Percutaneous versus surgical catheter insertion for peritoneal dialysis: a systematic review and meta-analysis of randomized controlled trials.

Introduction: Peritoneal dialysis (PD) is used as a kidney replacement therapy for patients with kidney failure. Institutional practices vary considerably, and the optimal technique for insertion of PD catheters is unknown. This study compared the efficacy and safety of surgical versus percutaneous approaches to PD catheter insertion for patients with end-stage kidney disease.

Methods: Electronic databases (MEDLINE, Embase, CENTRAL) were systematically searched and analysed for relevant randomized controlled trials (RCTs). Eligible RCTs for inclusion were those that compared surgical versus percutaneous approaches to catheter insertion for patients undergoing PD dialysis. Outcomes of interest were patient- and catheter-related complications. In this study risk of bias was assessed using the Cochrane Risk of Bias Tool for RCTs. The certainty of the evidence was evaluated using the Grading of Recommendations Assessment and Evaluation (GRADE) approach.

Results: Four studies (397 participants) were included. With regards to surgical approaches, only one study evaluated laparoscopic insertion; all other studies reported on open surgical techniques. Percutaneous insertion techniques varied significantly between the studies. No difference in patient mortality was found (RR = 0.82, 95% CI = 0.43-1.57, I² = 0%). Percutaneous techniques were associated with lower rates of early peritonitis (RR = 0.34, 95% CI = 0.12-0.91, I² = 0%) and long-term catheter failure (RR = 0.69, 95% CI = 0.47-1.00, I² = 0%) than surgical approaches. Percutaneous catheter insertion was also associated with reduced late peri-catheter leak rates (RR = 0.35, 95% CI = 0.12-0.98, I² = 0%) and peri-procedural complications (RR = 0.25, 95% CI = 0.07-0.90, I² = 0%). The overall risk of bias was moderate, and certainty of evidence was low or very low.

Conclusions: Whilst percutaneous PD insertion techniques may have lower early and late complications compared to surgical technique, there was a lack of high-quality evidence comparing outcomes between contemporary percutaneous and surgical PD catheter insertion techniques. Future RCTs are required to compare the safety and efficacy of modern percutaneous with laparoscopic techniques.