University of Iowa Health Care transplant surgeon Ramy El-Diwany, MD, PhD, recently performed the health system’s first robotic living donor nephrectomy, paving the way for more living kidney donations in the state. Today, just over 20% of kidney transplants nationally come from living donors, and that number is higher in Iowa.
Nephrectomy is the medical term for surgical removal of a kidney. Everyone has two kidneys, and living donors offer one of their healthy and type-matched kidneys to a recipient, while a deceased donation occurs after someone passes away.
During the procedure, a surgeon uses a robotic system to remove a healthy kidney from a living donor. Three 1-inch incisions are made in the abdomen and a camera is placed in one of the incisions so the surgeon can see the work while mobile robotic “arms” controlled by the surgeon are inserted into the other incisions to precisely separate the kidney, blood vessels, and ureter.
Once detached, the kidney is removed from the body through a small incision (the same kind used in most Cesarean sections). This extraction method results in a lower complication rate than other extraction methods and results in a better cosmetic outcome.
The minimally invasive procedure offers several benefits for living kidney donors, including quicker recovery, less pain, smaller scars, shorter hospital stays, and a faster return to normal activities compared with traditional kidney removal surgery, says Dr. El-Diwany, who’s worked in Iowa City since September 2025.
“Not only are donors having an improved overall experience, the quality and outcomes of the robotic nephrectomy are comparable, if not better, to traditional donor surgeries,” he said recently. “More importantly, living donor kidney transplants last several years longer on average when compared to deceased donor transplants, so any advance in living donation is a true win for our patients. We are excited about the possibilities this procedure enables both for donors and recipients.”
Robotic nephrectomies also allow for a wider pool of donors to be considered suitable for kidney donation. Once donors are confirmed to be healthy enough to live with one kidney, those with more complex anatomies or a higher body mass index (BMI) can now be considered thanks to the precision of robotic surgery. This technology helps overcome many of the technical challenges and surgical risks that can accompany obesity.
Because of the improved donor experience and wider eligibility of donor body types, physicians are optimistic that living kidney donor rates will increase statewide, providing more access to this life-changing donation.
Minority of transplants use robotics
Less than a third of such kidney transplants nationally are done using robotic surgery, El-Diwany said Friday, Feb. 27. The most common way kidney donations are performed is laparoscopically.
“That's using basically sticks with little instruments at the ends of them that you can control with your hands from outside of the body,” he said. “You’re very limited. You only have a couple degrees of rotation when you do that. With the robot there, they're instruments that go in through those same little holes in the abdominal wall. And those instruments on the inside have like wrists and have 540 degrees of rotation. So it's like you have both of your hands on the inside. You're not limited by the sticks.
“So what you're able to do that you're not really able to do so much laparoscopically is you can dissect around really tiny vessels and you can find donors that, some donors out there that have anatomic abnormalities where they have multiple vessels and things like that,” El-Diwany said. “And the robot really lets you sort of dissect those vessels. But it does require a transplant surgeon who's experienced in robotic surgery. And it does require some institutional support to be able to have that as a resource.”
UI has just done the kidney extraction robotically for living donors, and is working on doing a similar procedure for sewing in a kidney for the recipient, he said, noting just 1% nationally of those are done robotically.
Kidney disease affects 37 million Americans, and about 90% of them don't even know that they have kidney disease, the surgeon said. Of those who have been evaluated, 95,000 of them are listed for needing a transplant and about 9,000 people die every year waiting for a kidney, or more than 25 a day.
“It's really terrible,” El-Diwany said. “And depending on your blood type, you may have to wait five or six years on the wait list before you could get a good offer for a kidney transplant. So one of the things that living donation does is that it makes it so you don't have to wait on the wait list. You find someone who wants to donate a kidney for you, get a kidney right away. So gets you off the wait list. And the survival after a kidney transplant is very much determined by how long you got to wait on that wait list, how long you're on dialysis.”
The kidneys clean the blood by removing waste and extra fluid, which leaves the body as urine, according to Mayo Clinic. They also help control blood pressure and balance salt and minerals.
Living donors help people live longer
“Dialysis does keep you alive, but it does take years off your life expectancy while you're on dialysis. So kidney transplant is one of the most life-saving interventions that we can do for people with kidney disease,” El-Diwany said. “And living donors unquestionably help people live longer when compared to waiting for a deceased donor. And the kidneys tend to be better kidneys on average. So a person who gets a deceased donor kidney on average will last about 10, 15 years. But a living donor, 20, 25 years is the norm.”
“So we really love doing anything that we can do to extend the number of living donors,” he said. “Sometimes, a person's weight or their shape or the number of arteries or their anatomy or restrictions with a laparoscope, but using the robot, a lot of those restrictions are removed. So we're able to do more robotic surgery.”
The most important principle of living donation is that they leave the donor with the best possible kidney function.
The donated kidney may have extra blood vessels going to and from the kidney, or they might be real small. And in order to do the recipient surgery, to reconstruct those vessels, you might need to get a little bit further down where the artery comes off the aorta, or you might have to come around that artery and hook below it, the surgeon said.
“That motion, being able to put your essentially like having your hand on the inside is totally different when you're using a laparoscope,” El-Diwany said. “So it opens up a lot of possibilities in terms of what kinds of anatomy we can accept.”
“It could be like a perfect match for the recipient. And it's just, with the laparoscope, we're not confident that we'll be able to preserve all those vessels, and that person is sort of deemed ineligible. But with the robot, it really opens that up,” he said.
“We just are right only in the area that we need to be with the robot. We don't have to push a lot of things out of the way. And because of that, I think the surgery is more gentle on the patients. And so far, every living donor that we've done, we've been doing this since December, has gone home the next day. They are back to work within a couple weeks. They only take pain meds for a couple days.”
UI has done four robotic kidney donations since December. (MercyOne Genesis in Davenport does not perform any transplant surgery.)
There is no cost for someone who donates a kidney, and traditional health insurance covers recipients for robotic surgery, the same as laparoscopic, El-Diwany said.
“The robot really allows in all sorts of shapes and sizes to be able to donate,” he said of patients with higher BMI. “I do a lot of liver and bile duct surgery robotically as well. And I've done a gallbladder removal on someone who had a BMI of 90, which is over 500 pounds and a normal heightened person. And the robot made it just like it was any other case. So it does allow for minimally invasive surgery to happen more sort of ergonomically in situations that we otherwise wouldn't be able to do it.”
Higher Iowa rate for living donors
Of all kidney donations, 20% nationally are from living donors, and about 29% in Iowa. UI in Iowa City sees transplant patients from throughout the Midwest, and as far as Texas, El-Diwany said.
“So we have a pretty good, you know, record of people wanting to be very generous and make this amazing gift to loved ones or friends," he said. "This is sort of in keeping with our culture. And with the advent of the robot, more and more people are interested in donating because it's a little less invasive and the recovery is a little faster.
“Altruistic living donation is amazing. It saves way more than just one life, usually. It's a huge deal,” El-Diwany said. “So anytime someone comes forward saying they want to be an altruistic donor, it's huge. I mean, it blows me away. And it's a tremendous honor to be involved in their care. So that's one of the big things that we're hoping to get out, get the word out about the robot is that, the process of donation is minimally invasive and is really a good, positive experience for our donors. And we're hoping more people consider being donors and enable folks to get transplanted who otherwise might die waiting for a kidney transplant.”
UI Health Care is the only medical facility in Iowa currently offering robotic kidney donations. El-Diwany was trained in it as part of his residency at Johns Hopkins in Baltimore.
“I did my transplant fellowship there as well. And robotics was a big part of the training program there,” he said. “We did all of our living donor liver transplants robotically as well. So we have a lot of experience using the robot. And just anecdotally having done almost all of the surgeries both open robotically, laparoscopically, I think the best thing for the patients is the robot. And honestly, the best thing for the surgeons is the robot as well.
"So it's kind of a win-win for all of us when we get to use it. The biggest thing of course is enabling more surgeries, more transplants to happen, more lives saved. I think bottom line, we're really excited about anything that opens the door to more transplants here.”
Robotic training is not standard for medical schools nationwide, El-Diwany said.
“The American Board of Surgery, for instance, does not have a robotics requirement at all. And that's because they have to be mindful of the fact there are a lot of hospitals in this country that don't have robotics,” he said. “If you want to train somewhere and get board certified in general surgery, robotics may not be part of that, but we knew people who can take out gallbladders, even laparoscopically. Of course, we need more surgeons. So I think that's a balance between sort of recognizing that we got to train people but then also kind of keeping up with the newer technologies.”
“Living donors have the opportunity to truly give a life-changing gift to someone in need of a kidney,” says Alan Reed, MD, MBA, transplant surgeon and director of UI Health Care Transplant Center. “It is an honor to be able to use the latest surgical technology to not only perform a procedure that will enhance the life of the recipient, but to also provide a better experience and outcome for the donor.”
The robotic donor nephrectomy procedure is the latest example of UI Health Care’s investment in robotics to treat more Iowans while offering a better overall experience, generally designed to help patients heal faster, with less pain, and smaller incisions.
Last year, UI Health Care added three new da Vinci 5 robotic-assisted surgical systems, one of the latest minimally invasive technologies on the market, as part of the health system’s continued commitment to providing patients with the most advanced treatment options before they’re available elsewhere.
Minimally invasive surgical procedures often result in better outcomes for patients, including shorter hospital stays and faster recovery times. The three new da Vinci® 5s are the first in Iowa and will double capacity at university campus for robotic-assisted minimally invasive procedures, enabling approximately 1,000 additional procedures each year.
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