Open vs robot-assisted kidney transplant: Which approach is safer for ESKD patients?

Robot-assisted kidney transplantation falls short of establishing its superiority over an open surgery approach, but it does yield reductions in complication rates among adults with end-stage kidney disease (ESKD), according to the ORAKTx study presented at EAU 2026.

“[W]e did not demonstrate superiority of a robotic approach over an open approach in kidney transplantation, but we did observe a 10-percent difference in complication rates, which might warrant investigation in larger multicentre trials,” said lead author Dr Milla Ortved, Copenhagen University Hospital - Rigshospitalet, Urological Research Unit, Copenhagen, Denmark.

“And such trials might wish to incorporate cost-benefit analysis,” she added.

ORAKTs is the first randomized, parallel, open-label trial at Copenhagen University Hospital – Rigshospitalet to compare robot-assisted with open kidney transplantation.

A total of 107 adult patients with ESKD and no contraindication to robotic surgery, who planned to undergo living- or deceased donor kidney transplantation, were recruited between 8 May 2023 and 24 September 2025. Eligible participants were randomly allocated to receive either open- (n=53) or robot-assisted surgery (n=54).

Ortved and her team assessed postoperative complications using the Clavien-Dindo system.

The primary outcomes were the 30-day post-transplant rates of vascular and major surgical complication. This study was powered for 15-percent and 20-percent reductions in these respective outcomes. Secondary outcomes were recovery, urological complications, and kidney graft function.

The authors performed intention-to-treat analysis in all patients who underwent transplantation according to the assigned intervention.

Fifty-three patients in each arm underwent kidney transplantation and completed follow-up. Baseline characteristics were comparable between groups, and most participants received a kidney from a deceased donor. [EAU 2026, abstract LB011]

Complication rates

Thirteen patients (24.5 percent, 95 percent confidence interval [CI], 13.8‒38.3) in the open arm and seven (13.2 percent, 95 percent CI, 5.5‒25.3) in the robotic arm experienced major surgical complications (odds ratio [OR], 0.47, 95 percent CI, 0.14‒1.42; one-sided p=0.11).

Furthermore, 10 patients (18.9 percent, 95 percent CI, 9.4‒32.0) in the open arm and five (9.4 percent, 95 percent CI, 3.1‒20.4) in the robotic arm had vascular complications (OR, 0.45, 95 percent CI, 0.11‒1.59; one-sided p=0.13).

No significant between-group differences were seen in the secondary outcomes. However, patients in the robotic arm showed a higher rate of opioid use than those in the open arm.

“Our intent with this trial was to do a pragmatic trial that captured the overall kidney transplant cohort, but it has been argued that there are populations more suitable for a robotic approach such as those with obesity or those [undergoing] orthotopic kidney transplantation,” Ortved said.

“Whether robot-assisted kidney transplantation is relevant for all-comers or should be restricted to subgroups of patients such as those with obesity should be explored in larger multicentre trials,” according to the authors.

“Establishing such trials will likely require a collaborative effort from the transplant community and may wish to include cost-benefit analyses,” they added.

The study had certain limitations, including its single-centre design, the lack of masking, and the modest sample size, “which was based on the assumption that robotic [kidney transplantation] could offer very large reductions,” Ortved said.