Background: The use of living donors for transplantation in pediatric patients has been shown to provide the best long-term graft and patient survival, however they have been reported to account for only 28.5% of transplants in 2021. We present the use of robotically procured kidneys as a safe option for pediatric kidney transplant recipients, even in the presence of grafts with anatomical anomalies.
Methods: We reviewed all pediatric patients (<18 years of age) that received an open kidney transplant with a robotically procured living donor graft between 10/2022 and 07/2023. We evaluated recipient, donor and peri- and post-operative data, graft characteristics, and our surgical technique.
Results: Eight pediatric recipients were evaluated. Mean recipient age was 11 years old, and seven recipients were male. Mean cold and warm ischemia time was 73 minutes and 29 minutes, respectively. Two grafts had multiple renal vessels, one requiring back-table vascular reconstruction with deceased donor iliac vein system. Another graft with a short renal vein required extension with deceased donor external iliac vein. There were no cases of delayed graft function and no observed post-operative vascular or urological complications. Mean serum creatinine at 1- and 6-months post-transplant was 0.785 mg/dL (N=8) and 0.83 mg/dL (N=3), respectively. 
Conclusion: Augmenting the donor pool for pediatric kidney recipients is crucial. Our study shows that robotically procured kidneys, even with anatomical anomalies, are a safe and feasible source for pediatric transplantation. Allografts with vascular abnormalities can be securely transplanted after vascular reconstruction and can therefore increase the donor pool.