in terms of timing of vascular anastomosis, cold ischemia, and rewarming time as well as intra- and postoperative complications as compared to surgeries performed using grafts with single vessels.⁸

Figure. Surgical steps of robot-assisted kidney transplantation. A, End-to-side venous anastomosis between the renal vein and external iliac vein. B, End-to-side arterial anastomosis between the renal artery and external iliac artery. C, Lich-Gregoir ureteral reimplantation.

Although there is increasing evidence that RAKT is as effective as the open approach, it is still considered a promising technique to be offered only in elective cases. Furthermore, the limited use of RAKT in daily clinical practice worldwide is related to several potential drawbacks including the difficulty in managing RAKT from deceased donors, the problem of temperature control of the graft during the rewarming phase, the lack of haptic feedback that could be useful in patients with diffuse atherosclerotic plaques of the vessels, and finally the possible demanding learning curve as compared to the open approach. To fill these gaps, the Robotic Urology Section of the European Association of Urology Working Group recently provided evidence that broke such existing dogmas regarding the limits of the robotic approach in KT. RAKT from deceased donors is certainly demanding for transplant teams from both technical and logistical standpoints; however, expanding the indications of RAKT to such cases is an unmet clinical need since it represents the most frequent source of grafts worldwide. In this regard, a first scoping study and a subsequent prospective observational study also assessed the feasibility of the procedure in this setting, showing similar surgical and functional outcomes as compared to living donors.^9,10 Furthermore, with the aim to overcome the lack of regional hypothermia during RAKT as compared to the open approach where the kidney is usually kept below 20 °C during the procedure, to minimize the potential ischemic risk associated with the rewarming phase, novel systems of graft cooling have been implemented, leading to a constant temperature control of the graft.¹¹ Regarding the limitations of the robotic approach in manipulating vessels with diffuse atherosclerotic plaques and the inability to have tactile feedback during the procedure, the implementation of 3D augmented-reality tools has been proven to be effective to help the surgeon perform a safe vascular anastomosis, also reducing the risk of plaque rupture and thrombus spread.¹² Finally, to reduce the learning curve of the procedure, standardized curricula based on proficiency-based progression methodology may help novel adopters reach satisfactory outcomes, although after 35 cases it is possible to reach optimal surgical and functional outcomes, especially in well-trained robotic surgeons.¹³

In conclusion, although the open approach is still the standard of care in KT, RAKT is ready for prime time. A wider diffusion of experts on the technique and its implementation in deceased donors will allow us to reach more consistent results to clearly state which patient could benefit the most from robotic surgery also in KT.

Support: None.

Conflict of Interest: The Authors have no conflicts of interest to disclose.