Robotic Kidney Transplant with grafts having multiple renal arteries – Technical nuances


We have the KS Robotic Surgery Awards winner in the Urology category from the Robotic Surgeons Council of India November 2017 meetings:

Robotic Kidney Transplant with grafts having multiple renal arteries – Technical nuances

Feroz Amir Zafar, Rajesh Ahlawat, Fortis Escorts Kidney and Urology Institute, New Delhi, India

Here is the abstract:

Introduction and aim:

Kidney Transplant with multiple renal arteries is technically challenging. In grafts with lower polar accessory artery, there are additional concerns regarding the ureteric blood supply. In this setting, higher incidences of vascular and urological complications have been reported in some studies. Hence, there is a hesitation in using grafts with multiple arteries. In the current practice, excluding the otherwise suitable live donors only on the ground of technical challenges no longer seems to be acceptable. This becomes particularly more important in developing countries like India, where cadaveric donor program is still in its infancy and where living donor nephrectomy contributes to the majority of graft pool.

We present a video highlighting our technique and experience in Robotic kidney transplants using grafts with multiple vessels.


202 out of a total of 964 patients underwent Robotic Kidney transplant from February 2013 to June 2017. Multiple renal arteries were assessed preoperatively by studying CT renal angiographic 3D reconstruction images and also on the bench after graft retrieval. Depending on the location and size of graft vessels, decision was taken to make pantaloons, anastomose vessel separately to inferior epigastric or external iliac or sacrifice it if very insignificant.


Patients were divided into two groups based upon the number of renal arteries in the graft. Out of 202 grafts, 157 grafts (77.7%) had a single renal artery (SRA). Rest 45 patients (22.3%) had multiple renal arteries (MRA). 36 allografts had 2 renal arteries while 6 grafts had a single renal artery, which got divided into two during retrieval. Three grafts had 3 renal arteries. The mean age for MRA group was 37.5 and for SRA group was 39.08. Mean BMI was 25.95 and 24.7 in MRA & SRA group respectively. The mean warm ischemia time (WIT) in MRA group was 166 seconds, which was significantly higher than that in SRA group (147.8 seconds), p value 0.005. The mean total ischemia time in patients receiving graft with multiple renal arteries was significantly higher as compared to the patients receiving grafts with single renal artery (79.8 minutes in MRA vs. 65.2 min in SRA, p value 0.0001). Blood loss was found to be similar in the two groups. The mean creatinine levels at discharge (1.17 mg/dl in MRA group and 1.27 mg/dl in SRA group) and at 3 months (1.18 mg/dl in MRA group and 1.26 mg/dl in SRA group) were comparable.


Multiple renal arteries, albeit technically challenging, are not a contraindication for robotic kidney transplant. The outcomes are comparable with grafts having single renal artery.

Narrated video with PowerPoints, photos and robotic surgery footage, 06:53

Kidney, Robotics