A randomized clinical trial of living donor nephrectomy: a plea for a differentiated appraisal of mini-open muscle splitting incision and hand-assisted laparoscopic donor nephrectomy

Urologists' proficiency in various donor nephrectomy approaches: a real-life survey, systematic review, and meta-analysis of randomized controlled trials

INTRODUCTION

Donor nephrectomy (DN) is a unique surgical procedure in urological practice, as it involves exposing a healthy individual to the potential risks of surgery. This type of surgery exhibits heterogeneity in terms of approach (open, laparoscopic, or robotic), each with its unique set of advantages and disadvantages. Consequently, there is currently a lack of universally agreed upon clear guidelines. In these settings, this study aims to evaluate transplantation surgeons' knowledge through a real-life survey and compare it with data from published randomized controlled trials (RCTs).

EVIDENCE ACQUISITION

The study is divided into two parts, with the first part focusing on the outcomes of the real-life survey designed to assess surgeons' knowledge about different DN approaches and their real-world practices during the surgery. The second part involves a systematic review and meta-analysis of RCTs, specifically examining the outcomes of different surgical approaches to DN. The systematic review followed the PRISMA Guidelines and involved a search of PubMed and Web of Science for RCTs comparing the outcomes of different DN approaches. The risk of bias was assessed using the RoB-2 tool. The random effect model was mainly used to assess the mean difference of the included studies.

EVIDENCE SYNTHESIS

The study was conducted between July 2021 and January 2022 and surveyed 50 surgeons, of which 35 participants (70%) completed the survey. Regarding various approaches to DN, 97.14% of surgeons reported having experience with live DN, and 45.72% performed over 15 cases per year. The most performed approach was pure laparoscopic DN (68.57%). Pure laparoscopic DN was the preferred approach for 77.42% of respondents. The review process resulted in 335 articles, of which 35 were eligible for inclusion in the systematic review. In summary, most studies found that laparoscopic approaches, including standard, hand-assisted, LESS-DN, and mini-LDN, resulted in less postoperative pain, better cosmetic, and quicker recovery times compared to open approaches. The main limitation of the current study is the heterogeneity of the included studies.

CONCLUSIONS

The study provides valuable insights into the practices of renal transplantation surgeons, offering a comprehensive comparison to level 1 studies (RCTs) in the field. It underscores the continued significance of ODN in contemporary practice, particularly in light of recommendations from the EAU guidelines on renal transplantation. This reaffirms the need to consider the advantages and disadvantages of various approaches, including factors such as cost, postoperative pain, and cosmetic outcomes. While robotic-assisted DN holds promise, their adoption remains variable, potentially due to limited robust evidence.

Robotic versus laparoscopic versus open nephrectomy for live kidney donors

BACKGROUND

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.

OBJECTIVES

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.

SEARCH METHODS

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.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing LDN with ODN, HALDN, or RDN were included.

DATA COLLECTION AND ANALYSIS

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.

MAIN RESULTS

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.

AUTHORS' CONCLUSIONS

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.

The Non-Muscle-Splitting Mini-Incision Donor Nephrectomy Remains a Feasible Technique in the Laparoscopic Era of Living Kidney Donation

Laparoscopic donor nephrectomy (LDN) is the current gold standard in kidney donation. Mini-incision open donor nephrectomy (MINI) techniques have been used extensively but have become less popular. The aim of the present study was to compare the results and safety of a non-muscle-splitting MINI technique with the current gold standard of LDN. A single center retrospective cohort study of all living donor nephrectomies between 2011 and 2019 was used for the study. The primary outcome of this study was short term (<30 days) with Clavien–Dindo grade complications. Secondary outcomes included multivariable regression analysis of perioperative data. No differences in complication rates were observed between MINI and LDN and also after correction for known confounders. As expected, the operative time and first warm ischemia were significantly shorter in the MINI group and less blood loss was observed in the LDN group. Complications and conversion rate (LDN to open) among the LDN patients were in line with recent published meta-analyses. This study confirms the perioperative safety of living kidney donation in modern practice. Complication rates of both MINI and LDN procedures are limited and not different between procedures. In specific circumstances, the MINI procedure can still be considered a safe and feasible alternative for living kidney donation.

Comparison of Surgical Techniques in Living Donor Nephrectomy: A Systematic Review and Bayesian Network Meta-Analysis

Background

The aim of this study was to compare and evaluate surgical techniques used for living donor nephrectomy (LDN).

Material/Methods

We performed a meta-analysis to compare 4 surgical techniques: open LDN (OLDN), laparoscopic LDN (LLDN), hand-assisted LLDN (HALLDN), and robot-assisted LLDN (RLDN).

Results

No significant differences were found among these surgical techniques in terms of BMI, donor postoperative complications, 1-year graft survival, and DGF. Compared to the OLDN, the other 3 surgical techniques preferred to harvest the left kidney. When the right kidney was chosen as a donor, OLDN was the first-choice surgical technique. EBL was significantly lower in the HALLDN, LLDN, and RLDN groups when compared to the OLDN group. However, operative time and WIT were significantly shorter in the OLDN group. The RLDN group had an increased rate of donor intraoperative complications and a significantly lower VAS on day 1. The OLDN group required more morphine intake than the LLDN group. The length of hospital stay was significantly longer and AR was significantly higher in the OLDN group than in the LLDN and HALLDN groups.

Conclusions

There are no significant differences in donor postoperative complications, recipient DGF, and graft survival among the 4 surgical techniques. OLDN reduces WIT and operation time, but increases EBL and AR. RLDN and LLDN reduce the length of hospital stay, morphine intake, and VAS, and thus accelerate recovery. However, RLDN is associated with increased intraoperative complications.

Perioperative Events and Complications in Minimally Invasive Live Donor Nephrectomy: A Systematic Review and Meta-Analysis

BACKGROUND

Minimally invasive live donor nephrectomy has become a fully implemented and accepted procedure. Donors have to be well educated about all risks and details during the informed consent process. For this to be successful, more information regarding short-term outcome is necessary.

METHODS

A literature search was performed; all studies discussing short-term complications after minimally invasive live donor nephrectomy were included. Outcomes evaluated were intraoperative and postoperative complications, conversions, operative and warm ischemia times, blood loss, length of hospital stay, pain score, convalescence, quality of life, and costs.

RESULTS

One hundred ninety articles were included in the systematic review, 41 in the meta-analysis. Conversion rate was 1.1%. Intraoperative complication rate was 2.3%, mainly bleeding (1.5%). Postoperative complications occurred in 7.3% of donors, including infectious complications (2.6%), of which mainly wound infection (1.6%) and bleeding (1.0%). Reported mortality rate was 0.01%. All minimally invasive techniques were comparable with regard to complication or conversion rate.

CONCLUSIONS

The used techniques for minimally invasive live donor nephrectomy are safe and associated with low complication rates and minimal risk of mortality. These data may be helpful to develop a standardized, donor-tailored informed consent procedure for live donor nephrectomy.

Back-to-back comparison of mini-open vs. laparoscopic technique for living kidney donation

INTRODUCTION

Laparoscopic living donor nephrectomy is the standard of care at high-volume renal transplant centres, with benefits over the open approach well-documented in the literature. Herein, we present a retrospective analysis of our single-institution donor nephrectomy series comparing the mini-open donor nephrectomy (mini-ODN) to the laparoscopic donor nephrectomy (LDN) with regards to operative, donor, and recipient outcomes.

METHODS

From 2007-2011, there were 89 cases of mini-ODN, at which point our centre transitioned to LDN; 94 cases were performed from 2011-2014. In total, 366 patients were reviewed, including donor and recipient pairs. Donor and recipient demographics, intraoperative data, postoperative donor recovery, recipient graft outcomes, and financial cost were assessed comparing the surgical approaches.

RESULTS

We demonstrate a reduced estimated blood loss (347.83 vs. 90.3 cc), lower intraoperative complication rate (4 vs. 11) and shorter length of hospital stay (2.4 vs. 3.3 days) for patients in the LDN group. Operative time was significantly longer for the LDN group (108.4 vs. 165.9 minutes), although this did not translate to a longer warm ischemia time (mean 2.0 minutes for each group). The rate of delayed graft function and recipient 12-month creatinine were comparable for ODN and LND. Overall cost of LDN was $684 higher for an uncomplicated admission.

CONCLUSIONS

Despite a longer surgical time and higher upfront cost, our study supports that LDN yields several advantages over the mini-ODN, with a lower estimated blood loss, fewer intraoperative complications, and shorter length of hospital stay, all while maintaining excellent renal allograft outcomes.

The Course and Predictors of Health-Related Quality of Life in Living Kidney Donors: A Systematic Review and Meta-Analysis

A better understanding of the course and risk factors for impaired long-term health-related quality of life (HRQoL; ie, physical, psychological, and social-relational functioning) after kidney donation might help clinicians improve the care of live kidney donors. This systematic review and meta-analysis summarizes prospective studies about the course and predictors of HRQoL in living kidney donors. Studies indicate that shortly after donation, donors have lower HRQoL, with minor to moderate changes in psychological and social-relational functioning and major changes in physical functioning. At 3-12 months after donation, HRQoL returned to baseline or was slightly reduced, particularly for fatigue, but scores were still comparable to general population norms. Results were mainly robust across surgery techniques. A limited number of studies examined risk factors for impaired HRQoL, with low psychological functioning before donation as the most consistent predictor. Based on these results, clinicians can inform potential donors that, on average, kidney donors have high long-term HRQoL; however, donors with low psychological functioning at baseline are those most at risk of impaired long-term HRQoL. Future studies should focus on other potentially relevant predictors of postdonation HRQoL, including donor eligibility criteria and donor-recipient relationships, to optimize screening and interventions for donors at risk.

Can right-sided hand-assisted retroperitoneoscopic donor nephrectomy be advocated above standard laparoscopic donor nephrectomy: a randomized pilot study

Endoscopic techniques have contributed to early recovery and increased quality of life (QOL) of live kidney donors. However, laparoscopic donor nephrectomy (LDN) may have its limitations, and hand-assisted retroperitoneoscopic donor nephrectomy (HARP) has been introduced, mainly as a potentially safer alternative. In a randomized fashion, we explored the feasibility and potential benefits of HARP for right-sided donor nephrectomy in a referral center with longstanding expertise on the standard laparoscopic approach. Forty donors were randomly assigned to either LDN or HARP. Primary outcome was operating time, and secondary outcomes included QOL, complications, pain, morphine requirement, blood loss, warm ischemia time, and hospital stay. Follow-up time was 1 year. Skin-to-skin time did not significantly differ between both groups (162 vs. 158 min, P = 0.98). As compared to LDN, HARP resulted in a shorter warm ischemia time (2.8 vs. 3.9 min, P < 0.001) and increased blood loss (187 vs. 50 ml, P < 0.001). QOL, complication rate, pain, or hospital stay was not significantly different between the groups. Right-sided HARP is feasible but does not confer clear benefits over standard right-sided LDN yet. Further studies should explore the value of HARP in difficult cases such as the obese donor and the value of HARP for transplantation centers starting a live kidney donation program (Dutch Trial Register number: NTR3096). Nevertheless, HARP is a valuable addition to the surgical armamentarium in live donor surgery.