Development of robotic assisted kidney transplantation in the situation of deceased donor

Robotic-assisted kidney transplantation allows some patients (particularly obese recipients) to undergo kidney transplantation, whereas they would be contraindicated for kidney transplantation by conventional open approach. Nonetheless, in the context of deceased donors, RAKT is still controversial and underutilised due to specific logistical challenges, while this type of donor represents the majority throughout the world. [14,15] 

RAKT are only performed by surgeons with extensive experience in robotic and kidney transplantation surgeries. Unlike living donor kidney transplantation, which are performed as a part of elective surgery, kidney transplantations from deceased donor are performed in an emergency situation. Thus, in order to perform RAKT from deceased donors, both surgeons and robotic platforms have to be available.

In this specific frail population, expanding the indications for RAKT to deceased donors is of the utmost importance, to not deprive recipients without living donor of the benefits of minimally invasive surgery.

Recently, the ERUS-RAKT group reported the outcomes of deceased donor - RAKT performed in the centres involved. A decision-making strategy regarding selection of robotic vs open surgical approach for kidney transplantation was implemented. A total of 67 patients underwent deceased donor – RAKT. Most donors were donors after brain death (81%) and 39% were “expanded-criteria” donors. The median cold ischemia time was 14.8 hours. The median operative time and the median rewarming time were 220 min and 50 minutes, respectively. 

Major postoperative surgical complications (Clavien-Dindo ≥3) occurred in eleven patients (16%). Eighteen patients (27%) experienced delayed graft function. At a median follow-up of 27.1 months, graft survival was 92.6% and patient survival was 97.0%. The last median eGFR was 55.0 ml/min/1.73m2.

The outcomes of this series confirms that RAKT from deceased donors is feasible and safe at experienced centres, providing a viable way of expanding transplantation access to patients with ESKD. Notwithstanding the logistical barriers for DD-RAKT, careful recipient selection and organ matching are key factors to achieve the best perioperative and functional outcomes.

• Dr. Prudhomme is an Associate Member of the EAU Transplantation Section, Member of the EAU-YAU Kidney Transplantation Working Group, and works at the Department of Urology, Kidney Transplantation and Andrology, Toulouse University Hospital in France.

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