A Systematic Review of Clinical Outcomes in Laparoscopic versus Robotic Donor Nephrectomy

Abstract

Living donor kidney transplantation remains the preferred treatment for end-stage renal disease because it provides superior long-term outcomes compared with dialysis. The increasing use of minimally invasive techniques, particularly Laparoscopic Donor Nephrectomy (LDN) and Robotic Donor Nephrectomy (RDN), has prompted comparisons of their perioperative performance and donor outcomes. This study systematically reviewed evidence comparing postoperative renal function, hospital length of stay, perioperative parameters, and postoperative complications between LDN and RDN. A systematic review following PRISMA guidelines searched PubMed, Scopus, Web of Science, ScienceDirect, and Google Scholar for comparative studies published between 2010 and 2025. Methodological quality was assessed using the Newcastle–Ottawa Scale and the JBI Critical Appraisal Checklist. Ten studies met the inclusion criteria and were synthesized qualitatively. The evidence indicates that RDN and LDN produce comparable postoperative renal function, including stable estimated glomerular filtration rate (eGFR) and serum creatinine levels. Several studies reported shorter hospital stays, lower early postoperative pain scores, and faster recovery with RDN, although robotic procedures required longer operative times during early implementation. Complication rates were generally low and similar between techniques. Overall, both LDN and RDN are feasible and safe minimally invasive approaches for living donor nephrectomy. However, variations in study design, institutional experience, and outcome reporting limit definitive conclusions regarding the superiority of either technique, highlighting the need for standardized high-quality comparative studies.

Keywords: complications; hospital stay; laparoscopic donor nephrectomy; renal function; robotic donor nephrectomy.

Introduction

Kidney transplantation represents the definitive therapeutic intervention for individuals with end-stage renal disease (ESRD), demonstrating superior long-term survival and quality-of-life outcomes compared with dialysis modalities (Matas & Rule, 2022; Ortiz et al., 2025). The success of living donor kidney transplantation, however, depends not only on recipient graft outcomes but also on the preservation of donor safety and postoperative well-being during nephrectomy procedures (Chan et al., 2025; Napoli et al., 2024). Consequently, surgical techniques for donor nephrectomy continue to evolve toward minimally invasive approaches that reduce perioperative morbidity while maintaining graft integrity and functional outcomes (Plage et al., 2020).

Since its introduction in the 1990s, laparoscopic donor nephrectomy (LDN) has become the standard minimally invasive approach for living kidney procurement because of its association with reduced postoperative pain, shorter hospitalization, improved cosmetic outcomes, and faster recovery compared with open surgery, without compromising graft function (Wang et al., 2020). The technique also demonstrates acceptable intraoperative safety profiles characterized by low conversion rates and limited transfusion requirements (Zaytoun et al., 2021). Nevertheless, conventional laparoscopy remains technically demanding, particularly in complex donor anatomy and prolonged procedures, due to limitations in instrument dexterity, ergonomics, and depth perception.

Technological advancements in minimally invasive surgery have facilitated robotic donor nephrectomy (RDN), which incorporates three-dimensional visualization, articulated instrumentation, enhanced precision, and improved operator ergonomics (Munoz Abraham et al., 2025; Serni et al., 2021). These features may reduce surgeon fatigue and improve technical performance. Previous studies suggest robotic systems may stabilize perioperative performance and facilitate learning in experienced transplant centers (Khajeh et al., 2023; Pham et al., 2026).

Despite increasing clinical utilization of RDN, comparative evidence remains heterogeneous. Some studies report shorter hospitalization and lower postoperative pain with robotic approaches, while operative duration, warm ischemia time, and perioperative efficiency remain inconsistent across institutions and experience levels (Khajeh et al., 2023; Musquera et al., 2025). Acquisition costs, maintenance, infrastructure, and workforce training also influence implementation (Boyar et al., 2021; Hinojosa-Gonzalez et al., 2023; Serni et al., 2021).

Earlier comparative reviews primarily emphasized technical variables such as operative time, blood loss, and conversion rates. Donor-centered outcomes—including postoperative renal function, hospital length of stay, and standardized complication profiles—were often secondary. This review therefore provides an updated donor-centered synthesis of evidence published from 2010 to 2025, integrating contemporary robotic implementation experience and operational considerations.

The study aims to systematically compare LDN and RDN with emphasis on postoperative renal function, hospital length of stay, and perioperative and postoperative complications, while clarifying the evidentiary position of RDN and identifying priorities for standardized high-quality research.

Methods

Study Design

This systematic review comparatively evaluated clinical outcomes between LDN and RDN in living kidney donors. It focused on postoperative renal function, hospital length of stay, and perioperative and postoperative complications. The methodology followed PRISMA guidelines. Owing to heterogeneity in design, definitions, institutional protocols, and reporting formats, the review used structured narrative synthesis rather than quantitative meta-analysis; no pooled effect estimates or forest plots were generated.

Literature Search Strategy

A comprehensive search was conducted in PubMed, Scopus, Web of Science, ScienceDirect, and Google Scholar between January and March 2025, with the final search completed on 28 March 2025. Search terms combined LDN/RDN terminology with renal function, hospital stay, complications, and comparative-study terms using Boolean operators. Studies published from 2010 to 2025 were eligible. The first 200 Google Scholar results sorted by relevance were screened, and duplicates were removed.

Study Selection and Eligibility Criteria

Two reviewers independently screened titles, abstracts, and full texts. Disagreements were resolved by discussion or a third reviewer. Eligible studies directly compared LDN and RDN in living adult kidney donors, reported at least one donor-centered outcome, used prospective or retrospective comparative designs, and were published in English from 2010 to 2025. Non-comparative studies, case reports, abstracts, editorials, reviews without patient-level comparative data, pediatric or non-living donor procedures, insufficient reports, duplicates, and overlapping datasets were excluded.

Data Extraction

Two reviewers used a standardized extraction form to collect author, year, country, study design, sample size, donor demographics, operative time, estimated blood loss, warm ischemia time, postoperative serum creatinine and eGFR, hospital stay, complications, and principal findings. Discrepancies were resolved through discussion and verification against original articles.

Quality Appraisal

Methodological quality was assessed independently using the Newcastle–Ottawa Scale for cohort and observational comparative studies and the JBI Critical Appraisal Checklist where appropriate. Selection, group comparability, outcome assessment, and adequacy of follow-up were evaluated, with scoring differences resolved by consensus.

Data Synthesis and Analysis

Because of heterogeneity, results were synthesized narratively across three domains: postoperative renal function, length of hospital stay, and perioperative/postoperative complications. Descriptive tables and thematic interpretation were used to identify similarities, differences, and emerging cross-study patterns.

Result and Discussion

Search Strategy and Study Selection

The database search identified 400 records. After 80 records were removed before screening, 320 titles and abstracts were assessed and 200 were excluded. Of 120 full-text reports sought, 10 were unavailable. Among 110 reports assessed for eligibility, 83 were excluded for irrelevance, inadequate publication quality, or limited accessibility. Ten studies were ultimately included in the qualitative synthesis.

PRISMA Flow Diagram

The PRISMA 2020 diagram documents identification, screening, eligibility, and inclusion. It shows the contribution of each database, removal of duplicate and automated exclusions, title/abstract screening, full-text retrieval, reasons for exclusion, and final inclusion of 10 studies.

Quality Assessment and Risk of Bias

Most included studies showed moderate methodological quality and relatively low risk of bias in outcome reporting. Nevertheless, retrospective single-center designs, selection bias, differences in surgeon expertise, learning curves, and perioperative protocols limited external generalizability and contributed to clinical heterogeneity.

Synthesis and Interpretation of Findings

Both RDN and LDN generally produced comparable donor-centered outcomes. Postoperative eGFR and serum creatinine remained clinically acceptable after both procedures, and major complications, conversions, and adverse donor events were uncommon. Several studies found modestly shorter hospitalization and lower early postoperative pain with RDN, but these benefits were not uniform. RDN often required longer operative time during early implementation, reflecting robotic setup and learning-curve effects; thus, current findings do not establish overall clinical superiority.

Critical Evaluation of Evidence Quality and Heterogeneity

The consistency of donor safety findings supports the feasibility of both techniques in experienced centers. However, most evidence came from non-randomized retrospective cohorts with variable sample sizes. Differences in institutional robotic volume, procedural standardization, training infrastructure, and surgeon experience strongly influenced operative efficiency and complication reporting. Results from highly specialized centers should therefore be generalized cautiously.

Comparative Perspectives Across Geographic and Institutional Settings

Studies from Europe, Asia, and Latin America consistently reported acceptable renal outcomes and low complication rates when appropriate expertise was available. Yet access to robotic technology, training pathways, maintenance resources, and sustainable case volumes varied substantially. Adoption is therefore both a surgical and a healthcare-management decision involving institutional capacity, resource allocation, and economic feasibility.

Management and Social Implications

Robotic surgery may offer ergonomic benefits and incremental improvements in early recovery, but evidence does not support universal implementation. Potential reductions in hospitalization and analgesic use must be balanced against acquisition, maintenance, staffing, and training costs. Unequal access to robotic platforms may widen disparities between transplant centers; future evaluation should address accessibility, institutional equity, and sustainability alongside clinical outcomes.

Limitations and Future Research Directions

The evidence base was dominated by retrospective observational studies, heterogeneous outcome definitions, varying perioperative protocols, and short follow-up. Narrative synthesis precluded pooled effect estimates. Cost-effectiveness, donor quality of life, long-term renal function, and healthcare utilization remain insufficiently studied. Future research should use multicenter prospective or randomized designs, standardized outcomes, longer follow-up, learning-curve evaluation, and comprehensive health-economic analysis.

Summary of Key Findings

Both RDN and LDN are safe and clinically effective minimally invasive options. Preservation of renal function and low complication rates are the most consistent findings. Potential robotic benefits in recovery and ergonomics appear incremental and context dependent, supporting cautious integration rather than replacement of established laparoscopic approaches.

Conclusion

This systematic review indicates that RDN and LDN demonstrate generally comparable donor-centered clinical outcomes, particularly postoperative renal function preservation and perioperative safety. Both techniques were associated with stable eGFR, acceptable serum creatinine, and low major complication rates. Modest reductions in hospital stay and early pain were reported in some robotic cohorts but were not uniform.

Operative duration in RDN is strongly influenced by institutional learning curves and surgeon experience. High-volume centers reported progressive improvement after approximately 20–40 cases, suggesting that implementation maturity rather than inherent procedural superiority explains many observed differences.

The review contributes an updated donor-centered perspective based on evidence from 2010–2025. Broader robotic adoption should be guided by institutional case volume, surgeon proficiency, infrastructure, economic sustainability, and learning capacity. Current evidence does not establish clear long-term superiority over laparoscopy.

Future studies should prioritize multicenter prospective and randomized comparisons, standardized outcome reporting, consistent complication grading, longer follow-up, cost-effectiveness and cost–utility analysis, donor quality of life, functional recovery, and long-term graft outcomes.

Author Contributions

Muhammad Rizki Fadil led conceptualization, protocol development, literature searching, data extraction and analysis, and manuscript drafting and revision. Fabian Gamal Sutrisno contributed to screening, quality appraisal, and methodological review. Jeremia Yusak Lestari contributed to data extraction, table preparation, and interpretation. Archie Fontana Iskandar supported critical evidence analysis, discussion and managerial implications, and narrative consistency. All authors reviewed and approved the final manuscript.

Acknowledgements

The authors thank the Director and management of RSUD Cimacan, Cianjur Regency, West Java, for institutional support, flexibility, and guidance, and acknowledge colleagues in the Department of Surgery and the kidney transplant service team for clinical insights, moral support, and collaboration.

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