Background: Kidney transplantation provides increased survival for patients with end-stage renal disease. Living donation (LD) is critical in increasing donor pool but more importantly improves kidney allograft survival and recipient quality of life.  However, barriers to LD lie with the burden of traditional donor recovery, open or laparoscopic. We report here a case series of 74 patients submitted to robotic-assisted donor nephrectomies and 20 robotic transplants.
Methods: Prospectively collected data of patients submitted to robotic-assisted left or right donor nephrectomies at the Miami Transplant Institute, from October 2021 to April 2023. Data relative to the pre-operative, intra-operative and post-operative periods: clinic-demographic characteristics of the patients, surgical metrics, and pathology findings noted. Continuous variables were analyzed with Student t-test, categorical variables were analyzed with chi-square test. A p-value of less than 0.05 was considered to be statistically significant.
Results: 33 of the 74 cases (44.6%) were male. Median age was 37 years old. Median BMI was 24.2 (IQR 22.7–28.2). 47 (63.5%) patients donated the kidney to a relative. Donor kidney anatomy consisted of a single artery, vein, and ureter in 57 (77%) of the cases. 17 cases had multiple arteries that were successfully reconstructed in the back table.  There were anatomical technical difficulties in 7 (9.5%) cases. Pfannenstiel incision was used in nearly 96% of cases. The median intra-operative robotic console time was 45 min. The median size of graft arteries was 4 (IQR 3.75-4) cm, graft vein was 5 (IQR 4–5.75) cm, and ureter was 15 cm. Robotic stapler devices were used in all cases. Foley catheter was removed in the operating room in 100% of the cases and median length of stay was less than 24 hours. Macroscopic procurement damage was appreciated in 1 (1.4%) case. There were 4 (5.4%) postoperative readmissions, 12 (16.2%) postoperative complications, and no surgical reinterventions. None of the patients had to be converted to laparoscopic or open operations. There were no statistically significant differences between groups analyzed. Graft function was immediate in 72 of the cases, but DGF was noted in 2 out of the 74 cases (2.7%): both of those were transplanted robotically. Out of the 72 cases, 18 were transplanted robotically and had immediate graft function.
Conclusion: Robotic-assisted donor nephrectomy is a safe procedure associated with a minor risk of complications, and excellent immediate graft function.  It should be the surgical approach of choice for living donors in transplant centers where robotic surgery is available to advance care and provide the best quality of treatment for these individuals.