Safety and effectiveness of laparoscopic renal biopsy: a single-center review and meta-analysis

Abstract

Background

While renal biopsy remains the preferred diagnostic method for assessing proteinuria, hematuria, or renal failure, laparoscopic renal biopsy (LRB) can serve as an alternative for high-risk patients when percutaneous kidney biopsy (PKB) is not recommended. This study was aimed to evaluate the safety of LRB.

Methods

In study 1, Fourteen patients from January 2021 to January 2023 had a LRB taken for various indications, such as morbid obesity, abnormal kidney construction, uncontrolled hypertension, and coagulopathy. We also conducted a Meta-analysis of the success rate and complication rate of previous LRB in study 2.

Results

All the patients completed biopsies and adequate renal tissues were obtained. The success rate was 100%. The median number of glomeruli obtained was 22.5 (range:12.0, 45.0). The complication rate was 7.1% (urinary tract infection). There were no significant differences between levels of hemoglobin, serum creatinine, and urinary NAGL before and after surgery. In the meta-analysis, the success rate of operation, satisfactory rate of sample, and complication rate of surgery were 99.9%, 99.1%, and 2.6% respectively.

Conclusion

LRB can achieve a good success rate and specimen retrieval and does not increase the risk of complications for high-risk patients. It can present as one of the alternative methods for patients with glomerular diseases.

Keywords:

• Laparoscopic
• renal biopsy
• high-risk
• meta-analysis

Introduction

Kidney biopsy is a firmly established diagnostic procedure for individuals experiencing hematuria, glomerular proteinuria, and unexplained renal failure. Percutaneous kidney biopsy (PKB) under ultrasound is widely applied because of the accuracy and minimally invasive. Nonetheless, PKB has some absolute and relative contraindications such as morbid obesity, solitary kidney, uncontrolled hypertension, high localized retroperitoneal kidneys, and coagulation disorders. There were several reports about serious complications such as the removal of kidneys and death [1,2]. The incidence of bleeding was 7.8% reported by Al Turk [3]. Open biopsy can be a reliable option and performed either by open surgery [4–6] or laparoscopy [7–9] while open surgery is traumatic and needs a long recovery time. Therefore, LRB as well as CT-guided renal biopsy, transjugular renal biopsy, and transurethral renal biopsy are all alternative options [10–12]. The first LRB was reported in 1991 by an American urologist [13]. In the past two decades, the effectiveness and safety of LRB have been observed in several studies and showed that adequate tissues can be obtained by this procedure [14,15]. Also, LRB can be applied in children [9,14]. These studies consistently considered LRB to be effective and safe. Furthermore, the occurrence of bleeding is significantly reduced because it can be hemostatic under direct vision. The application of LRB is less in China [16]. Thus, we retrospectively summarized the characteristics of cases and technical experience of LRB in our hospital in study 1 and conducted a Meta-analysis of the success rate and complication rate of LRB in study 2.

Study 1

Methods

Patients

Fourteen patients undergoing LRB from January 2021 to January 2023 in our center (Center for Kidney Disease, 2^nd affiliated hospital of Nanjing Medical University) were included in this study. The indications for biopsy of these patients include hematuria, moderate or massive proteinuria, and unexplained renal insufficiency. There are contraindications of these patients evaluated by nephrologists and sonographers. All patients signed informed consent and chose to take LRB. The study was approved by the Ethics Committee of the 2^nd affiliated hospital of Nanjing Medical University (2021XJ005-01).

Anesthesia and surgery

All the patients were evaluated by the anesthesiologist and met the criteria of the American Society of Anesthesiologists (ASA).

After inducing general endotracheal anesthesia, patients were placed in the left or right decubitus position. Firstly, the trocar position for observation was determined by selecting a point 3 cm above the iliac crest along the mid-axillary line. Following space expansion, manual finger localization within the retroperitoneal cavity was conducted to finalize the placement of the two trocars for operation. The puncture point on the posterior axillary line was typically selected 1-2 cm below the 12th rib impression, while the puncture point on the anterior axillary line was symmetrically positioned with the posterior axillary line puncture point, adjusted downward by approximately 1 cm based on the operator’s positioning. The pneumoperitoneum was established with CO₂ and maintained at a pressure of 13 mmHg.

After exposing the lower pole of the kidney, a 16-gauge automatic puncture gun was used. Two kidney tissues were collected from each patient, with an average length of 1.2 cm. After sampling, hemostatic gelatin was applied to stop the bleeding for 5-10min. Most patients obtained satisfactory results after 5 min of compression, while a few patients needed to extend the compression time appropriately. After confirming no active bleeding, abdominal drainage tube was routinely placed in the abdomen and the operation was completed.

Postoperative care

All the patients were recommended to have bed rest for the first 24 h after the surgery. The patient’s blood pressure (BP) and pulse should be dynamically monitored by specialized nurses, ensuring that the blood pressure remains below 140/90 mmHg. 24-h drainage was also monitored to ensure the safety of the patients. Regular inquiries about pain and hematuria were also ensured following the procedure. Observations were conducted to assess whether the patient developed new symptoms such as lower back pain, and abdominal pain.

Observation biomarkers

Blood routine, liver function, kidney function, and urinary neutrophil gelatinase-associated lipocalin (NAGL) tests were performed in all patients before and 24 h after surgery.

Blood and urine samples were obtained following overnight fasting before the surgery and 24 h after the surgery. Hemoglobin, serum albumin, and serum creatinine were measured using automatic analyzers (Beckman Coulter AU5800 and Sysmex XN-350). Urinary NAGL was measured using a commercially available chemiluminescence method (Vazyme, China).

Statistical analysis

Data were analyzed using SPSS Statistics 25.0. Mean ± Standard deviation ($\overline{x}$±SD) was used if the continuous data were normally distributed, and a t-test was applied to analyze the significance. If the continuous data did not fit the normal distribution, they were described by the quartile M (p25, p75), and the Wilcoxon rank sum test was used. Categorical variables were expressed as numbers with percentages, and the difference was determined by the Chi-squared test. p < 0.05 was considered statistically significant.

Ethical approval

Ethical approval for the study was granted by the Medical Ethics Committee of the Second Affiliated Hospital of Nanjing Medical University (ID: (2021) XJ 005-01)

Results

Clinical characteristics of the patients

The clinical characteristics of 14 patients were listed in Table 1. Ten of fourteen were males, and the average age was 50.4 ± 16.8 years. Contraindications of PKB were found in all patients, including morbid obesity (defined as BMI ≥ 40.0 kg/m² [17]) in 3 cases, poor renal structure (the presence of renal atrophy, thinning of the renal cortex, or multiple cysts observed under ultrasonography [18,19]) in 7 cases, uncontrolled hypertension (defined as office BP (systolic BP ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg) on three or more antihypertensive drugs, one of them being a diuretic [20]) in 3 cases, and abnormal coagulation (use of clopidogrel) in 2 cases. One case had two contraindications of PKB. LRB was successfully completed in all patients, with a median operative time of 60.1 (40 to 100) minutes. Three patients suffering from morbid obesity had BMI values of 42.6, 43.7, and 43.8 kg/m², respectively. All three patients were confirmed through ultrasound to have a skin-to-kidney distance of ≥14cm, making it challenging to obtain satisfactory samples through needle puncture. Two patients underwent laparoscopic surgery for co-existent adrenal nodules and poor renal structure, and concurrent renal biopsies were performed for pathological examination.

Table 1. The clinical characteristics of patients.

Number	Sex	Age	Scr (μmol/L)	Albumin (g/L)	BP (mmHg)	BMI (kg/m^2)	Indications for LRB
1	male	48	496	22.2	179/114	28.7	Uncontrolled hypertension, poor renal structure
2	male	41	584	33.5	176/109	32.0	Poor renal structure
3	male	25	165	42.4	140/107	24.0	Uncontrolled hypertension
4	male	76	555.3	45.0	154/93	17.2	Abnormal coagulation
5	female	43	56.3	33.7	136/81	43.8	Morbid obesity
6	female	70	52.3	34.3	135/81	43.7	Morbid obesity
7	male	52	959	38.8	142/115	23.8	Poor renal structure
8	male	47	304.2	43.0	189/128	28.6	Uncontrolled hypertension
9	female	64	127	44.4	115/73	26.8	Poor renal structure
10	male	67	234.6	42.5	135/75	27.0	Poor renal structure
11	male	67	155.1	26.4	125/80	20.8	Abnormal coagulation
12	male	44	644.9	25.8	156/119	22.0	Poor renal structure
13	female	42	323	48.5	144/98	22.8	Poor renal structure
14	male	19	129	13.3	181/95	42.6	Morbid obesity

Abbreviations: Scr: Serum creatinine, BP: Blood pressure, BMI: Body mass index, LRB: Laparoscopic renal biopsy.

Pathologic diagnosis

LRB biopsy samples were satisfactory in this study, and the median number of glomeruli observed in renal pathology was 22.5 (range: 12.0 to 45.0). Pathologic diagnosis of the kidney was confirmed in all patients after the procedure, most of them were independent pathological types, including IgA nephropathy (1 case), membranous nephropathy (2 cases), focal segmental glomerulosclerosis (1 case), diabetic nephropathy (1 case), etc. 4 patients were diagnosed with combined types (Table 2). It is noteworthy that two patients with membranous nephropathy presented with different clinical manifestations. Both patients exhibited normal renal function accompanied by mild microscopic hematuria. However, one patient had moderate proteinuria (1-2 g/d), while the other presented with proteinuria within the range of nephrotic syndrome. Their serum anti-phospholipase A₂ receptor (PLA₂R) antibodies were negative, and the definitive diagnosis of membranous nephropathy and hepatitis B-related renal injury was ultimately confirmed through renal pathology. Alongside the severe and intricate clinical symptoms, patients in study 1 simultaneously displayed complex renal pathological diagnoses. Correspondingly, the rates of combinations of two and three pathological types were 21.4% and 7.1%, respectively.

Table 2. Pathological diagnosis of patients.

Pathological diagnosis	Number
Minimal change disease	1
IgA nephropathy	1
Membranous nephropathy	2
Focal segmental glomerular sclerosis	1
Diabetic nephropathy	1
Hypertensive nephropathy	2
Acute interstitial nephritis	1
Tubulointerstitial nephritis	1
Diabetic nephropathy with hypertensive nephropathy	1
IgA nephropathy with tubulointerstitial nephritis	2
Focal segmental glomerular sclerosis with diabetic nephropathy and tubulointerstitial nephritis	1

Complications

Intraoperative: All patients underwent endotracheal intubation under general anesthesia. The vital signs were stable and there were no anesthesia accidents or surgery-related complications.

Postoperative: (1) infection: one case with type 2 diabetes had a fever and symptoms of urinary tract irritation 24 h after surgery, with urine white blood cells and leukocyte esterase positive, urinary culture negative. The patient received empirical antibiotic therapy following the diagnosis of a urinary tract infection. No other patients developed infective complications; (2) bleeding: all patients had no gross hematuria, sudden worsening lumbago, or abdominal pain after surgery. The mean preoperative and postoperative hemoglobin of patients were 113.4 ± 24.1 g/L and 108.0 ± 27.9 g/L, respectively, with no significant statistical difference (t = 0.527, p = 0.59, Figure 1A). Only one patient required a blood transfusion due to a decrease in hemoglobin levels from 84.0 g/L before surgery to 71.0 g/L; (3) kidney injury: The median preoperative and postoperative serum creatinine of patients were 304.2 (141.1, 569.7) μmol/L and 325.0 (171.6, 549.5) μmol/L, respectively (z=-0.308, p = 0.73, Figure 1B); the median preoperative and postoperative urinary NAGL were 213.6 (52.0, 391.8) ng/ml and 192.1 (60.0, 325.0) ng/ml (z=-0.505, p = 0.58, Figure 1C). There were no significant differences in serum creatine and urinary NAGL before and after surgery; (4) pain: Only one patient used the analgesia pump for 24 h after the operation while other patients could tolerate the pain.

Figure 1. The hemoglobin levels, serum creatinine levels and urinary NAGL levels before and after the operation. The mean preoperative and postoperative hemoglobin of patients were 113.4 ± 24.1 g/L and 108.0 ± 27.9 g/L, respectively (B). The median preoperative and postoperative serum creatinine of patients were 304.2 (141.1, 569.7) μmol/L and 325.0 (171.6, 549.5) μmol/L, respectively (A). The median preoperative and postoperative urinary NAGL were 213.6 (52, 391.8) ng/ml and 192.1 (60.0, 325.0) ng/ml, respectively (C).

Clinical follow-up result

We conducted follow-up on patients 3 months post-surgery. It is worth noting that, upon further examination through pathology, 3 patients were ultimately confirmed to be in CKD Stage 5 and subsequently received planned maintenance renal replacement therapy. 11 patients showed no significant difference in their serum creatinine during the follow-up period compared to preoperative values [165(127,315) vs 172(96.9,305), p = 0.25] (Supplemental Figure 1). All patients did not exhibit perirenal hematoma in the renal ultrasound follow-up conducted 3 months post-operative.

Study 2

Methods

Data sources and search strategy

Conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, this systematic review and meta-analysis aimed to evaluate the effectiveness and safety of LRB.

We searched the PubMed database, Web of Science, Wanfang Data, and China National Knowledge Internet (CNKI) from database building time to Dec 2023. Subject words and free words were combined to search. The search terms relating to ‘laparoscopy’, ‘retroperitoneoscopy’, ‘renal biopsy’, ‘kidney biopsy’, ‘laparoscope renal biopsy’, ‘laparoscope kidney biopsy’, ‘retroperitoneoscopic renal biopsy’, ‘retroperitoneoscopic kidney biopsy’, ‘laparoscopic-assisted renal biopsy’ and ‘laparoscopic-assisted kidney biopsy’.

Study selection

We searched for published matched pair analysis and retrospective studies that explored the indications, technique tips, and complications of LRB in both children and adults. The researcher conducted a systematic search and meticulously assessed identified studies to verify their compliance with the following criteria: 1) The study is a randomized controlled trial, cohort, case-control study, letter or case report with research data; 2) The study focuses on the application of laparoscope in renal biopsy for renal pathologic diagnosis; 3) Language of study is all language. The excluded criteria include: 1) The study is about renal malignant; 2) The full text cannot be obtained, or data cannot be extracted; 3) The study type is a comment, review, letter, meta-analysis, or case report without research data.

Literature screening and data extraction

Literature screening and data extraction were performed independently by two investigators and cross-checked. In case of discrepancy, they were resolved through discussion or negotiated by the third investigators. Data extraction included publication time, author, country, study type, number of patients, age of patients, gender of patients, outcomes, etc.

Quality assessment

The quality of the literature was evaluated by the Newcastle-Ottawa Scale (NOS) which included 3 modules and 8 items. The full score was 9, with 7-9 classified as high quality, 4-6 as medium quality, and ≤ 3 as low quality. The initial rating was carried out by two authors and reviewed by a third author if there was any discrepancy.

Data synthesis and analysis

The outcomes were defined as the success rate of operation, satisfactory rate of sample, and complication rate of surgery. R 4.0 software was used for data analysis, and the ‘meta’ package was used for meta-analysis. Heterogeneity was detected by the Cochrane Q test. If there was no statistical heterogeneity between studies (I²<50%, p > 0.1), a common effect model was applied for meta-analysis. If there was statistical heterogeneity (I²<50%, p < 0.1), then a random response model was used. Publication bias was assessed using Egger’s test and a funnel plot. The symmetrical funnel plot and p > 0.05 indicated no significant publication bias. If there was publication bias, the trim and filling method was used to reduce or increase the dummy study and then the publication bias was further assessed. In addition, we conducted subgroup analyses based on age, publication region, and publication year. The study population was stratified into pediatric and adult groups, and further categorized into research conducted in Asian and Western regions, as well as studies published before and after 2005.

Results

Searching results

5920 articles were found after the initial search. Among the 5920 records, 3828 records were identified through the PubMed database, 1195 records were through the Web of Science database, 32 records were through Cochrane Library, 233 records were through Wanfang data, and 632 records were through CNKI. After reading all the study titles and abstracts, 5778 records were excluded because of the wrong topic. Again, 125 studies were excluded due to a lack of relevant data by reading the full text. Among the remaining 17 records, 2 studies were from China-Japan Friendship Hospital with overlapping data, and the study with fewer subjects was excluded [21]. Finally, 16 records were included in our study [7,8,14–16,22–32]. The screening flow chart is shown in Figure 2.

Figure 2. PRISMA flow chart of the literature search. PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyzes.

Characteristics and quality assessment of the included records

All the included studies were retrospective studies and the quality scores of these studies showed medium or high quality. The characteristics and quality assessment are shown in Table 3.

Table 3. Clinical characteristics and quality assessment of the included records.

First author, Year, Ref	Country	Study type	N	Male	Female	Age	Quality score
Gaur et al. 1994 [22]	India	Retrospective	17	10	7	10–57	6
Chen et al. 1997 [23]	USA	Retrospective	8	3	5	29–80	5
Gimenez et al. 1998 [7]	USA	Retrospective	32	11	21	3–79	5
Gupta et al. 2000 [24]	USA	Case report	3	2	1	47–66	3
Takeda et al. 2000 [25]	Japan	Letter	11	5	6	2–15	5
Caione et al. 2000 [26]	Italy	Retrospective	20	11	9	2–18	5
Shetye et al. 2003 [8]	USA	Retrospective	74	29	45	3–79	6
Luque et al. 2006 [27]	Spain	Retrospective	53	28	25	1–18	6
Jesus et al. 2007 [14]	Brazil	Retrospective	17	5	12	2–12	6
Anas et al. 2008 [28]	Japan	Retrospective	21	14	7	21–83	5
Acikgöz et al. 2008 [29]	Turkey	Retrospective	9	5	4	/	4
Bastos et al. 2009 [30]	Brazil	Letter	5	/	/	1–13	3
Repetto et al. 2011 [31]	Italy	Retrospective	40	/	/	/	7
Micali et al. 2014 [32]	Italy	Retrospective	14	10	4	18–80	5
Aoun et al. 2019 [15]	Lebanon	Retrospective	40	16	24	20–77	8
Zou et al. 2023 [16]	China	Retrospective	104	71	33	23–76	7

Meta-Analysis

The success rate of operation was 99.9% analyzed through the common effect model (Figure 3). There was no significant bias evaluated by Egger’s test (t=-1.69, p = 0.1127) and funnel plot (Supplemental Figure 2). The satisfactory rate of the sample was 99.1% analyzed through the common effect model (Figure 4). There was no significant bias evaluated by Egger’s test (t= −0.24, p = 0.8165) and funnel plot (Supplemental Figure 3). The complication rate of surgery was 2.6% through the common effect model (Figure 5). There was no significant bias evaluated by Egger’s test (t = 1.85, p = 0.0858) and funnel plot (Supplemental Figure 4). There was no statistical heterogeneity between studies (I²<50%, p > 0.1).

Figure 3. The success rate of operation analyzed through the common effect model. The success rate of operation was 99.9%.

Figure 4. The satisfactory rate of sample analyzed through the common effect model. The satisfactory rate of sample was 99.1%.

Figure 5. The complication rate of surgery analyzed through the common effect model. The complication rate of surgery was 2.6%.

Subgroup analysis

Among the 16 studies, 5 studies included children younger than 18 years while 6 studies included adults aged more than 18 years. 5 studies included children and adults and the outcomes were not distinguished between adults and children. After analyzing the operation success rate, sample satisfaction rate, and surgical complication rate of adults and children, we found that both adult and child patients had high operation success rates (100% vs 99.5%) (Supplemental Figure 5 A and Supplemental Figure 6 A) and sample satisfaction rate (97.6% vs 100%) (Supplemental Figure 5B and Supplemental Figure 6B), and a low complication rate (1.2% vs 2.6%) (Supplemental Figure 5 C and Supplemental Figure 6 C). In the subgroup analysis of the regions where the study was published, the operation success rate (99.9% vs 100%) (Supplemental Figure 7 A and Supplemental Figure 8 A) and the sample satisfaction rate (99.6% vs 97.8%) (Supplemental Figure 7B and Supplemental Figure 8B) were both high in the Western and Asian studies. However, the surgical complication rate was higher in Western studies than in Asian studies (4.9% vs 1.4%) (Supplemental Figure 7 C and Supplemental Figure 8 C). In terms of publication time, the operation success rate (99.9% vs 100%) (Supplemental Figure 9 A and Supplemental Figure 10 A) and the sample satisfaction rate (98.8% vs 99.1%) (Supplemental Figure 9B and Supplemental Figure 10B) were similar in early and late-stage studies while the surgical complication rate of early studies was higher than late-stage studies (7.8% vs 1.7%) (Supplemental Figures 9 C and 10C). The types and number of surgical complications in different studies are shown in Table 4.

Table 4. The types and number of surgical complications of different studies.

First author, Year, Ref	Total, n	Complications, n	Detailed complications (n)
Gaur et al. 1994 [22]	17	2	Bleeding (1), gross hematuria (1).
Chen et al. 1997 [23]	8	0	/
Gimenez et al. 1998 [7]	32	3	Inadvertent spleen biopsy (1), bleeding (1), death (1).
Gupta et al. 2000 [24]	3	0	/
Takeda et al. 2000 [25]	11	0	/
Caione et al. 2000 [26]	19	1	Peritoneal tear (1).
Shetye et al. 2003 [8]	74	10	Bleeding (3), initial biopsy of non-renal tissue (2), seromuscular bowel injury (1), death (1), deep venous thrombosis (1), pulmonary edema (1), hyperkalaemia (1).
Luque et al. 2006 [27]	53	1	Bleeding (1).
Jesus et al. 2007 [14]	15	3	Peritoneal tear (1), perirenal hematoma (1), peritoneum was opened and the open biopsy was performed (1).
Anas et al. 2008 [28]	21	1	Hernia (1).
Acikgöz et al. 2008 [29]	9	0	/
Bastos et al. 2009 [30]	5	0	/
Repetto et al. 2011 [31]	40	3	Post biopsy renal bleeding (1), minor bleeding from the port site (2).
Micali et al. 2014 [32]	14	0	/
Aoun et al. 2019 [15]	40	0	/
Zou et al. 2023 [16]	104	2	Disseminated intravascular coagulation (1), injury at the hilum of the kidney (1).

Discussion

Our study demonstrated that LRB can be processed successfully and safely in patients with uncontrolled hypertension, morbid obesity, and poor kidney structure. Effective and accurate pathologic diagnosis can be made by LRB and there were no serious complications. These results were consistent with previous studies confirmed by Meta-analyses. There was no bleeding, seromuscular bowel injury, pulmonary edema, or inability to obtain specimens as reported in another study may be due to the limited cases. Furthermore, we did not find any adverse effect of LRB on renal function in the short-term postoperative period. As we know, this is the first study concerned with the impact of LRB on renal function.

Although the discovery of some disease-specific biomarkers has led to improved diagnosis of kidney disease, such as PLA₂R [33] and anti-thrombospondin type-1 domain-containing 7 A (THSD7A) [34], which are specific antibodies for idiopathic membranous nephropathy, kidney histopathological examination remains the gold standard for the diagnosis of other glomerular diseases. In our study, two patients with membranous nephropathy, despite having diverse clinical characteristics and testing negative for antibodies, one was diagnosed with hepatitis B-related membranous nephropathy while another was primary membranous nephropathy through pathological examination. This finding supports the importance of renal pathology for diagnosis and treatment, even in high-risk patients.

The first open kidney biopsy was performed in 1923 [4]. PKB is a common method to obtain kidney tissues because local anesthesia is used, and it is minimally invasive. However, there are relative and absolute contraindications of PKB, such as abnormal coagulation, morbid obesity, solitary kidney, poor visualization on ultrasonography, and uncontrolled hypertension. When PKB is contraindicated while a biopsy is necessary for diagnosis, an open kidney biopsy was once an important option. Sufficient tissues could be obtained by open surgery and hemostasis can be processed under direct vision. Nevertheless, the application of open surgery is limited due to trauma, post-operation pain, and delayed recovery.

It must be considered that some alternative techniques also hold high clinical value in high-risk patients. In TJRB, renal parenchymal hemorrhage is drained through the renal venous system, thereby preventing blood loss through the renal capsule. Compared to PKB, it allows for obtaining sufficient renal tissue for histopathological diagnosis without increasing the risk of serious complications [10]. Even in patients with coagulopathy and/or thrombocytopenia (especially true for major bleeding risk scores ≥20), TJRB is associated with a lower risk of major bleeding than PKB [11]. Existing studies also have demonstrated that CT-guided renal biopsy is an accurate and safe alternative method for diagnosing renal diseases in patients with specific conditions that make PKB challenging. In the study conducted by Javier Vian and colleagues, it showed a similar diagnostic rate to that of PKB (92.9% vs. 90.8%, p = 0.437). Additionally, there was no significant increase in the incidence of severe complications, including post-biopsy hypotension (1.8% vs. 2.5%, p = 0.621) and blood transfusion (0% vs. 4.3%, p = 0.122) [12]. Moreover, it demonstrated excellent sensitivity in detecting small perinephric hematomas.

LRB is a reliable option for high-risk patients because it is minimally invasive and hemostasia is achieved under direct vision. Previous studies have demonstrated that LRB can obtain adequate samples in both children and adults. The diagnostic rate is 95%∼100% and there are few complications post-operation of LRB. As mentioned in the Meta-analysis, the surgical complication rate was higher in early studies and Western studies. The immaturity of laparoscopy in the early stage should be taken into consideration. Due to the early launch of LRB in Europe and America, about 50% of the included studies were early studies published by the Western region while most of the included studies were late stage (about 66.7%) in the Asian region. Fourteen LRBs were performed in our center, and only one patient suffered a urinary tract infection after surgery. One patient needed a blood transfusion after the operation but not due to obvious bleeding. Primary drawbacks associated with LRB include its invasive nature and the necessity for general anesthesia, which may entail accompanying complications. The reported complications include bleeding, bowel injury, deep venous thrombosis, pulmonary edema, hyperpotassemia, and urinary leakage. These complications can be avoided by experienced surgeons. In addition, we should pay attention to the influence of CO₂ absorption and increased intra-abdominal pressure. CO₂ may inhibit heart constriction, reduce heart output, constrict renal vessels, and then decrease renal blood flow [35]. Increased abdominal pressure will lead to parenchymal compression, increased pressure of the renal vein, and obstruction of outflow [36–38]. To evaluate the impact of CO₂ absorption and increased intra-abdominal pressure on kidney function, the levels of serum creatine and urinary NAGL before and after surgery were measured. Although limited to the number of patients, it covered stages 1-5 of chronic kidney disease (CKD). It’s worth noting that, upon further examination through pathology, 3 patients were ultimately confirmed to be in CKD Stage 5 and subsequently received planned maintenance renal replacement therapy. The remained patients did not show deterioration of renal function after surgery. Totally, 14 patients performed LRB through retroperitoneum access successfully and there were no serious complications. Compared with PKB, LRB is more expensive and requires general anesthesia, so the risks of anesthesia need to be fully assessed before surgery. Consequently, LRB proves to be a secure and effective option for high-risk patients.

Renal biopsy is the method of choice for the diagnosis of parenchymal kidney disease and allows differentiation of active inflammation form irreversible chronic changes and provides the basis for clinicians to make treatment decisions. If preexisting risks cannot be adequately reduced and there is an urgent indication for biopsy, alternative procedures such as LRB should be considered. Furthermore, the amount of kidney tissue obtained from PKB is inadequate for diagnosis in some cases. There is a study compared the sample acquisition rates of LRB and PKB, demonstrating that LRB was associated with a greater number of glomeruli (50, 20-77) compared to PKB (10, 7-15) [15]. The present study also confirmed that adequate samples could be obtained by LRB. In addition, the pathological characteristics of included patients were complex. Thus, LRB provides a chance to make a precise pathological diagnosis and give target therapies to these patients.

The limitation of this study is its small size and single-center retrospective design. We conducted a further Meta-analysis to demonstrate the generalizability of the results in this study. Taking into consideration the success rate and complications risks associated with LRB, these factors are influenced by preoperative assessment and management of LRB, as well as the surgeon’s proficiency in performing the procedure. Therefore, prospective research with a larger sample size in the multicenter setting under standardized training protocols needs to be conducted to fully assess the risks of complications associated with LRB in the future. Secondly, alternative methods like transjugular renal biopsy, CT-guided renal biopsy, and transurethral renal biopsy, shouldn’t be disregarded, although, due to technical reasons, we have not been able to carry them out at this time. As laparoscopic surgical kidney biopsies might have been linked to prolonged recovery times and anesthesia-related and surgical risks associated with the procedure, the advantages of other available renal biopsy alternatives suggest that we should choose carefully to provide the best option for patients.

For future research, more patients should be included, and long-time follow-up was required to further evaluate the influence of LRB on renal function. Furthermore, clinical cohort studies are needed to assess the differences between LRB and other available renal biopsy alternatives, aiming to provide optimized clinical choices to the patients and clinical practitioners. Nevertheless, LRB is confirmed as a safe and reliable alternative for high-risk patients.

Authors’ contributions

P.W. guaranteed the complete integrity of this research. P.W., L.J. and J.Y. designed this study. L.X., X.B., J.Y., and Y.F. were responsible for carrying out the clinical studies. L.X., X.B., and H.X. all contributed to gathering the data. Data analysis and manuscript writing were performed by X.B. and L.X. The paper was revised by J.Y. after being edited by P.W. and L.J. All authors have reviewed and given their approval to the final manuscript. L.X. and X.B. contributed to this work equally.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The datasets used in this work are accessible upon reasonable request from the corresponding author.

Additional information

Funding

This work was supported by the National Natural Science Foundation of China Grants 82100758 (to P. Wen), Science and Technology Support Program of Jiangsu Province BK20210980 (to P. Wen).