*Purpose: Robotic surgery is increasingly used in complex operations, including living-donor kidney transplantation. At this time, knowledge of the number of cases required to attain procedural proficiency is lacking. Here, we describe our experience during 80 consecutive robotic kidney transplant (RKT) recipients. The aim of the study was to identify the learning curve associated with RKT at a high-volume transplant center in a diverse patient population.

*Methods: A retrospective review of 80 consecutive patients, who underwent RKT from May 2014 to December 2019, was evaluated for several quality metrics and perioperative factors. Selection for RKT was based on robot availability. Outcomes were followed for up to 2-years. Patients were analyzed in groups of 20 to minimize demographic differences and optimize the ability to detect statistically meaningful changes in performance.

*Results: A total of 80 patients were identified (5 in 2014, 3 in 2015, 10 in 2016, 18 in 2017, 17 in 2018, 27 in 2019). The median age was 48 (IQR 35-60). The majority of patients were male (n=55(68.8%)), white (n=45(57.0%)), and had a median BMI of 29.2 (IQR 24.7-33.1). The median operative time (OR) was 303.5 minutes (IQR 274.8-337.3) and estimated blood loss (EBL)was 75 mL (IQR 50-150). The median warm ischemia time (WIT) was 50 minutes (IQR 43-60), and there were 3 (3.8%) open conversions. The groups differed in both OT and WIT. There was a significant trend for shorter WIT with more cases done (J=1308.5; p=0.049), but not for OT. Post-hoc analysis demonstrated differences between WIT between the 1^sttwenty cases (63 (50-74)) and all subsequent cases (2^ndtwenty 47 (42-52), 3^rdtwenty 50 (43-60), 4^thtwenty 51 (45-57)), whereas there were differences noted between groups after the 1^sttwenty cases. There were no cases of delayed graft function, although we did experience two graft losses secondary to rejection and one death following opportunistic infection in kidney following liver transplant. Two patients required operative ureteral revision (performed robotically), while two patients required ureteral stent placements.

*Conclusions: This investigation reflects the largest experience of purely robotic kidney transplantation in the United States, to date. In this study, RKT was demonstrated to be safe with decreased WIT demonstrated with increased number of cases performed. The learning curve needed to attain proficiency for RKT was approximately 20 cases. This learning curve was representative of a transplant surgery team, rather than a single attending surgeon. Actual learning curve may be less steep, as an increasing number of surgeons are already utilizing the platform. Additionally, learning curve may be smaller with more cases performed, dedicated training, and with utilization of newer Davinci models.

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