Widening the Donor Pool with Robotic-Assisted Donor Nephrectomy

Cleveland Clinic’s Transplant Center in Weston, Florida, recently performed its first case of robotic-assisted donor nephrectomy (RADN), joining a growing trend that may increase living kidney donation rates nationwide.

“Robotic technology is improving the donation process for living kidney donors without compromising the quality of the transplanted kidney for recipients,” states Khaled Refaai, MD, a urologist and the lead kidney transplant specialist at Cleveland Clinic Weston Hospital. "It’s an important step forward as we broaden access to life-changing transplant options and expand what’s possible in living donor care.”

With nearly 90,000 people in the United States waiting for a kidney transplant, Dr. Refaai hopes the benefits of robotic-assisted surgery will increase the willingness of individuals to become living donors.

Living kidney donation

The first successful organ transplant performed in the United States was with a living donor kidney in 1954. Many things have changed since then, including the fact that most kidney transplants today involve deceased donor organs. Last year just 23% (6,419) of kidneys transplanted came from a living donor, according to Organ Procurement and Transplantation Network (OPTN) data.

In cases of living kidney donation, laparoscopic surgery has largely replaced open surgery as the gold standard since its introduction in 1995. More recently, robotic-assisted donor nephrectomy has emerged as an alternative. First performed in 2002, RADN has slowly gained inroads at select transplant centers across the country, and subsequent research has demonstrated better perioperative results with RADN in the hands of experienced surgeons

“We’re seeing shorter operative times, lower rates of conversion to open surgery, fewer surgical complications, and shorter hospital stays with a robotic approach versus laparoscopy,” explains Dr. Refaai. “As more transplant centers invest in the technology and surgeons gain experience, I believe the robotic approach will become the preferred method.”

Building on a legacy

Dr. Refaai trained in robotic-assisted surgery and the management of complex urological and transplant cases during a fellowship at Cleveland Clinic’s main campus in Ohio prior to joining Weston Hospital in 2024.

Cleveland Clinic is home to one of the world’s earliest kidney transplant programs – established in 1963 – and today is a pioneer in robotic-assisted kidney transplantation. It was the first in the world to successfully perform a robotic single-port (SP) kidney transplant in 2019 and last year conducted a nearly simultaneous robotic SP kidney transplant procedure for a donor and recipient using one robot.

“My colleagues in Ohio now perform about 30% of their kidney transplants robotically. They do the most robotic kidney transplants annually not only in the United States but also in the world", says Dr. Refaai. “It was a privilege to train with world leaders, and now as colleagues working collaboratively. It’s an incredible honor to bring my experience in robotic-assisted donor nephrectomy to Cleveland Clinic Florida.”

The first patients

In May, a 75-year-old woman who donated a kidney to her 75-year-old husband was the first patient at Cleveland Clinic Weston Hospital to undergo a RADN. Five days later, a 53-year-old woman had the same procedure, donating a kidney to her 51-year-old husband.

“Both surgeries were very successful, and in each case, the donors went home after just one night in the hospital,” says Dr. Refaai. “We’ve done a handful of robotic-assisted donor nephrectomies since May, and more are scheduled.”

The procedures are performed with a daVinci® Surgical System, using three or four ports – depending on which kidney is removed – and a lower abdominal incision to extract the kidney. Dr. Refaai points to the improved vascular dissection that can be achieved with a high-definition 3D view of the surgical field and the greater precision and surgical dexterity provided by the robotic instruments.

“This advancement allows us to provide more options to our living kidney donor. For selective cases, this option can provide better and safer surgery and improves the quality of care for our patients who are giving the gift of life,” says Dr. Refaai. “Likewise, organ recipients are receiving kidneys that are precisely recovered and go to work right away after transplantation.”

Donor benefits

Early graft function, greater graft longevity and improved recipient survival are among the many advantages of living kidney transplantation. It is also well established that donor nephrectomy is safe and does not affect overall survival of healthy donors who follow a healthy lifestyle after donation. “But we are always looking for opportunities to improve the donation process,” Dr. Refaai says.

Among the donor benefits observed with RADN are:

• Reduced pain and need for pain medications.
• Shorter hospital stays.
• Faster recovery.

“With robotic-assisted surgery, living donors experience a faster return to their baseline and and may enjoy better cosmetic results, and most importantly, we are able to minimize potential short-term risks,” he adds.

Widening the donor pool

Another benefit of robotic surgery reported in the literature is the potential to include donors with complex vascular anatomy or a higher body mass index (BMI) who may not be candidates for laparoscopic surgery. Dr. Refaai agrees, noting that a robotic-assisted approach allows him to more easily navigate variant structures and multiple vessels while maximizing the length of the renal vein for extraction.

“Some donors come to us after being declined by other centers because we have broader eligibility criteria and a reputation for taking on high risk cases,” shares Dr. Refaai. “I hope that by offering robotic-assisted donor nephrectomy, we will widen the pool of eligible donors and more patients with end-stage kidney disease will receive a living donor transplant.”

Cleveland Clinic Florida’s Transplant Center is one of two in the state performing both living donor kidney and liver transplantations for adult recipients. Since its launch in 2013, the transplant specialists at Weston Hospital have performed over 250 living donor transplantations.