Robot-assisted kidney transplantation (RAKT) is a safe surgical procedure that has been adopted in Europe since 2015 [1], [2]. Up until July 2023, a total of 622 heterotopic RAKT cases from living donors have been performed within the European Association of Urology Robotic Urology Section (ERUS)-RAKT Working Group [3]. While the first cases were conducted in very selected patients, a growing confidence with complex scenarios, such as obese patients and grafts with multiple vessels, and the standardization of the technique have led to an expansion of the indications of this surgery [4], [5], [6], [7]. RAKT has been demonstrated to lead to good perioperative surgical results, as well as excellent long-term functional and survival outcomes [3].

Nonetheless, it is still unclear whether and when RAKT should be preferred to open kidney transplantation (OKT). To date, few retrospective cohort studies provided a head-to-head comparison of these two techniques in kidney transplantation (KT) from living donors [8]. In the largest study performed to date, Ahlawat et al. [9] compared OKT and RAKT, finding that RAKT was associated with lower estimated blood loss (EBL), lower postoperative pain, reduced wound complications, and symptomatic lymphoceles. This was a cornerstone study, but the generalizability of the results was limited by its sample size and single-center nature. Moreover, complication rates may have been underestimated, since data regarding postoperative ileus and bowel obstruction were not captured routinely.

Considering these limitations, we aimed to determine whether RAKT, compared with OKT from living donors, results in improved renal function at 1 mo after KT and whether it leads to lower perioperative complication rates and better long-term outcomes, including dialysis-free (DFS), graft (GS), reintervention-free (RFS), and overall (OS) survival.