EURURO Vol. 72 No. 2

218 320

Platinum Priority – Editorial
Referring to the article published on pp. 205–217 of this issue
Is Robotic Kidney Transplant the Near Future?
Antonio Alcaraz Lluis Peri, Laura Izquierdo, Mireia Musquera
Department of Urology. Hospital Clinic[3_TD$DIFF]-IDIBAPS. University of Barcelona, Barcelona, Spain
This issue of European Urology includes a systematic review
of minimally invasive, laparoscopic, and robotic-assisted
techniques versus open techniques for kidney transplant
recipients by Wagenaar et al
Our first remark on the topic is the scarce data found by
the authors, as well as the low quality of the studies
included in the systematic review. Thus, 18 studies were
found, among which only one was a randomised controlled
trial (RCT) but did not target the main question of the study
of whether laparoscopic kidney transplant (LKT)/robotic
kidney transplant (RKT) was superior to conventional open
kidney transplant (OKT); instead, whether the incision
length in OKT impacts on short and long-term outcomes
was assessed. Clearly, with this low level of evidence, a
meta-analysis was not feasible and therefore a systematic
review was performed, applying the most advanced and
precise methodology. Only weak conclusions have been
made owing to the limitation of the available data. First,
minimally invasive techniques showed promising results
with regard to complications and recovery, and they could
be considered for clinical use. Second, for open surgery,
which is clearly the standard, the smallest possible Gibson
incision appeared to yield the most favourable results.
which is a sensible conclusion. However, a couple of
remarks are warranted. A Gibson or Gibson-like incision
used to be the traditional open approach, understood as an
oblique incision from the symphysis in the midline and
curving in a lateral and superior direction to the iliac crest.
This incision, which splits the different muscle layers of the
abdominal wall in the direction of the fibres, has been
replaced in recent years by the pararectal hockey stick-
shaped incision to allow better exposure. However, it is
hampered by wall relaxation in one out of four patients and
incisional hernia in one out of six . As in many other
surgical procedures, the pressure on open surgeons because
of the arrival of minimally invasive techniques (LKT/RKT),
together with new data, like those reported by Wagenaar
et al, should make us return to a small Gibson-like incision.
We would like to concentrate on the main question: LKT/
RKT or OKT? The primary treatment in end-stage renal
disease is kidney transplant. Therefore, the most important
postoperative outcomes are graft and patient survival. Data
from the studies included in the meta-analysis were not
sufficient to answer the question, and they merely indicated
that these techniques are promising. In brief, LKT/RKT
should still be considered experimental.
The first question is whether use of minimally invasive
techniques in transplant surgery makes sense. The answer
is yes, for two reasons. First, it has been systematically
proven that laparoscopy, whether robot-assisted or not, is
less invasive than open surgery for any procedure in terms
of not only the biological inflammatory response but
also clinical outcomes, such less postoperative pain, early
recovery, and better cosmesis something that would
also apply to LKT/RKT in comparison to OKT. Second,
patients with end-stage renal disease who are candidates
for transplant are more frail than conventional patients who
usually undergo laparoscopic/robotic surgery. In addition,
such patients will require immunosuppressive induction
and postoperative treatment using, among others, mTOR
inhibitors and steroids that delay wound healing. In
summary, there is important room for improvement that
can be filled by LKT/RKT techniques.
Transplantation is a conservative area in terms of
introducing new techniques. It took 10 yr from the first
laparoscopic living donor nephrectomy in 1995 until its
recognition as a standard technique along with open
nephrectomy according to clinical guidelines Nowadays,
available at
journal homepage:
DOI of original article: .
* Corresponding author. Department of Urology. Hospital Clinic, University of Barcelona, Villarroel, 170, Barcelona 08036, Spain. Tel. +34 93 2275545;
Fax: +34 93 2275545.
E-mail address: (A. Alcaraz).
0302-2838/# 2017 Published by Elsevier B.V. on behalf of European Association of Urology.