Living donor nephrectomy is unique in that the donor assumes an operative risk yet has no underlying disease and does not have any direct medical benefit from the procedure. This explains the clear imperative to ensure that donor complications are minimized [3
]. While LDN and HALDN techniques have been shown to be safe compared to open surgery, both techniques appear to have different rates and types of complications. The data we analyzed suggest that LDN donors experience higher rates of intraoperative complications than HALDN donors. Furthermore, the incidence of major bleeding and overall vascular injury was also greater in the LDN group and more commonly required open conversion and blood transfusions. Conversely, the rate of postoperative wound infections renal and ureteric injuries appeared to be greater in the HALDN group.
While proponents of HALDN point out the advantages of a kidney extraction site and improved tactile control during the procedure, investigators have questioned if HALDN patients suffer from a greater number of post-operative complications [50
]. Our data analysis strongly supports the impression that HALDN donors have greater incision morbidity than LDN donors. This contrasts with the findings of Kocak et al., who reported no significant differences in incision morbidity in a large direct comparison of LDN and HALDN donor complications [35
]. We have no data to explain this discrepancy, but it may suggest that institutional practices and technical experiences play a role in determining outcomes unique to each study. We did not find significant differences in the rate of re-hospitalization due to infection nor the rate of re-operation for incisional hernia.
Post-operative bowel complications were cited as significant sources of donor morbidity in HALDN and thus are the reason why some centers choose to employ the LDN technique in favor of HALDN [35
]. We identified greater rates of ileus in HALDN donors and re-hospitalization due to ileus. Unexpectedly, post-operative renal and ureteric complications were also significantly elevated among HALDN donors. This may be a concern and may motivate surgeons to select the LDN in preference to the HALDN technique. However, we found that 50% of observations came from one HALDN trial [25
] and 25% came from another [29
]. Therefore the increased rate of ureteric and renal complications could be due to unidentified center specific practices that are not found at other institutions.
There is debate in the literature if one laparoscopic technique is preferential to the other in obese donors. Heimbach et al. found that HALDN was safe in obese donors (BMI>30 kg/m2
); however total operative times and intraoperative complications were increased in significantly obese donors [29
]. In contrast, Sundaram et al. did not find significantly elevated operative or post-operative complication rates in obese LDN donors [49
]. In our limited analysis, we found that obese LDN and HALDN donors had nearly equivalent BMIs of 26.8
, respectively. We did not identify differential conversion rates secondary to obesity; however, there is insufficient data to draw firm conclusions on this topic.
Total operative time, warm ischemia time, and length of stay are surrogate measures of outcome. Warm ischemia time was the only operative parameter that was significantly different between the LDN and HALDN groups, with shorter WIT reported in HALDN procedures. Investigators have attributed this difference to the increased tactile control in HALDN, leading to faster vessel management and kidney extraction [3
]. We did not find any statistical difference for either total operative time or length of hospital stay between the techniques. The studies that directly compared the latter two variables in LDN and HALDN procedures reported conflicting trends. It was difficult to compare total operative time with confidence because investigators do not always report a uniform end point that would allow a direct a comparison between institutions. Despite this limitation we observed a wide range in total operative times for each technique (LDN 78.4–253 minutes; HALDN 83–283 minutes). This suggests that center-specific practices and/or experiences influence the operative time reported in the literature.
Our data summarizes the rates of complications and operative statistics reported in the peer-reviewed literature of large institutional studies. Therefore, there are limitations to our study. We have no resources to test the validity of the published findings or identify all the center specific variables that determined the reported outcome. We therefore cannot guarantee that the observations calculated from the summated data can be generalized to other transplant centers. Our conclusions are therefore limited to the specific dataset that was analyzed. While the datasets include a large number of patients, there could be a systematic bias associated with restricting our search to published studies. The use of publications with diverse study designs prevented us from using meta-analysis. Thus, we used simple observational outcomes from the published peer-reviewed literature to create a dataset for analysis and did not use a common measure of effect size. Because we were unable to control the effects of all study characteristics, the dataset incorporates several sets of assumptions and conditions. Even though the data set must be interpreted with caution, it provides a large compendium of outcome information as a first step in assessing performance for quality outcome purposes.
At present there is no evidence that proves one laparoscopic technique is superior to the other. There are however consistent trends in the data suggesting that intraoperative injuries are more common in LDN patients while post-operative injuries are more common in HALDN donors. Analysis of major donor morbidity differentiates the two techniques. Transfusions and conversion to open procedures from vascular injury are the most common sources of major donor morbidity reported in the literature. These are cited more frequently in LDN procedures. Conversely, there did not appear to be a difference in the overall rate of major post-operative complications. As such, this paper suggests that the HALDN approach has less associated risk of major donor morbidity.