While robot-assisted kidney transplantation (RAKT) from living donors has been shown to achieve favourable outcomes, there is a lack of evidence on the safety and efficacy of RAKT as compared with the gold standard open kidney transplantation (OKT) in the setting of deceased donors, who represent the source of most grafts worldwide.
To compare the intraoperative, perioperative, and midterm outcomes of RAKT versus OKT from donors after brain death (DBDs).
Data from consecutive patients undergoing RAKT or OKT from DBDs at a single academic centre between October 2017 and December 2020 were prospectively collected.
The primary outcomes were intraoperative adverse events, postoperative surgical complications, delayed graft function (DGF), and midterm functional outcomes. A multivariable logistic regression analysis assessed the independent predictors of DGF, trifecta, and suboptimal graft function (estimated glomerular filtration rate [eGFR] 45 ml/min/1.73 m) at the last follow-up.
Overall, 138 patients were included (117 [84.7%] OKTs and 21 [15.3%] RAKTs). The yearly proportion of RAKT ranged between 10% and 18% during the study period. The OKT and RAKT cohorts were comparable regarding all graft-related characteristics, while they differed regarding a few donor- and recipient-related factors. The median second warm ischaemic time, ureterovesical anastomosis time, postoperative complication rate, and eGFR trajectories did not differ significantly between the groups. A higher proportion of patients undergoing OKT experienced DGF; yet, at a median follow-up of 31 mo (interquartile range 19–44), there was no difference between the groups regarding the dialysis-free and overall survival. At the multivariable analysis, donor- and/or recipient-related factors, but not the surgical approach, were independent predictors of DGF, trifecta, and suboptimal graft function at the last follow-up. The study is limited by its nonrandomised nature and the small sample size.
Our study provides preliminary evidence supporting the noninferiority of RAKT from DBDs as compared with the gold standard OKT in carefully selected recipients.
Kidney transplantation using kidneys from deceased donors is still being performed with an open surgical approach in most transplant centres worldwide. In fact, no study has compared the outcomes of open and minimally invasive (robotic) kidney transplantation from deceased donors. In this study, we evaluated whether robotic kidney transplantation using grafts from deceased donors was not inferior to open kidney transplantation regarding the intraoperative, postoperative, and midterm functional outcomes. We found that, in experienced hands and provided that there was a time-efficient organisation of the transplantation pathway, robotic kidney transplantation from deceased donors was feasible and achieved noninferior outcomes as compared with open kidney transplantation.
Open kidney transplantation (OKT) is the gold standard treatment for patients with end-stage renal disease, providing better survival and quality of life as compared with dialysis .
Elective robot-assisted kidney transplantation (RAKT) from living donors has been shown to achieve favourable outcomes  and to have the potential to minimise surgical morbidity as compared with OKT . Nonetheless, RAKT is still controversial and underutilised in the setting of deceased donors, who represent the most frequent source of grafts in most countries worldwide .
While being more demanding for transplant teams from both technical and logistical standpoints , expanding the indications for RAKT to deceased donors is an unmet clinical need: a higher number of fragile and immunocompromised recipients could indeed benefit from minimally invasive surgery. In this regard, the feasibility and preliminary outcomes of RAKT from deceased donors has previously been reported by our group . However, to date, there is a lack of evidence on the comparative effectiveness of RAKT versus OKT in this context.
To fill this gap, we sought to compare the intraoperative, perioperative, and midterm functional outcomes of RAKT versus OKT from donors after brain death (DBDs) over a 4-yr period.
After ethical committee approval, data from consecutive patients undergoing RAKT or OKT from DBDs at our centre between October 2017 and December 2020 were prospectively collected in our institutional database. A comprehensive overview of the steps required to develop our RAKT programme is reported in previous publications . Patients who underwent RAKT or OKT from living donors or from donors after circulatory death were excluded from this study ().
DBDs were considered “expanded criteria donors” (ECDs) if they were aged >60 or 50–59 yr with two of the following features: history of hypertension, terminal serum creatinine ≥1.5 mg/dl, or death resulting from a cerebrovascular accident .
The Berlin initiative study: the methodology of exploring kidney function in the elderly by combining a longitudinal and cross-sectional approach.
The Chronic Kidney Disease Epidemiology Collaboration formula was used to calculate estimated glomerular filtration rate (eGFR) in patients aged 70 yr , while the Berlin Initiative Study formula was used for patients aged ≥70 yr .
Cold ischaemia time (CIT) was defined as the time of cold storage, while second warm ischaemic time (SWIT) as the time needed during the construction of vascular anastomoses until revascularisation. For RAKT, SWIT (also defined as “rewarming time” ) was defined as the time between graft insertion in the abdominal cavity and revascularisation.
Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.
Intraoperative complications were reported according to the Intraoperative Adverse Incident Classification (EAUiaiC) by the European Association of Urology (EAU) ad hoc Complications Guidelines Panel , while postoperative surgical complications were according to both the modified Clavien-Dindo system  and the Comprehensive Complication Index .
Delayed graft function (DGF) was defined as the need of dialysis in the first postoperative week . Trifecta was defined as the contemporary achievement of the following outcomes: (1) no DGF, (2) no major (Clavien-Dindo grade ≥3) postoperative surgical complications, (3) eGFR ≥30 ml/min/1.73 m at hospital discharge.
All recipients underwent computed tomography angiogram to assess their vascular anatomy and the potential presence of atherosclerotic plaques of iliac vessels.
Preoperative evaluation of donors, postoperative management of recipients, and follow-up after RAKT/OKT were performed by our multidisciplinary transplant team according to established guidelines and our institutional protocol .
Flowchart showing the decision-making strategy regarding selection of the open versus robotic surgical approach for kidney transplantation from donors after brain death (DBDs) at our centre. Once the kidney offer has been received, the kidney has been evaluated for its suitability for transplantation by the Regional Transplant Authority (RTA; Centro Regionale Allocazione Organi e Tessuti [CRAOT]), and selection of the potential recipient has been finalised, specific criteria must be met to perform robot-assisted kidney transplantation (RAKT). If one or more criteria are not respected, then open kidney transplantation (OKT) is performed. In particular, there must be no recipient-related contraindications for RAKT (currently represented by recipient age