Authors' objectives:

The objective of this review was to assess the safety and efficacy of laparoscopic livedonor nephrectomy in comparison with open live-donor nephrectomy - the current standard approach for living donor nephrectomy.

Authors' results and conclusions: There were 72 included studies of which 44 were comparative and 28 were case series or case reports. The quality of the available evidence was average. There was only one randomised controlled trial and six non-randomised comparative studies with concurrent controls identified. The RCT was of average to good quality; however, the non-randomised concurrently controlled studies were limited by poor reporting of methodological detail such as inclusion/exclusion criteria, matching and losses to follow-up. The rest of the comparative evidence used historical controls and was therefore limited by the historical nature of the data such that systematic differences in data collection methods, hospital protocols, donor health status and kidney selected for transplant may have biased the results. In terms of safety, for donors, there did not appear to be any distinct difference between the laparoscopic and open approaches. No donor mortality was reported for either procedure and the complication rates were similar although the types of complications experienced differed between the two procedures. The conversion rate for LLDN to an open procedure ranged from 0% to 13%. In terms of efficacy, LLDN appears to be a slower operation with longer warm ischaemia times than OLDN but this did not appear to have resulted in increased rates of delayed graft function for recipients. Donor postoperative recovery and convalescence (parenteral narcotic use, time to oral intake, time to ambulation, length of hospital stay and return to work) appeared to be superior for LLDN making it a potentially more attractive operation for living donors. Whilst in the short-term graft function and survival did not appear to differ between the two techniques, long-term complication rates and allograft function remain somewhat unclear at this point in time and further long-term followup is required. LLDN remains a technique in evolution with no clear indications of whether handassisted LLDN or any of the other technical modifications are superior to standard LLDN. Surgical skill is an important factor affecting the success of the procedure, and the availability of a surgical team consisting of experienced laparoscopic and transplant surgeons has been recommended to optimise outcomes. Similarly, careful assessment and management of older donors, obese donors and donors with multiple renal arteries should mean that these groups can be suitable for LLDN. Evidence is increasing to support the use of the right kidney instead of the left, if necessary, provided sufficient surgical skill exists for this technically more demanding procedure. Further research on paediatric recipients of laparoscopically procured kidneys, and on the cost of LLDN is required.

Authors' recommendations: Evidence ratin: The available evidence-base was rated as average. Safety: LLDN was rated at least as safe as OLDN for donors in the short-term, although long-term complication rates have not yet been fully established. Efficacy: LLDN was rated at least as efficacious as OLDN for donor, with advantages in terms of convalescence. Graft function and survival appear to be similar for recipients in the short term but long-term efficacy could not be determined a this time. Recommendations: While additional high-quality randomised controlled trials would strengthen the evidence-base for LLDN compared to OLDN, the practical difficulties of conducting such trials is acknowledged. However, additional well conducted concurrently controlled comparative studies and the publication of long-term follow-up data would assist in resolving some the remaining questions regarding the safety and efficacy of LLDN. The Transplant Section of the Royal Australasian College of Surgeons should define appropriate training and accreditation processes for this technically demanding procedure. As the technique is no longer considered to be new, the Australian LLDN audit (which has been managed by ASERNIP-S to date) will be handed over to the Australian Transplant Registry. Given the remaining issues regarding, in particular long-term efficacy for recipients, an update and reappraisal of this review should occur within two to five years.

Authors' methods: Systematic review

Project Status: Completed

URL for project: http://www.surgeons.org/racs/research-and-audit/asernip-s/asernip-s-publications/systematic-reviews.aspx

Year Published: 2003

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: Australia

Organisation Name: Australian Safety and Efficacy Register of New Interventional Procedures-Surgical

Contact Address: ASERNIP-S 24 King William Street, Kent Town SA 5067 Australia Tel: +61 8 8219 0900

Contact Name: racs.asernip@surgeons.org

Contact Email: racs.asernip@surgeons.org

Copyright: Australian Safety and Efficacy Register of New Interventional Procedures - Surgical