Introduction & Objectives: Robot-assisted kidney transplantation (RAKT) has been increasingly adopted in the treatment of kidney failure, as a robotic approach may even further reduce morbidity. However, there is a paucity of literature addressing its application in pediatric patients. Pediatric RAKT presents unique challenges to both the surgical and anesthesia teams, largely due to the distinctive anatomical and physiological characteristics of this population. Despite these complexities, early evidence indicates that pediatric RAKT is safe and feasible, with excellent graft function outcomes when performed by an experienced team. We present the largest European series of pediatric RAKT, including a video emphasizing surgical technique, troubleshooting in case of arterial embolism, and key differences from the well-studied adult population.
Materials & Methods: Between August 2017 and June 2024, 10 pediatric patients (8-17 years old) underwent RAKT at a single European reference center. All surgeries were performed using the Da Vinci Xi® system by 2 expert transplant surgeons. Special attention was given to individualized port placement based on patient characteristics. Low-pressure pneumoperitoneum (8 mmHg) was used in all cases. All donor kidneys were obtained from living related adult donors in an adjacent operating room, also using a robotic approach. Arterial anastomosis was performed using the external iliac artery (80%) or common iliac artery (20%); venous anastomosis using the external iliac vein (60%) or common iliac vein (40%). Descriptive statistics were used to report outcomes.
Results: All surgeries were completed successfully. In 2 cases, robotic arterial embolectomy was performed during the same surgery with peroperative resolution and excellent graft outcome. No other intra-operative complications occurred. Short-term (<90 days) complications included 2 patients with urinary tract infection (UTI), resolved with antibiotics (Clavien-Dindo 2), and 1 patient with long QT syndrome and anemia (Clavien-Dindo 2). Acute cellular rejection was observed in 1 patient at 1 month and resolved with pulse corticoid therapy. With the exception of 1 patient with UTI (Clavien-Dindo 2), no long term complications were observed at a median follow-up of 20 (IQR 7-64) months. Median pre- and postoperative (3 month) glomerular filtration rate (GFR) values were 8.8 (IQR 6.8-10.7) mL/min and 70.3 (61.8-80.5) mL/min, respectively. Median follow-up GFR was 75.6 (IQR 68.4-90.6) mL/min at 1 year (n=7) and 77.1 (IQR 53.9-107.4) mL/min at 2 years (n=6). No patients received subsequent therapy for graft failure or kidney function deterioration.
Conclusions: Notwithstanding significant differences from the adult population, pediatric RAKT is safe and feasible when performed in expert hands and by an experienced multidisciplinary team. It allows for adequate kidney function outcomes while utilizing minimally invasive methods to the maximal extent possible.