Robotic versus laparoscopic versus open nephrectomy for live kidney donors.
Waiting lists for kidney transplantation continue to grow. Live kidney donation significantly reduces waiting times and improves long-term outcomes for recipients. Major disincentives to potential kidney donors are the pain and morbidity associated with surgery. This is an update of a review published in 2011.
To assess the benefits and harms of open donor nephrectomy (ODN), laparoscopic donor nephrectomy (LDN), hand-assisted LDN (HALDN) and robotic donor nephrectomy (RDN) as appropriate surgical techniques for live kidney donors.
We contacted the Information Specialist and searched the Cochrane Kidney and Transplant Register of Studies up to 31 March 2024 using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov.
Randomised controlled trials (RCTs) comparing LDN with ODN, HALDN, or RDN were included.
Two review authors independently screened titles and abstracts for eligibility, assessed study quality, and extracted data. We contacted study authors for additional information where necessary. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.
Thirteen studies randomising 1280 live kidney donors to ODN, LDN, HALDN, or RDN were included. All studies were assessed as having a low or unclear risk of bias for selection bias. Five studies had a high risk of bias for blinding. Seven studies randomised 815 live kidney donors to LDN or ODN. LDN was associated with reduced analgesia use (high certainty evidence) and shorter hospital stay, a longer procedure and longer warm ischaemia time (moderate certainty evidence). There were no overall differences in blood loss, perioperative complications, or need for operations (low or very low certainty evidence). Three studies randomised 270 live kidney donors to LDN or HALDN. There were no differences between HALDN and LDN for analgesia requirement, hospital stay (high certainty evidence), duration of procedure (moderate certainty evidence), blood loss, perioperative complications, or reoperations (low certainty evidence). The evidence for warm ischaemia time was very uncertain due to high heterogeneity. One study randomised 50 live kidney donors to retroperitoneal ODN or HALDN and reported less pain and analgesia requirements with ODN. It found decreased blood loss and duration of the procedure with HALDN. No differences were found in perioperative complications, reoperations, hospital stay, or primary warm ischaemia time. One study randomised 45 live kidney donors to LDN or RDN and reported a longer warm ischaemia time with RDN but no differences in analgesia requirement, duration of procedure, blood loss, perioperative complications, reoperations, or hospital stay. One study randomised 100 live kidney donors to two variations of LDN and reported no differences in hospital stay, duration of procedure, conversion rates, primary warm ischaemia times, or complications (not meta-analysed). The conversion rates to ODN were 6/587 (1.02%) in LDN, 1/160 (0.63%) in HALDN, and 0/15 in RDN. Graft outcomes were rarely or selectively reported across the studies. There were no differences between LDN and ODN for early graft loss, delayed graft function, acute rejection, ureteric complications, kidney function or one-year graft loss. In a meta-regression analysis between LDN and ODN, moderate certainty evidence on procedure duration changed significantly in favour of LDN over time (yearly reduction = 7.12 min, 95% CI 2.56 to 11.67; P = 0.0022). Differences in very low certainty evidence on perioperative complications also changed significantly in favour of LDN over time (yearly change in LnRR = 0.107, 95% CI 0.022 to 0.192; P = 0.014). Various different combinations of techniques were used in each study, resulting in heterogeneity among the results.
LDN is associated with less pain compared to ODN and has comparable pain to HALDN and RDN. HALDN is comparable to LDN in all outcomes except warm ischaemia time, which may be associated with a reduction. One study reported kidneys obtained during RDN had greater warm ischaemia times. Complications and occurrences of perioperative events needing further intervention were equivalent between all methods.
Kourounis G
，Tingle SJ
，Hoather TJ
，Thompson ER
，Rogers A
，Page T
，Sanni A
，Rix DA
，Soomro NA
，Wilson C
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Pfannenstiel laparoendoscopic single-site (LESS) vs conventional multiport laparoscopic live donor nephrectomy: a prospective randomized controlled trial.
To present outcomes of a randomized, patient-blinded controlled trial on Pfannenstiel laparoendoscopic single-site (LESS) vs conventional multiport laparoscopic live donor nephrectomy.
Patients presenting as left kidney donors between January 2009 and November 2011 were randomized to LESS donor nephrectomy (LESS-DN: n = 15) or conventional laparoscopic donor nephrectomy (LDN: n = 14). Patients were blinded to the surgical approach preoperatively and attempts to continue patient blinding postoperatively were made by applying dressings consistent with multiple conventional laparoscopic incisions for all patients. De-identified data related to the operation, peri-operative course and postoperative follow-up were prospectively collected and compared between the two groups with an intention-to-treat analysis.
There were no significant differences between the groups when comparing operating time, estimated blood loss (EBL), i.v. fluid administration, renal allograft warm ischaemia time (WIT), length of hospital stay (LOS) and total inpatient analgesic requirements. Quantitative pain assessment was not significantly different on postoperative day (POD) #0, however, it was significantly lower in the LESS-DN group, beginning on POD #1 (P < 0.05). The changes in haematocrit and serum creatinine in the two groups were not significantly different, and there were no blood transfusions in either group, nor was there a decline in estimated glomerular filtration rate to <60 mL/min per 1.73 m² of body surface area in any patients. Two patients in the LESS-DN group were converted to conventional LDN, both because of failure to progress effectively. All allografts were functional at the time of transplantation and revascularization, with no cases of hyperacute rejection.
Peri-operative variables including EBL, WIT and LOS were equivalent when comparing Pfannenstiel LESS-DN with conventional LDN. Patient-reported visual analogue pain scale scores were significantly lower in the LESS-DN group beginning on the first postoperative day.
Richstone L
，Rais-Bahrami S
，Waingankar N
，Hillelsohn JH
，Andonian S
，Schwartz MJ
，Kavoussi LR
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Robot-assisted laparoscopic vs laparoscopic donor nephrectomy in renal transplantation: A meta-analysis.
Currently, the robot-assisted laparoscopic donor nephrectomy (RDN) technique is used for live donor nephrectomy. Does it provide sufficient safety and benefits for living donors? We conducted a meta-analysis to assess the safety and efficacy of RDN compared with the laparoscopic donor nephrectomy (LDN).
Eligible studies were retrieved and screened from electronic databases from 1999 onward: PubMed, Cochrane Library, and Web of Science. Relevant parameters were explored using Review Manager V5.3 and included operative time, warm ischemia time, estimated blood loss, and length of hospital stay.
Compared with RDN, LDN had shorter operative time (min; weighted mean difference (WMD): -0.53; 95% CI: [-0.85, 0.20]; P = 0.001) and warm ischemia time (second; WMD: -55.01; 95% CI: [-71.56, 38.45]; P < 0.00001) and less estimated blood loss (mL; WMD: -28.30, 95% CI: [-46.37, 10.24], P = 0.002). The pooled analysis of postoperative pain showed lower visual analog scale (VAS) scores for RDN compared with LDN (WMD:1.28, P < 0.00001). We also observed that length of hospital stay, postoperative serum creatinine (SCr) in donors, postoperative estimated glomerular filtration rate (eGFR) of recipients and postoperative complications for donors were not significantly different between groups.
As long as RDN is practiced proficiently, it is believed that RDN is a feasible alternative to LDN.
Wang H
，Chen R
，Li T
，Peng L
... -
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