Robotic-Assisted vs Open Kidney Transplantation: A Propensity Matched Analysis

Robotic-Assisted vs Open Kidney Transplantation: A Propensity Matched Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Robotic-Assisted vs Open Kidney Transplantation: A Propensity Matched Analysis Harshdeep Singh, Siddharth Yadav, Anup Kumar, TK Aravind, Avishek Mandal, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6708855/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract BACKGROUND Kidney transplantation, the primary treatment for ESRD, has evolved since 1956. This study evaluates the clinical outcomes of robotic-assisted kidney transplantation (RAKT) and open kidney transplantation (OKT), highlighting RAKT's benefits in magnification, ergonomics, and early recovery, especially in obese patients. MATERIAL AND METHODS A retrospective analysis using propensity score matching was performed on a cohort of 15 patients who received live donor robotic-assisted kidney transplants from February 2019 to April 2024, with same number of patients receiving OKT during the same period. Demographic data, ischemia and operative times, recovery, post-operative creatinine trends, and 1-month complications were recorded. Chi-square, Mann–Whitney U tests and independent t-tests were employed for data analysis based on variable type and distribution. RESULTS In a study of 30 patients (15 RAKT and 15 OKT), both groups had similar demographics and intraoperative parameters. Serum creatinine levels at 3 and 6 months showed no significant differences (p = 0.483 and 0.081). RAKT had longer rewarming times (74.60 vs 66 minutes, p = 0.01) but lower blood loss (150 vs 256.66 ml, p = 0.0004). RAKT patients ambulated (2 vs 2.46 days, p = 0.01) and passed flatus (2.8 vs 3.6 days, p = 0.03) earlier but had longer drain (7.26 vs 5.66 days, p = 0.006) and catheter removal times (9.46 vs 7.33 days, p = 0.025). OKT patients had lower tacrolimus levels (11.22 vs 6.42 µg/L, p = 0.01). Most complications were minor. CONCLUSION This propensity-matched analysis shows that both RAKT and OKT are effective and safe. However, RAKT is associated with certain advantages, including lower intraoperative blood loss, earlier postoperative mobilization, and quicker return of bowel function. Further large-scale studies are warranted to validate the generalizability of these outcomes. Robotic Open Transplantation Propensity Figures Figure 1 Figure 2 BACKGROUND Kidney transplantation (KTP) remains the most effective therapeutic option available for individuals with end stage renal disease (ESRD) [ 1 ]. The operative techniques for KTP have been continuously improving since its inception in 1956 [ 2 ]. This has resulted in significant decline in mortality and morbidity with improved overall outcomes [ 3 ]. Despite being a traditional set standard, the open kidney transplantation (OKT) has been linked to higher post-operative pain scores and greater incidence of wound related complications, with subsequent delayed recovery leading to an evolving interest towards minimally invasive modalities in renal transplantation. This interest was further kindled with the first laparoscopic donor nephrectomy being performed in a 40-year-old male in 1995 [ 4 ]. With evolution of robotic technology in early 2000s and popularity of the Da Vinci surgical system, robotics made its first impression in the field of kidney transplantation in 2002 by Hoznek et al. in France [ 5 ]. Robotics became an ideal foil in the search for minimal invasion as it brought into play various distinct technical advantages such as enhanced magnifications and better ergonomics. Hence as expected, these advantages translated to improved clinical outcomes like shorter hospital stay, lesser wound complications and earlier patient recovery [ 6 ]. We conducted a propensity matched analysis of live Robot Assisted Kidney Transplant (RAKT) vs OKT at our centre with the goal of assessing safety and medium-term efficacy of the procedure. MATERIALS AND METHODS This retrospective propensity matched comparative study analyses patients who underwent RAKT (live donor) between February 2019 and April 2024. The control group was selected from patients who received OKT at our institute during the same period, with approval of institutional ethics committee. All 15 patients who underwent RAKT as the initial experience of our center were included and controls, of the patients who underwent OKT in the same time frame were selected after propensity matching to balance the demographic and preoperative parameters (Recipients age, gender, body mass index (BMI), donor age, gender, estimated glomerular filtration rate (eGFR) and the side of donor kidney to ensure a fair comparison. The study included only patients with end-stage renal disease who underwent live donor kidney transplantation. The exclusion criteria comprised of deceased donor transplantation, non-naive recipients, patients on peritoneal dialysis, those receiving multiple vessel kidneys and those with autosomal dominant polycystic kidney disease. Both the recipients (Routine baseline blood Investigations, Immunological tests, Ultrasonography of Urinary system with Colour Doppler of Iliac vessels and Micturating Cystourethrogram) and the donors (Routine Blood Investigations, Ultrasound of Urinary system, Immunological Tests, Computed Tomography Angiography of renal vasculature and Radionuclide renal scintigraphy) were evaluated as per the standard transplant workup protocol. All the enrolled donors underwent renal donation by laparoscopic nephrectomy under general anaesthesia by different transplant urologist working in the department. The Da Vinci Xi system was used to perform RAKT, with a procedural description of important surgical steps depicted in Fig. 1 . Controls were selected after propensity matching as per protocol for the demographic and preoperative parameters enumerated previously. The collected data was then analysed for the primary (serum creatinine levels at 3rd and 6th month postoperatively) and secondary outcomes (intraoperative and post operative parameters including cold ischemia time, warm ischemia time, re-warming time, total ischemia duration, estimated blood loss, need for perioperative transfusions, time to ambulation, time to passing flatus, day of drain tube and per urethral catheter removal, length of stay, Tacrolimus blood levels with time, nadir creatinine with time) in addition to the documentation of complications as per the Clavien Dindo scale [ 7 ]). All measured parameters or documented events were strictly made in accordance to the current standard definitions. Post transplant follow-up was conducted for a minimum of 6-months and all the patients, irrespective of the approach, were maintained with immunosuppressive therapy consisting of prednisolone, tacrolimus and mycophenolate mofetil as per the institutional nephrology team practice. Figure 2 depicts flow of the study protocol. STATISTICAL ANALYSIS Propensity matching was performed using the XL stat method. Data were recorded in a Microsoft Excel worksheet, and statistical analyses were performed using IBM SPSS Statistics version 25.0. Associations between categorical variables were assessed using the Chi-square test. For continuous variables, the independent samples t-test was applied when data followed a normal distribution, while the Mann–Whitney U test was used for non-normally distributed data. A p-value of less than 0.05 was considered statistically significant. RESULTS Salient pre-treatment baseline demographic data are depicted in table 1(a) while table 1(b) provides the post-operative data of both the groups. Baseline characteristics were comparable across all parameters, except for preoperative hemoglobin, which showed a statistically significant difference between the groups (p = 0.0005). Post-treatment analysis showed that the primary outcome measures—serum creatinine levels at the 3rd and 6th postoperative months—were comparable between the two groups (p = 0.483 and 0.081, respectively). The rewarming time (p = 0.014) and estimated blood loss (p = 0.0004)were significantly inferior in the RAKT and OKT groups respectively.When considering the post-operative parameters, RAKT fared better in terms of time to ambulation (2.46 ± 0.63 vs. 2 ± 0, p = 0.010) and time to passage of flatus (3.6 ± 1.05 vs. 2.8 ± 0.67, p = 0.030) when compared to the OKT group. On the other hand, the drain (5.66 ± 3.01 vs. 7.26 ± 2.12, p = 0.006) and per urethral catheter (7.33 ± 1.83 vs. 9.46 ± 2.38, p = 0.025) removal duration was longer in the RAKT group. Complications observed in both arms of the study were largely minor with the exceptions of a few as depicted in table 1(b) , the most notable of which was one patient developing sepsis in the RAKT arm. DISCUSSION The advent of robotic surgery provided patients with an attractive and feasible option of minimally invasive techniques in transplant medicine with possible superiority in both the patient recovery as well as surgeon comfort. The possible combination of excellent ergonomics, earlier patient recovery and comparable if not better intraoperative outcomes in certain domains justify the extra research limelight on the robotic renal transplants in recent times. In the current study, RAKT had comparable intraoperative outcomes with the traditional OKT with the exception of the amount of estimated blood loss being lower in the robotic arm (256.66 ± 88.37 vs. 150 ± 75.59, p = 0.0004). The rewarming time was, as expected, higher in the RAKT arm (66 ± 9.03 vs. 74.60 ± 14.90, p = 0.014) considering its technical nuances. The RAKT group demonstrated quicker time to ambulation (2.46 ± 0.63 vs. 2 ± 0, p = 0.010) and faster passage of flatus (3.6 ± 1.05 vs. 2.8 ± 0.67, p = 0.030) compared to the OKT group. However, drain removal (5.66 ± 3.01 vs. 7.26 ± 2.12, p = 0.006) and catheter removal times (7.33 ± 1.83 vs. 9.46 ± 2.38, p = 0.025) were longer in the RAKT group. Overall, most complications were minor, with one notable case of sepsis in the RAKT arm. The total operative time (316.66 ± 18.77 vs. 303.33 ± 29.19, p = 0.250), warm (4.33 ± 0.89 vs. 4.06 ± 1.03, p = 0.670) and cold ischemia times (33.53 ± 9.14 vs. 31.93 ± 6.70, p = 0.858) were comparable in both groups of patients. However, rewarming time was significantly longer in RAKT patients by around 8 minutes (66 ± 9.03 vs.74.60 ± 14.90, p = 0.014) in comparison to the open group with the difference being statistically significant. Probable reasons to account for the time difference may have been the time spent in manipulation of graft kidney into position, application of vascular clamps and time taken to close the Pfannenstiel incision to regenerate the pneumoperitoneum. Our findings corroborated to the similar published studies on the subjects with authors citing identical reasons for their time difference [8, 10-11]. Table 2(a) briefly depicts the observed rewarming times in published studies on the subject in comparison with the current study. Estimated Blood loss between both the groups was noted to be higher in the open group in comparison to the robotic group (256.66 ± 88.37 vs. 150 ± 75.59p = 0.0004) as naturally expected considering certain attributes of the open procedure like invasiveness and reduced operative space leading to anastomotic difficulties and consequently increased losses during the same. Despite blood losses ranging from 150 – 250ml in both the groups, these losses did not translate to the need for blood transfusions in most of the cases of both the groups (0.73 ± 1.48 vs.0.2 ± 0.56, p = 0.153). Our findings were also in line with the similar published medical literature on the subject [8, 13]. Table 2(b) briefly depicts the observed estimated blood loss in published studies on the subject in comparison with the current study. When comparing notable postoperative parameters, time to ambulation (2.46 ± 0.63 vs. 2 ± 0, p = 0.010) and time to first passing flatus (3.6 ± 1.05 vs. 2.8 ± 0.67, p = 0.030) were observed to be shorter in the robotic arm with the difference being statistically significant. The above observation was expected considering the robotic transplant to be a minimally invasive intervention thereby culminating in reduced incision lengths, lesser pain scores and earlier physiological recovery post-surgery. All the factors mentioned formerly seem to provide logic explanations to our observations. Interestingly, as opposed to most published studies on the subject revealing earlier drain removal in the robotic arms [8, 13], our study depicted quite the opposite (5.66 ± 3.01 vs. 7.26 ± 2.12, p =0.006). The major reason attributed for earlier drain removal in robotic transplants was the intraperitoneal approach favouring lymph absorption and reduced incidence of lymphocele formation. Our results representing paradoxical delayed drain removal times and per urethral catheter removal times (7.33 ± 1.83 vs. 9.46 ± 2.38, p = 0.025) probably would be attributed to surgeon apprehension considering our robotic experience to be evolving and we were in the initial learning curve of our experience. Moreover, many patients had Table 2(c) briefly depicts the observed drain removal duration in published studies on the subject in comparison with the current study. When comparing other post operative parameters like length of hospital stay, post operative haemoglobin reduction and nadir creatinine trends upto 6 months, both arms were similar in our study. The above-mentioned similarity can be attributed to good operating surgeon experience, technical stability and decent donor selection yielding optimal outcomes. Identical length of stay observed between both groups can be attributed to factors like relative early experience in RAKT and surgeon discretion on patient’s discharges. These factors are attributed especially in the light of low complication rates in both arms of the study (Table 1b). In present study, Tacrolimus levels at day 3 were significantly higher in the robotic arm in comparison to the open arm (6.42 ± 3.36 vs. 11.22 ± 6.71, p = 0.010). This finding can be attributed to the intraperitoneal nature of robotic transplant along with contact of bowel with the hypothermic solution infused graft kidney probably, leading to altered bowel function causing modifications in tacrolimus absorption kinetics. Similar results of significant difference between both groups were observed for day 2 Tacrolimus level by Maheshwari et al. as well (11.38 ± 6.93 vs. 17.98 ± 14.41, p = 0.001) [9]. We wish to observe outcomes in a larger transplant patient population in the future to confirm this postulation and derive conclusions on the same. A majority of complications in both the arms of the study were minor (Clavien-Dindo IIIa or less) with serious complications noted in a minority (3 in OKT group and1 in the RAKT group). All the minor complications were managed expectantly. The differences in the complication rate could have arisen as a result of small sample size and propensity matching of the RAKT cases with OKT cases where coincidentally higher number of complication cases got included in our study population secondary to our approach of matching baseline characteristics of the patients. Considering our limited study population, we would like to observe data on a larger patient population in the future to arrive at a conclusion on the complications rates, observe unique complications in both management modalities and standardise treatment protocols on management of the same. Our study is one of the few ones comparing RAKT and OKT which are performed during same period. The use of propensity score matching to balance covariates and reduce confounding has enhanced validity of our findings by creating comparable groups, leading to more reliable estimation of measured parameters. However, our study has notable limitations. A key limitation is its retrospective nature, along with being restricted to a single-center experience and involving a limited number of patients. To improve the quality of evidence and address these limitations, a large-scale, multi-institutional, prospective randomized trial would be ideal. Furthermore, the 6-month follow-up period for all patients may be brief; a longer follow-up could provide more comprehensive insights into the long-term outcomes of RAKT. Owing to relatively early experience in robotic transplants, our data on domains such as drain removal, per-urethral catheter removal times and hospital stay duration may not reflect the worldwide trend in more experienced centres. We aim to study the same with a greater patient population in the near futures as our experience widens with time. CONCLUSIONS Robot assisted kidney transplants are non-inferior when compared to the traditional open renal transplants especially considering similarity in the functional outcomes and complications with the added advantages of minimal invasion such as lower blood loss, earlier ambulation and quicker recovery of bowel function. Our experience on robotic transplants is relatively limited and evolving, thereby limiting our inferences to universal application. We wish to address the above short coming with future studies with larger patient population. Abbreviations Body mass index (BMI) Cold ischemia time (CIT) Delayed graft function (DGF) Estimated blood loss (EBL) Estimated glomerular filtration rate (eGFR) Expanded polytetrafluoroethylene (ePTFE) Kidney transplantation (KTP) Open kidney transplantation (OKT) Robotic assisted kidney transplantation (RAKT) Total ischemia time (TIT) Warm ischemia time (WIT) Declarations Ethics approval and consent to participate: This is an observational study. The Institutional Research Ethics Committee has confirmed that no ethical approval is required. Consent for publication: Yes Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Author Contribution All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Harshdeep Singh, Siddharth Yadav and Anup Kumar. The first draft of the manuscript was written by Harshdeep Singh and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Data Availability The datasets used and analysed during the current study are available from the corresponding author on reasonable request. References Collins AJ, Foley RN, Chavers B, Gilbertson D, Herzog C, Johansen K et al. United States renal data system 2011 annual data report: atlas of chronic kidney disease & end-stage renal disease in the United States. Am J Kidney Dis 2012; 59 Suppl 1: A7, e1-420. Harrison JH, Merrill JP, Murray JE. Renal homotransplantation in identical twins. Surg Forum 1956; 6: 432–60. Schulz KH, Thaiss F. Long-term outcome with end-stage renal disease - survival is not enough: does dialysis or kidney transplantation matter?. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2012; 55: 543–51. Ratner LE, Ciseck LJ, Moore RG, Cigarroa FG, Kaufman HS, Kavoussi LR. Laparoscopic live donor nephrectomy. Transplantation. 1995 Nov 15;60(9):1047-9. A. Hoznek, S. K. Zaki, D. B. Samadi et al., “Robotic assisted kidney transplantation: an initial experience,” Journal of Urology, vol. 167, no. 4, pp. 1604-6, 2002. Patil A, Ganpule A, Singh A, Agrawal A, Patel P, Shete N, Sabnis R, Desai M. Robot-assisted versus conventional open kidney transplantation: a propensity matched comparison with median follow-up of 5 years. Am J Clin Exp Urol. 2023 Apr 15;11(2):168-176. Dindo D, Demartines N, Clavien PA. Classification of surgicalcomplications: a new proposal with evaluation in a cohort of 6336patients and results of a survey. Ann Surg 2004; 240: 205–13. Tuğcu V, Şener NC, Şahin S, Yavuzsan AH, Akbay FG, Apaydın S. Robot-assisted kidney transplantation: comparison of the first 40 cases of open vs robot-assisted transplantations by a single surgeon. BJU Int. 2018 Feb;121(2):275-280. Kishore TA, Kuriakose MJ, Pathrose G, Raveendran V, Kumar KV, Unni VN. Robotic assisted kidney transplantation in grafts with multiple vessels: single center experience. Int Urol Nephrol . 2020;52(2):247-252. Maheshwari R, Qadri SY, Rakhul LR, Chaturvedi S, Desai P, Grover R, Chhabra G, Khullar D, Kumar A. Prospective Nonrandomized Comparison Between Open and Robot-Assisted Kidney Transplantation: Analysis of Midterm Functional Outcomes. J Endourol. 2020 Sep;34(9):939-945. Pein U, Girndt M, Markau S, Fritz A, Breda A, Stöckle M, Mohammed N, Kawan F, Schumann A, Fornara P, Weigand K. Minimally invasive robotic versus conventional open living donor kidney transplantation. World J Urol. 2020 Mar;38(3):795-802. Tinney F, Ivanics T, Stracke J, Malinzak L, Elsabbagh AM, McEvoy T et al. Robotic-assisted Versus Open Technique for Living Donor Kidney Transplantation: A Comparison Using Propensity Score Matching for Intention to Treat. Transplant Direct. 2022;8(5):e1320 Karadag S, Eksi M, Ozdemir O, et al. Comparison of Open and Robot-Assisted Kidney Transplantation in terms of Perioperative and Postoperative Outcomes. Int J Clin Pract . 2022;2022:2663108. Tables Tables 1 and 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files TABLES.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6708855","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":462149654,"identity":"062361a3-10dc-4732-9745-0b4866b59ec5","order_by":0,"name":"Harshdeep Singh","email":"","orcid":"","institution":"Vardhaman Mahavir Medical College and Safdarjung Hospital","correspondingAuthor":false,"prefix":"","firstName":"Harshdeep","middleName":"","lastName":"Singh","suffix":""},{"id":462149655,"identity":"d417a010-9df6-4bf9-a92d-ffceea227bbd","order_by":1,"name":"Siddharth 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external iliac vein with robotic bulldog clamps\u003c/p\u003e\n\u003cp\u003eC – Linear venotomy made along the anterior border of the external iliac vein\u003c/p\u003e\n\u003cp\u003eD – End to side venous anastamosis in continuous fashion done using gore-tex sutures (CV 6’0 sutures)\u003c/p\u003e\n\u003cp\u003eE – Clamping rearrangement done with robotic clamps applied to the renal vein of the transplant kidney and external iliac artery clamping\u003c/p\u003e\n\u003cp\u003eF – Linear arteriotomy on the anterior border of the external iliac artery\u003c/p\u003e\n\u003cp\u003eG – End to side arterial anastamosis in continuous fashion done using gore-tex sutures (CV 6’0 sutures)\u003c/p\u003e\n\u003cp\u003eH – Ureteroneocystostomy created using modified lischgregoir technique with Vicryl 4-0 sutures and 6Fr x 16cm DJS as splint.\u003c/p\u003e\n\u003cp\u003eKey: a – \u0026nbsp;\u0026nbsp;External iliac artery, v – External iliac vein, b – Urinary bladder, U – \u0026nbsp;\u0026nbsp;ureter, * - Bulldog clamps.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6708855/v1/62c9a5779c4581307a837f72.jpg"},{"id":83607563,"identity":"3a735fa0-6f4e-4fae-8e5b-56a823fc2efa","added_by":"auto","created_at":"2025-05-29 11:18:45","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":81521,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart depicting study protocol process.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6708855/v1/654b61435a2c2c84a242e99c.jpg"},{"id":94987244,"identity":"432c4f57-76a4-4fa5-af76-98b2efce41cb","added_by":"auto","created_at":"2025-11-03 07:01:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":631637,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6708855/v1/8086f65f-15b6-4ce6-8e00-b75b5215eadb.pdf"},{"id":83607561,"identity":"ec6615b9-33d7-4611-af55-e1e12c828d4d","added_by":"auto","created_at":"2025-05-29 11:18:45","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":23387,"visible":true,"origin":"","legend":"","description":"","filename":"TABLES.docx","url":"https://assets-eu.researchsquare.com/files/rs-6708855/v1/39982cb2f0ecbefbb655f3e4.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Robotic-Assisted vs Open Kidney Transplantation: A Propensity Matched Analysis","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eKidney transplantation (KTP) remains the most effective therapeutic option available for individuals with end stage renal disease (ESRD) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The operative techniques for KTP have been continuously improving since its inception in 1956 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This has resulted in significant decline in mortality and morbidity with improved overall outcomes [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Despite being a traditional set standard, the open kidney transplantation (OKT) has been linked to higher post-operative pain scores and greater incidence of wound related complications, with subsequent delayed recovery leading to an evolving interest towards minimally invasive modalities in renal transplantation. This interest was further kindled with the first laparoscopic donor nephrectomy being performed in a 40-year-old male in 1995 [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. With evolution of robotic technology in early 2000s and popularity of the Da Vinci surgical system, robotics made its first impression in the field of kidney transplantation in 2002 by Hoznek et al. in France [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Robotics became an ideal foil in the search for minimal invasion as it brought into play various distinct technical advantages such as enhanced magnifications and better ergonomics. Hence as expected, these advantages translated to improved clinical outcomes like shorter hospital stay, lesser wound complications and earlier patient recovery [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. We conducted a propensity matched analysis of live Robot Assisted Kidney Transplant (RAKT) vs OKT at our centre with the goal of assessing safety and medium-term efficacy of the procedure.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003eThis retrospective propensity matched comparative study analyses patients who underwent RAKT (live donor) between February 2019 and April 2024. The control group was selected from patients who received OKT at our institute during the same period, with approval of institutional ethics committee. All 15 patients who underwent RAKT as the initial experience of our center were included and controls, of the patients who underwent OKT in the same time frame were selected after propensity matching to balance the demographic and preoperative parameters (Recipients age, gender, body mass index (BMI), donor age, gender, estimated glomerular filtration rate (eGFR) and the side of donor kidney to ensure a fair comparison. The study included only patients with end-stage renal disease who underwent live donor kidney transplantation. The exclusion criteria comprised of deceased donor transplantation, non-naive recipients, patients on peritoneal dialysis, those receiving multiple vessel kidneys and those with autosomal dominant polycystic kidney disease. Both the recipients (Routine baseline blood Investigations, Immunological tests, Ultrasonography of Urinary system with Colour Doppler of Iliac vessels and Micturating Cystourethrogram) and the donors (Routine Blood Investigations, Ultrasound of Urinary system, Immunological Tests, Computed Tomography Angiography of renal vasculature and Radionuclide renal scintigraphy) were evaluated as per the standard transplant workup protocol. All the enrolled donors underwent renal donation by laparoscopic nephrectomy under general anaesthesia by different transplant urologist working in the department. The Da Vinci Xi system was used to perform RAKT, with a procedural description of important surgical steps depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Controls were selected after propensity matching as per protocol for the demographic and preoperative parameters enumerated previously. The collected data was then analysed for the primary (serum creatinine levels at 3rd and 6th month postoperatively) and secondary outcomes (intraoperative and post operative parameters including cold ischemia time, warm ischemia time, re-warming time, total ischemia duration, estimated blood loss, need for perioperative transfusions, time to ambulation, time to passing flatus, day of drain tube and per urethral catheter removal, length of stay, Tacrolimus blood levels with time, nadir creatinine with time) in addition to the documentation of complications as per the Clavien Dindo scale [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]). All measured parameters or documented events were strictly made in accordance to the current standard definitions. Post transplant follow-up was conducted for a minimum of 6-months and all the patients, irrespective of the approach, were maintained with immunosuppressive therapy consisting of prednisolone, tacrolimus and mycophenolate mofetil as per the institutional nephrology team practice. Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e depicts flow of the study protocol.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSTATISTICAL ANALYSIS\u003c/h2\u003e \u003cp\u003ePropensity matching was performed using the XL stat method. Data were recorded in a Microsoft Excel worksheet, and statistical analyses were performed using IBM SPSS Statistics version 25.0. Associations between categorical variables were assessed using the Chi-square test. For continuous variables, the independent samples t-test was applied when data followed a normal distribution, while the Mann\u0026ndash;Whitney U test was used for non-normally distributed data. A p-value of less than 0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eSalient pre-treatment baseline demographic data are depicted in \u003cstrong\u003etable 1(a)\u003c/strong\u003e while \u003cstrong\u003etable 1(b)\u003c/strong\u003e provides the post-operative data of both the groups. Baseline characteristics were comparable across all parameters, except for preoperative hemoglobin, which showed a statistically significant difference between the groups\u0026nbsp;(p = 0.0005).\u0026nbsp;Post-treatment analysis showed that the primary outcome measures—serum creatinine levels at the 3rd and 6th postoperative months—were comparable between the two groups (p = 0.483 and 0.081, respectively).\u0026nbsp;The rewarming time (p = 0.014) and estimated blood loss (p = 0.0004)were significantly inferior in the RAKT and OKT groups respectively.When considering the post-operative parameters, RAKT fared better in terms of time to ambulation (2.46 ± 0.63 vs. 2 ± 0, p = 0.010) and time to passage of flatus (3.6 ± 1.05 vs. 2.8 ± 0.67, p = 0.030) when compared to the OKT group. On the other hand, the drain (5.66 ± 3.01 vs. 7.26 ± 2.12, p = 0.006) and per urethral catheter (7.33 ± 1.83 vs. 9.46 ± 2.38, p = 0.025) removal duration was longer in the RAKT group. Complications observed in both arms of the study were largely minor with the exceptions of a few as depicted in \u003cstrong\u003etable 1(b)\u003c/strong\u003e, the most notable of which was one patient developing sepsis in the RAKT arm.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe advent of robotic surgery provided patients with an attractive and feasible option of minimally invasive techniques in transplant medicine with possible superiority in both the patient recovery as well as surgeon comfort.\u0026nbsp;The possible combination of excellent ergonomics, earlier patient recovery and comparable if not better intraoperative outcomes in certain domains justify the extra research limelight on the robotic renal transplants in recent times.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the current study, RAKT had comparable intraoperative outcomes with the traditional OKT with the exception of the amount of estimated blood loss being lower in the robotic arm (256.66 ± 88.37 vs. 150 ± 75.59, p = 0.0004). The rewarming time was, as expected, higher in the RAKT arm (66 ± 9.03 vs. 74.60 ± 14.90, p = 0.014) considering its technical nuances. The RAKT group demonstrated quicker time to ambulation (2.46 ± 0.63 vs. 2 ± 0, p = 0.010) and faster passage of flatus (3.6 ± 1.05 vs. 2.8 ± 0.67, p = 0.030) compared to the OKT group. However, drain removal (5.66 ± 3.01 vs. 7.26 ± 2.12, p = 0.006) and catheter removal times (7.33 ± 1.83 vs. 9.46 ± 2.38, p = 0.025) were longer in the RAKT group. Overall, most complications were minor, with one notable case of sepsis in the RAKT arm.\u003c/p\u003e\n\u003cp\u003eThe total operative time (316.66 ± 18.77 vs. 303.33 ± 29.19, p = 0.250), warm (4.33 ± 0.89 vs. 4.06 ± 1.03, p = 0.670)\u0026nbsp;and cold ischemia times (33.53 ± 9.14 vs. 31.93 ± 6.70, p = 0.858) were comparable in both groups of patients. However, rewarming time was significantly longer in RAKT patients by around 8 minutes (66 ± 9.03 vs.74.60 ± 14.90, p = 0.014)\u0026nbsp;in comparison to the open group with the difference being statistically significant. Probable reasons to account for the time difference may have been the time spent in manipulation of graft kidney into position, application of vascular clamps and time taken to close the Pfannenstiel incision to regenerate the pneumoperitoneum. Our findings corroborated to the similar published studies on the subjects with authors citing identical reasons for their time difference [8, 10-11]. \u003cstrong\u003eTable 2(a)\u003c/strong\u003e briefly depicts the observed rewarming times in published studies on the subject in comparison with the current study.\u003c/p\u003e\n\u003cp\u003eEstimated Blood loss between both the groups was noted to be higher in the open group in comparison to the robotic group (256.66 ± 88.37 vs. 150 ± 75.59p = 0.0004)\u0026nbsp;as naturally expected considering certain attributes of the open procedure like invasiveness and reduced operative space leading to anastomotic difficulties and consequently increased losses during the same. Despite blood losses ranging from 150 – 250ml in both the groups, these losses did not translate to the need for blood transfusions in most of the cases of both the groups (0.73 ± 1.48 vs.0.2 ± 0.56, p = 0.153). Our findings were also in line with the similar published medical literature on the subject [8, 13]. \u003cstrong\u003eTable 2(b)\u003c/strong\u003e briefly depicts the observed estimated blood loss in published studies on the subject in comparison with the current study.\u003c/p\u003e\n\u003cp\u003eWhen comparing notable postoperative parameters, time to ambulation (2.46 ± 0.63 vs. 2 ± 0, p = 0.010) and time to first passing flatus (3.6 ± 1.05 vs. 2.8 ± 0.67, p = 0.030) were observed to be shorter in the robotic arm with the difference being statistically significant. The above observation was expected considering the robotic transplant to be a minimally invasive intervention thereby culminating in reduced incision lengths, lesser pain scores and earlier physiological recovery post-surgery. All the factors mentioned formerly seem to provide logic explanations to our observations.\u003c/p\u003e\n\u003cp\u003eInterestingly, as opposed to most published studies on the subject revealing earlier drain removal in the robotic arms [8, 13], our study depicted quite the opposite (5.66 ± 3.01 vs. 7.26 ± 2.12, p =0.006). The major reason attributed for earlier drain removal in robotic transplants was the intraperitoneal approach favouring lymph absorption and reduced incidence of lymphocele formation. Our results representing paradoxical delayed drain removal times and per urethral catheter removal times (7.33 ± 1.83 vs. 9.46 ± 2.38, p = 0.025) probably would be attributed to surgeon apprehension considering our robotic experience to be evolving and we were in the initial learning curve of our experience. Moreover, many patients had \u003cstrong\u003eTable 2(c)\u003c/strong\u003e briefly depicts the observed drain removal duration in published studies on the subject in comparison with the current study.\u003c/p\u003e\n\u003cp\u003eWhen comparing other post operative parameters like length of hospital stay, post operative haemoglobin reduction and nadir creatinine trends upto 6 months, both arms were similar in our study. The above-mentioned similarity can be attributed to good operating surgeon experience, technical stability and decent donor selection yielding optimal outcomes. Identical length of stay observed between both groups can be attributed to factors like relative early experience in RAKT and surgeon discretion on patient’s discharges. These factors are attributed especially in the light of low complication rates in both arms of the study \u003cstrong\u003e(Table 1b).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn present study, Tacrolimus levels at day 3 were significantly higher in the robotic arm in comparison to the open arm (6.42 ± 3.36 vs. 11.22 ± 6.71, p = 0.010). This finding can be attributed to the intraperitoneal nature of robotic transplant along with contact of bowel with the hypothermic solution infused graft kidney\u0026nbsp;probably, leading to altered bowel function causing modifications in tacrolimus absorption kinetics. Similar results of significant difference between both groups were observed for day 2 Tacrolimus level by Maheshwari et al. as well (11.38 ± 6.93 vs. 17.98 ± 14.41, p = 0.001)\u0026nbsp;[9]. We wish to observe outcomes in a larger transplant patient population in the future to confirm this postulation and derive conclusions on the same.\u003c/p\u003e\n\u003cp\u003eA majority of complications in both the arms of the study were minor (Clavien-Dindo IIIa or less) with serious complications noted in a minority (3 in OKT group and1 in the RAKT group). All the minor complications were managed expectantly. The differences in the complication rate could have arisen as a result of small sample size and propensity matching of the RAKT cases with OKT cases where coincidentally higher number of complication cases got included in our study population secondary to our approach of matching baseline characteristics of the patients. Considering our limited study population, we would like to observe data on a larger patient population in the future to arrive at a conclusion on the complications rates, observe unique complications in both management modalities and standardise treatment protocols on management of the same.\u003c/p\u003e\n\u003cp\u003eOur study is one of the few ones comparing RAKT and OKT which are performed during same period. The use of propensity score matching to balance covariates and reduce confounding has enhanced validity of our findings by creating comparable groups, leading to more reliable estimation of measured parameters. However, our study has notable limitations. A key limitation is its retrospective nature, along with being restricted to a single-center experience and involving a limited number of patients. To improve the quality of evidence and address these limitations, a large-scale, multi-institutional, prospective randomized trial would be ideal. Furthermore, the 6-month follow-up period for all patients may be brief; a longer follow-up could provide more comprehensive insights into the long-term outcomes of RAKT. Owing to relatively early experience in robotic transplants, our data on domains such as drain removal, per-urethral catheter removal times and hospital stay duration may not reflect the worldwide trend in more experienced centres. We aim to study the same with a greater patient population in the near futures as our experience widens with time.\u0026nbsp;\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eRobot assisted kidney transplants are non-inferior when compared to the traditional open renal transplants especially considering similarity in the functional outcomes and complications with the added advantages of minimal invasion such as lower blood loss, earlier ambulation and quicker recovery of bowel function. Our experience on robotic transplants is relatively limited and evolving, thereby limiting our inferences to universal application. We wish to address the above short coming with future studies with larger patient population.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBody mass index (BMI)\u003c/p\u003e\n\u003cp\u003eCold ischemia time (CIT)\u003c/p\u003e\n\u003cp\u003eDelayed graft function (DGF)\u003c/p\u003e\n\u003cp\u003eEstimated blood loss (EBL)\u003c/p\u003e\n\u003cp\u003eEstimated glomerular filtration rate (eGFR)\u003c/p\u003e\n\u003cp\u003eExpanded polytetrafluoroethylene (ePTFE)\u003c/p\u003e\n\u003cp\u003eKidney transplantation (KTP)\u003c/p\u003e\n\u003cp\u003eOpen kidney transplantation (OKT)\u003c/p\u003e\n\u003cp\u003eRobotic assisted kidney transplantation (RAKT)\u003c/p\u003e\n\u003cp\u003eTotal ischemia time (TIT)\u003c/p\u003e\n\u003cp\u003eWarm ischemia time (WIT)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e \u003cp\u003eThis is an observational study. The Institutional Research Ethics Committee has confirmed that no ethical approval is required.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication:\u003c/strong\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Harshdeep Singh, Siddharth Yadav and Anup Kumar. The first draft of the manuscript was written by Harshdeep Singh and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCollins AJ, Foley RN, Chavers B, Gilbertson D, Herzog C, Johansen K et al. United States renal data system 2011 annual data report: atlas of chronic kidney disease \u0026amp; end-stage renal disease in the United States. Am J Kidney Dis 2012; 59 Suppl 1: A7, e1-420.\u003c/li\u003e\n\u003cli\u003eHarrison JH, Merrill JP, Murray JE. Renal homotransplantation in identical twins. Surg Forum 1956; 6: 432\u0026ndash;60.\u003c/li\u003e\n\u003cli\u003eSchulz KH, Thaiss F. Long-term outcome with end-stage renal disease - survival is not enough: does dialysis or kidney transplantation matter?. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2012; 55: 543\u0026ndash;51.\u003c/li\u003e\n\u003cli\u003eRatner LE, Ciseck LJ, Moore RG, Cigarroa FG, Kaufman HS, Kavoussi LR. Laparoscopic live donor nephrectomy. Transplantation. 1995 Nov 15;60(9):1047-9. \u003c/li\u003e\n\u003cli\u003eA. Hoznek, S. K. Zaki, D. B. Samadi et al., \u0026ldquo;Robotic assisted kidney transplantation: an initial experience,\u0026rdquo; Journal of Urology, vol. 167, no. 4, pp. 1604-6, 2002.\u003c/li\u003e\n\u003cli\u003ePatil A, Ganpule A, Singh A, Agrawal A, Patel P, Shete N, Sabnis R, Desai M. Robot-assisted versus conventional open kidney transplantation: a propensity matched comparison with median follow-up of 5 years. Am J Clin Exp Urol. 2023 Apr 15;11(2):168-176.\u003c/li\u003e\n\u003cli\u003eDindo D, Demartines N, Clavien PA. Classification of surgicalcomplications: a new proposal with evaluation in a cohort of 6336patients and results of a survey. Ann Surg 2004; 240: 205\u0026ndash;13.\u003c/li\u003e\n\u003cli\u003eTuğcu V, Şener NC, Şahin S, Yavuzsan AH, Akbay FG, Apaydın S. Robot-assisted kidney transplantation: comparison of the first 40 cases of open vs robot-assisted transplantations by a single surgeon. BJU Int. 2018 Feb;121(2):275-280.\u003c/li\u003e\n\u003cli\u003eKishore TA, Kuriakose MJ, Pathrose G, Raveendran V, Kumar KV, Unni VN. Robotic assisted kidney transplantation in grafts with multiple vessels: single center experience. \u003cem\u003eInt Urol Nephrol\u003c/em\u003e. 2020;52(2):247-252.\u003c/li\u003e\n\u003cli\u003eMaheshwari R, Qadri SY, Rakhul LR, Chaturvedi S, Desai P, Grover R, Chhabra G, Khullar D, Kumar A. Prospective Nonrandomized Comparison Between Open and Robot-Assisted Kidney Transplantation: Analysis of Midterm Functional Outcomes. J Endourol. 2020 Sep;34(9):939-945.\u003c/li\u003e\n\u003cli\u003ePein U, Girndt M, Markau S, Fritz A, Breda A, St\u0026ouml;ckle M, Mohammed N, Kawan F, Schumann A, Fornara P, Weigand K. Minimally invasive robotic versus conventional open living donor kidney transplantation. World J Urol. 2020 Mar;38(3):795-802. \u003c/li\u003e\n\u003cli\u003eTinney F, Ivanics T, Stracke J, Malinzak L, Elsabbagh AM, McEvoy T et al. Robotic-assisted Versus Open Technique for Living Donor Kidney Transplantation: A Comparison Using Propensity Score Matching for Intention to Treat. Transplant Direct. 2022;8(5):e1320\u003c/li\u003e\n\u003cli\u003eKaradag S, Eksi M, Ozdemir O, et al. Comparison of Open and Robot-Assisted Kidney Transplantation in terms of Perioperative and Postoperative Outcomes. \u003cem\u003eInt J Clin Pract\u003c/em\u003e. 2022;2022:2663108.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Robotic, Open, Transplantation, Propensity","lastPublishedDoi":"10.21203/rs.3.rs-6708855/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6708855/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBACKGROUND\u003c/b\u003e\u003c/p\u003e \u003cp\u003eKidney transplantation, the primary treatment for ESRD, has evolved since 1956. This study evaluates the clinical outcomes of robotic-assisted kidney transplantation (RAKT) and open kidney transplantation (OKT), highlighting RAKT's benefits in magnification, ergonomics, and early recovery, especially in obese patients.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMATERIAL AND METHODS\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA retrospective analysis using propensity score matching was performed on a cohort of 15 patients who received live donor robotic-assisted kidney transplants from February 2019 to April 2024, with same number of patients receiving OKT during the same period. Demographic data, ischemia and operative times, recovery, post-operative creatinine trends, and 1-month complications were recorded. Chi-square, Mann\u0026ndash;Whitney U tests and independent t-tests were employed for data analysis based on variable type and distribution.\u003c/p\u003e\u003cp\u003e\u003cb\u003eRESULTS\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIn a study of 30 patients (15 RAKT and 15 OKT), both groups had similar demographics and intraoperative parameters. Serum creatinine levels at 3 and 6 months showed no significant differences (p\u0026thinsp;=\u0026thinsp;0.483 and 0.081). RAKT had longer rewarming times (74.60 vs 66 minutes, p\u0026thinsp;=\u0026thinsp;0.01) but lower blood loss (150 vs 256.66 ml, p\u0026thinsp;=\u0026thinsp;0.0004). RAKT patients ambulated (2 vs 2.46 days, p\u0026thinsp;=\u0026thinsp;0.01) and passed flatus (2.8 vs 3.6 days, p\u0026thinsp;=\u0026thinsp;0.03) earlier but had longer drain (7.26 vs 5.66 days, p\u0026thinsp;=\u0026thinsp;0.006) and catheter removal times (9.46 vs 7.33 days, p\u0026thinsp;=\u0026thinsp;0.025). OKT patients had lower tacrolimus levels (11.22 vs 6.42 \u0026micro;g/L, p\u0026thinsp;=\u0026thinsp;0.01). Most complications were minor.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCONCLUSION\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis propensity-matched analysis shows that both RAKT and OKT are effective and safe. However, RAKT is associated with certain advantages, including lower intraoperative blood loss, earlier postoperative mobilization, and quicker return of bowel function. Further large-scale studies are warranted to validate the generalizability of these outcomes.\u003c/p\u003e","manuscriptTitle":"Robotic-Assisted vs Open Kidney Transplantation: A Propensity Matched Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-29 11:10:40","doi":"10.21203/rs.3.rs-6708855/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"67a792d6-d7db-4ba3-bc48-9f38b477814e","owner":[],"postedDate":"May 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-01T10:23:42+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-29 11:10:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6708855","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6708855","identity":"rs-6708855","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}