Key messages
- Keyhole surgery was found to be associated with less pain and less hospital stay for donors than open surgery.
- Kidneys recovered using the open or hand-assisted surgery technique were deprived of oxygen for shorter periods of time compared to the standard or robotic keyhole surgery technique.
Why use keyhole surgery rather than traditional surgery for people donating a kidney?
Extracting healthy kidneys for transplantation can be done with open surgery (a single large cut) or keyhole surgery (several smaller cuts). Many types of keyhole surgery are now used, including hand-assisted keyhole surgery and robot-assisted keyhole surgery. However, with all types of surgery, there are potential complications, including pain, length of procedure, blood loss and time spent in hospital.
What did we want to find out?
We wanted to find out if keyhole surgery improved the outcomes in people donating a kidney compared to traditional surgery.
What did we do?
We searched for all trials that assessed the benefits and harms of randomly allocating people donating a kidney to either keyhole or traditional surgery. We compared and summarised the results of the trials and rated our confidence in the information based on factors such as trial methods and sizes.
What did we find?
Twelve studies compared 1230 healthy kidney donors using these different types of surgeries. Standard keyhole surgery was found to be associated with less pain and less hospital stay for donors than open surgery. Kidneys recovered using the open or hand-assisted surgery technique were deprived of oxygen for shorter periods of time compared to the standard or robotic keyhole surgery technique. Complications that require further treatment, surgery, or both were low with all types of surgery.
What are the limitations of the evidence?
There are not yet enough studies to compare newer robotic-assisted keyhole surgery with other types of surgery.
How up to date is the evidence?
The evidence is up to date as of 31 March 2024.
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.
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.