First-Ever Robot-Assisted Kidney Transplants After Cystectomy and Urinary Diversion Reported

By Soham NandiReviewed by Bethan DaviesFeb 7 2025

A new study published in European Urology Open Science highlights a major breakthrough in kidney transplantation.

Researchers successfully performed robot-assisted kidney transplantation (RAKT) on two patients who had previously undergone cystectomy and urinary diversion (UD) for benign bladder disease. Both patients maintained stable kidney function with no complications, suggesting that this minimally invasive approach could open new doors for treating end-stage renal disease (ESRD) and lower urinary tract dysfunction.

Why This Matters

RAKT is reshaping kidney transplantation, particularly for patients with ESRD and lower urinary tract dysfunction. Traditionally, combining RAKT with UD has been a challenge due to surgical complexity and concerns over post-op recovery under immunosuppression. This study presents the first documented cases of successful RAKT following simple cystectomy (SC) and UD, showing that a robotic approach can offer a safer, more efficient alternative for these complex procedures.

The Case Studies

For their analysis, the researchers used the da Vinci X robotic platform to perform RAKT on two patients, both of whom had previously undergone bladder removal and UD.

Case Study No. 1

A 73-year-old man with ESRD due to vesicoureteral reflux (VUR) faced recurrent infections and incontinence due to a severely dysfunctional bladder. The kidney transplantation board determined that his bladder was non-viable, leading to a combined procedure: robot-assisted cystoprostatectomy, intracorporeal ileal conduit creation, and heterotopic RAKT using a kidney donated by his 50-year-old daughter.

The procedure, using a four-arm robotic setup, involved removing the bladder, preparing a 20-centimeter ileal segment for UD, and positioning the kidney graft via a Pfannenstiel incision. Vascular and ureteroileal anastomoses were performed with precision using 6-0 Gore-Tex sutures for vascular connections and a 4-0 Monocryl suture for ureteroileal anastomosis, supported by a single-J stent.

The entire surgery took 330 minutes—55 minutes for cystectomy, 110 minutes for transplantation, and 43 minutes for vascular anastomosis. Post-op, the patient’s serum creatinine levels dropped significantly from 287 micromoles per liter (μmol/L) on day one to 148 μmol/L after 90 days. Importantly, he had no complications, no evidence of hydronephrosis, and remained symptom-free.

Case Study No. 2

A 34-year-old woman with bladder pain syndrome and interstitial cystitis developed ESRD due to bilateral pyonephrosis and VUR. Chronic infections and severe pain led doctors to opt for a two-stage approach.

In the first stage, she underwent robot-assisted cystectomy, intracorporeal ileal conduit creation, and bilateral nephrectomy. After eight months on hemodialysis, she was cleared for RAKT. In the second stage, she received a kidney from her 70-year-old mother, which was transplanted in the right iliac fossa with a ureteroileal anastomosis. Vascular anastomosis was completed using 6-0 Gore-Tex sutures, while the ureteroileal anastomosis was secured with a 4-0 Monocryl suture and a single-J stent for drainage.

By day five post-transplant, her creatinine level had stabilized at 120 μmol/L, and she experienced no Clavien-Dindo grade I–V complications within 90 days.

The Bigger Picture

The success of RAKT in these cases suggests that ileal conduit creation during kidney transplantation is a viable approach for ESRD patients with lower urinary tract dysfunction. However, concerns remain about how immunosuppressive therapy may impact healing at the anastomosis or incision site. Studies suggest that UD can be performed safely at the time of transplantation or as a separate procedure.

Combining the procedures in a single surgery reduces the number of operations and minimizes the risk of complications such as mucus buildup in a non-functional ileal conduit. Additionally, delaying transplantation can complicate iliac vessel dissection, increasing the risk of surgical complications.

Some experts suggest alternative urinary diversions, such as continent UD or terminal cutaneous ureterostomies, which also yield good renal function outcomes. However, these methods require self-catheterization or stoma dilation, increasing the risk of infections. Available evidence suggests that RAKT lowers surgical risks compared to open kidney transplantation while ensuring positive long-term results.

These two cases mark an important step forward in robotic kidney transplantation. While the procedure shows immense promise—especially for immunocompromised patients—it should be performed at high-volume centers with specialized expertise in robotic urological surgery and kidney transplantation.

The Bottom Line

This study reinforces the potential of RAKT following cystectomy and UD, proving that patients can maintain stable kidney function with minimal complications. As robotic technology continues to evolve, this approach could become a preferred option for complex transplant cases. However, given the technical expertise required, it remains best suited for high-volume medical centers with specialized experience.

Journal Reference

Pérez-Reggeti, J. I., Etcheverry, B., Fiol, M., Territo, A., Afferi, L., Buisan, O., Riera, L., Suarez-Novo, J. F., Breda, A., & Vigués, F. (2024). Robot-assisted Kidney Transplantation in Patients Undergoing Cystectomy with Urinary Diversion: First Cases Reported by the ERUS-RAKT Working Group. European Urology Open Science, 71, 144–147. DOI:10.1016/j.euros.2024.12.002 https://www.sciencedirect.com/science/article/pii/S2666168324014332?dgcid=api_sd_search-api-endpoint

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