Robot-assisted kidney transplantation using right- vs. left-sided grafts from living donors: a prospective multicenter study from the ERUS-RAKT working group.

Background: Kidney transplantation using right-sided graft (RSG) is technically challenging and may be associated with increased risk of complications and/or suboptimal graft function. Our study aims to compare perioperative and functional outcomes of robot-assisted kidney transplantation (RAKT) using RSG vs. left-sided graft (LSG).

Methods: The multi-institutional, prospectively collected EAU Robotic Urology Section (ERUS)-RAKT database was queried to select consecutive patients undergoing RAKT from living donors between 7/2015 and 11/2023. Intraoperative outcomes and early (30 days) postoperative complications and functional results were the main study end-points. Dialysis-free survival was explored as a secondary outcome.

Results: Overall, 624 RAKTs were included, of which 526 (84%) using LSGs and 98 (16%) using RSGs. Preoperative characteristics did not significantly differ between the RSG and LSG groups. The median console time did not differ between the two groups while the use of RSGs was associated with a longer median rewarming time (46 vs. 43 min). No difference in intraoperative adverse events and postoperative high-grade complications between the two groups were reported (4% vs. 5.4%, P=0.4). At multivariable analysis, kidney side did not predict high-grade complications; the only significant factor predicting this outcome was the Centre's experience in RAKT (measured by the case number). RAKT achieved similar dialysis-free survival rates using LSGs and RSGs.

Conclusions: In experienced centers, RAKT using RSG from living donors is safe and achieves favorable perioperative and mid-term functional outcomes. While larger studies with longer follow-up are needed to confirm our findings, our study can influence the practice of living donor nephrectomy if RAKT is available.