Extraperitoneal Robot-Assisted Kidney Transplant: Initial Experience and Propensity-Matched Comparison with Transperitoneal RAKT

Abstract

Introduction and Objectives:

Traditionally, robot-assisted kidney transplant (RAKT) is performed using a transperitoneal approach, with patient in steep Trendelenburg position, leading to potential concerns for cardio-respiratory, bowel, and ocular complications. To circumvent these, we evaluated the feasibility, technical aspects, and outcomes of an extraperitoneal approach (EP-RAKT) and compared it with the transperitoneal approach (TP-RAKT).

Materials and Methods:

We reviewed our prospective database of patients who underwent RAKT with extraperitoneal approach between June 2023 and May 2024. This cohort was propensity matched in a 12 ratio with patients who underwent RAKT with transperitoneal approach for confounding variables (age, sex, BMI, graft kidney GFR, and graft number of vessels). Clinical parameters were recorded for all patients, including their demographic profile, radiological parameters, operative details and postoperative outcomes, and the cohorts were compared for intraoperative and postoperative outcomes.

Results:

During our study period, 10 patients underwent EP-RAKT and were propensity matched with 20 patients with similar characteristics who underwent TP-RAKT. The mean duration of postoperative ileus (1.3 vs. 2.9 days), mean drain output (131 vs. 786 mL), and mean postoperative pain score (Visual Analog Scale score 10.2 vs. 14.8) were shorter for the extraperitoneal when compared with transperitoneal approach. No statistical differences were observed between the two groups for blood loss, rewarm ischemia time, vascular anastomosis time, or graft function. Patients in EP-RAKT group had more consistent tacrolimus levels in the therapeutic range in early postoperative period. However, the mean total operative time (288 ± 35.2 vs. 240 ± 28.2 minutes) and the mean time spent in port placement and bed preparation (50.8 ± 8.4 vs. 28.3 ± 6.1 minutes) were longer in EP-RAKT vs TP-RAKT.

Conclusions:

EP-RAKT is a safe and feasible procedure, with similar graft function and reduced early postoperative complications compared with TP-RAKT, albeit with higher operative times.