A Comparison of Technique Modifications in Laparoscopic Donor Nephrectomy: A Systematic Review and Meta-Analysis

Abstract

ObjectiveTo compare the effectiveness of different technique modifications in laparoscopic donor nephrectomy.DesignSystematic review and meta-analyses.Data SourcesSearches of PubMed, EMBASE, Web of Science and Central from January 1st 1997 until April 1st 2014.Study DesignAll cohort studies and randomized clinical trials comparing fully laparoscopic donor nephrectomy with modifications of the standard technique including hand-assisted, retroperitoneoscopic and single port techniques, were included.Data-Extraction and AnalysisThe primary outcome measure was the number of complications. Secondary outcome measures included: conversion to open surgery, first warm ischemia time, estimated blood loss, graft function, operation time and length of hospital stay. Each technique modification was compared with standard laparoscopic donor nephrectomy. Data was pooled with a random effects meta-analysis using odds ratios, weighted mean differences and their corresponding 95% confidence intervals. To assess heterogeneity, the I2 statistic was used. First, randomized clinical trials and cohort studies were analyzed separately, when data was comparable, pooled analysis were performed.Results31 studies comparing laparoscopic donor nephrectomy with other technique modifications were identified, including 5 randomized clinical trials and 26 cohort studies. Since data of randomized clinical trials and cohort studies were comparable, these data were pooled. There were significantly less complications in the retroperitoneoscopic group as compared to transperitoneal group (OR 0.52, 95%CI 0.33–0.83, I2 = 0%). Hand-assisted techniques showed shorter first warm ischemia and operation times.ConclusionsHand-assistance reduces the operation and first warm ischemia times and may improve safety for surgeons with less experience in laparoscopic donor nephrectomy. The retroperitoneoscopic approach was significantly associated with less complications. However, given the, in general, poor to intermediate quality and considerable heterogeneity in the included studies, further high-quality studies are required.Trial RegistrationThe review protocol was registered in the PROSPERO database before the start of the review process (CRD number 42013006565).

Cumulative Sum Analysis of the Learning Curve for Modified Retroperitoneoscopic Living-Donor Nephrectomy

“…Regarding postoperative complications, in our study, 82 donors (67.8%) had no complications, 27 (22.3%) had grade I complications, 11 (9.1%) had grade II complications, and 1 (0.8%) had grade III complications according to the modified Clavien classification system. According to published reports, the degrees of complication in the present study are acceptable [18]. Regarding the recipient outcomes, no DGF or graft losses occurred within 6 months post-transplantation.…”

“…To contextualize our findings, we compared our results to those of published studies evalu- [18,19,28]. This rough comparison highlights that our modified method has the advantages of a short operating time, optimized WIT, and low EBL.…”

“…Gill et al [17] performed the first pure RPLDN. Recent systematic reviews and meta-analyses highlight that RPLDN has the advantages of fewer complications and a lower DGF rate compared with LLDN [18,19]. Wolf et al [20] reported efficacious and safe hand-assisted laparoscopic donor nephrectomy.…”

Deep neuromuscular blockade improves surgical conditions during low-pressure pneumoperitoneum laparoscopic donor nephrectomy

“…Modifications of the standard transperitoneal laparoscopic approach, such as the hand-assisted and/or retroperitoneoscopic approach, have been introduced to refine the surgical technique. However, till date no evidence exists that the hand-assisted and/or retroperitoneoscopic approach improve the clinical outcome after LDN as compared to the standard transperitoneal procedure [ 4 ]. Less invasive technique modifications such as laparoendoscopic single site (LESS) or natural orifice transluminal (NOTES) improve the cosmetic result, but are associated with a longer learning curve and higher costs [ 5 – 8 ].…”

Hand‐assisted laparoscopic retroperitoneal donor nephrectomy: A single‐institution experience of over 500 cases—Operative technique and clinical outcomes

“…Several other laparoscopic approaches have been attempted including hand‐assisted intraperitoneal approaches, robotic surgery, and retroperitoneoscopic approaches . Hand‐assisted laparoscopic donor nephrectomies are an attractive option and have been widely used because they allow for an easier dissection of the renal vessels, minimize the surgical incision size, reduce warm ischemia time, and allow greater control of bleeding …”