Introducing robot-assisted kidney transplantation in a high-volume centre in Denmark: a pilot and feasibility study

Abstract

Robot-assisted kidney transplantation (RAKT) may reduce surgical complications compared to open kidney transplantation (OKT), but no randomised trials have explored this to date. The aim of the present study is to explore the feasibility of introducing RAKT at our institution, making it available in deceased donor transplantation and evaluate early surgical outcomes prior to performing a randomised trial comparing RAKT to OKT. RAKT was performed at Department of Urology, Copenhagen University Hospital, Rigshospitalet, Denmark. The patients were included from June 2022 until May 2023. The data were collected through the national electronic health records. The data include recipient, donor and intraoperative characteristics, postoperative complications within 90 days graded according to Clavien-Dindo classification and days alive and out of hospital (DAOH). The functional outcomes include eGFR, plasma creatinine, delayed graft function, and rejection episodes. Sixteen RAKTs were performed. Fourteen cases were transplantations with living donors and two cases were with deceased donors. There were no major intra-operative adverse events and no conversions. The median operative time was 223 min and median blood loss 150 ml. The median length of stay was 7 days and median DAOH was 82. Seven complications occurred in five patients at 90 days postoperatively; however, there were no major surgical complications. This study comprehensively assesses patient morbidity following RAKT in a small cohort with results indicating favourable outcomes. This supported our clinical assumption of reduced complications for a randomised trial comparing OKT and RAKT (the ORAKTx trial) which has been initiated (NCT identifier 05730257).

Keywords: Kidney failure; Robotic surgery; Surgical complications; Transplantation; Urology.

Fig. 1

Flowchart of the logistical strategy for deceased donor RAKT. The flowchart was developed based on experiences in the present study and inspired by Vignolini et al. [9]. Once the alert for a kidney offer is made to the department the first step (TEAM) is to determine whether the RAKT surgical team can be assembled. The second step (OPERATING ROOM) is to check whether there are any robotic procedures planned during the expected time of transplantation and if so, evaluate if the surgical schedule can be rearranged to free the robotic operating room. The third step (RECIPIENT) is to evaluate if the recipient is eligible for RAKT with the three clinical criteria highlighted. Previous multiple and extensive abdominal surgery may prohibit laparoscopic access to the abdominal cavity and placement of the graft in the iliac fossa, comorbidities may contraindicate the required Trendelenburg position and severe atherosclerosis at the external iliac vessels may contraindicate robotic suturing and clamping. The final step (GRAFT) is for the surgeon to evaluate if the graft vascular anatomy allows for RAKT, with highly complex vascular anatomy requiring multiple anastomoses being a potential exclusion criterion. CT computed tomography, OR operating room, RAKT robot-assisted kidney transplantation