Sun et al.

BMC Nephrology (2020) 21:60

https://doi.org/10.1186/s12882-020-01724-w

RESEARCH ARTICLE Open Access

Randomized controlled trials for

comparison of laparoscopic versus
conventional open catheter placement in
peritoneal dialysis patients: a meta-analysis
Mei-Lan Sun1†, Yong Zhang2†, Bo Wang3, Te-An Ma4, Hong Jiang4, Shou-Liang Hu4, Piao Zhang5 and
Yan-Hong Tuo6*

Abstract
Background: The application of laparoscopic catheterization technology in peritoneal dialysis (PD) patients has
recently increased. However, the advantages and disadvantages of laparoscopic versus conventional open PD
catheter placement are still controversial. The aim of this meta-analysis is to assess the complications of
catheterization in PD patients and to provide a reference for choosing a PD-catheter placement technique in the
clinic.
Methods: We searched numerous databases, including Embase, PubMed, CNKI and the Cochrane Library, for
published randomized controlled trials (RCTs).
Results: Eight relevant studies (n = 646) were included in the meta-analysis. The pooled results showed a lower
incidence of catheter migration (OR: 0.42, 95% CI: 0.19 to 0.90, P: 0.03) and catheter removal (OR: 0.41, 95% CI: 0.21
to 0.79, P: 0.008) but a higher incidence of bleeding (OR: 3.25, 95% CI: 1.18 to 8.97, P: 0.02) with a laparoscopic
approach than with a conventional approach. There was no significant difference in the incidence of omentum
adhesion (OR: 0.32, 95% CI: 0.05 to 2.10, P: 0.24), hernia (OR: 0.38, 95% CI: 0.09 to 1.68, P: 0.20), leakage (OR: 0.69,
95% CI: 0.38 to 1.26, P: 0.23), intestinal obstruction (OR: 0.96, 95% CI: 0.48 to 1.91, P: 0.90) or perforation (OR: 0.95,
95% CI: 0.06 to 15.42, P: 0.97). The statistical analysis showed no significant difference in early (OR: 0.44, 95% CI: 0.15
to 1.33, P: 0.15), late (OR: 0.89, 95% CI: 0.41 to 1.90, P: 0.76) or total (OR: 0.68, 95% CI: 0.42 to 1.12, P: 0.13) peritonitis
infections between the 2 groups, and there are no no significant difference in early (OR: 0.39, 95% CI: 0.06 to 2.36,
P: 0.30), late (OR: 1.35, 95% CI: 0.78 to 2.33, P: 0.16) or total (OR: 1.20, 95% CI: 0.71 to 2.02, P: 0.17) tunnel or exit-site
infections between the 2 groups.
Conclusion: Laparoscopic catheterization and conventional open catheter placement in PD patients have unique
advantages, but laparoscopic PD catheterization may be superior to conventional open catheter placement.
However, this conclusion needs to be confirmed with further large-sample-size, multi-centre, high-quality RCTs.
Keywords: Laparoscopic catheter placement, Conventional open catheter placement, Peritoneal dialysis,
Complications, Meta-analysis, Mei-Lan sun and Yong Zhang are contributed equally to this work

* Correspondence: [email protected]
†
Mei-Lan Sun and Yong Zhang contributed equally to this work.
6
Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical
College, Huazhong University of Science and Technology, Wuhan, Hubei,
China
Full list of author information is available at the end of the article

© The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Sun et al. BMC Nephrology (2020) 21:60 Page 2 of 10

Background Selection criteria

Alternative treatments for end-stage renal disease (ESRD) in- Three researchers (ZY, ZP and SML) conducted a prelim-
clude kidney transplantation, haemodialysis and peritoneal inary review independently to search for randomized con-
dialysis (PD). PD has become the preferred alternative treat- trolled trials (RCTs) that met the inclusion criteria. Any
ment for end-stage renal disease because of its low cost, sim- discrepancy was resolved by consensus and discussion
ple technology, strong patient independence, few dietary (Fig. 1). The following criteria were used for inclusion: 1)
restrictions, stable haemodynamics and good protection of the study was an RCT; 2) the study compared the out-
residual renal function [1]. Although PD is an effective treat- comes of a laparoscopic PD catheter insertion technique
ment for end-stage renal disease, the success of PD depends with those of conventional insertion; 3) relative risk (RR)
on successful PD-catheter. Successful placement of PD cath- and 95% confidence interval (CI) were calculated; and 4)
eters can improve the efficiency of PD, reduce complications more than 1 complication was described. The main char-
such as peritonitis and drifting catheters, and prolong the life acteristics of the included studies are listed in Table 1.
of patients [2]. Successful placement is also a prerequisite for
effective progress in PD. [3] The main operation methods Risk of bias assessment
for PD catheterization are traditional operation and laparo- The quality of all trials was assessed by three authors
scopic operation. The traditional operation for PD catheter (ZY, ZP, and SML) independently according to the
insertion involves “blind” insertion of the catheter through a Cochrane quality criteria (Table 2). Any disagreement
small lower abdominal incision using a malleable catheter was settled by discussion with a fourth author (WB)
guide [4]. This operation has certain blindness, and the oper- until a consensus was reached.
ating space is narrow, so it is not easy to accurately locate
[5]. Compared with the traditional operation, the laparo- Statistical analysis
scopic operation has the advantages of less trauma and faster Revman 5.3 software was used to perform the statistical
recovery after the operation [6], but it requires expensive analyses. The odds ratio (OR) with its 95% confidence
equipment and specially trained personnel; thus, the proced- interval (CI) was used for dichotomous data. If there was
ure is not easily popularized. Several authors [4, 7–10] found no significant heterogeneity, a weighted fixed-effect
a benefit by the addition of laparoscopic guidance, while model was used. Otherwise, a random-effects model was
others [11–14] showed these equivalent in terms of compli- used [21]. Heterogeneity was analysed statistically by the
cations and catheter survival. I2 and Chi2 statistics. The critical value for homogeneity
Because of this argument, a previous meta-analysis was a P value less than 0.05. A sensitivity analysis was
compared the complications between laparoscopic place- conducted by omitting each study in turn to evaluate the
ment and conventional insertion of a catheter [15]. The quality and consistency of the results.
study showed that laparoscopic catheter placement had Heterogeneity was determined as follows: an Ι2 statistic
no superiority to the traditional operation, but only four of 0 to 25% was considered low heterogeneity; 25 to 50%
RCTs were included in the meta-analysis. As several was medium heterogeneity; 50 to 75% was high hetero-
new RCTs have been published recently, an updated geneity; and 75 to 100% was considered powerful hetero-
meta-analysis is needed to re-evaluate the results. geneity. The P value was determined using the χ2 test; it
In this meta-analysis, we systematically reviewed and ana- was considered statistically significant when P < 0.05 [22].
lysed previous randomized controlled trials to compare the
complications from conventional versus laparoscopic cath- Results
eter placement in PD patients. The results of our study will Study selection
provide a reference for future methods of PD catheterization. We identified a total of 776 articles in the initial retrieval.
In this study, 69 duplicate articles were discarded after
Methods carefully reviewing the titles and abstracts. When evalu-
Search strategy ated in detail, 697 articles were excluded because 189 were
Three researchers (ZY, ZP and SML) performed a com- basic research studies, 171 were non-controlled studies,
prehensive literature search, and 8 relevant studies were and 337 were case reports or reviews. The remaining 10
obtained that conformed to all of the eligible criteria. articles were reviewed for a more detailed assessment. An
We searched the electronic databases PubMed, Embase, additional 2 articles were excluded due to a lack of avail-
CNKI, and Cochrane Library for studies published prior able data. Finally, 8 studies with 646 participants fulfilled
to May 6, 2019. The following keywords were used: the inclusion criteria for this meta-analysis. The main
“Laparoscopic”, “Peritoneal Dialysis”, “Dialysis”, “Con- characteristics of the included RCTs (country, sample size,
ventional”, “Open”, and “Catheter”. Reference lists from design, patient age, intervention and follow-up) are de-
the identified studies were included to enrich the scribed in Table 1. The retrieval strategy is described in
analysis. the flow diagram (Fig. 1).
Sun et al. BMC Nephrology (2020) 21:60 Page 3 of 10

Fig. 1 Flow chart of the studies included in the meta-analysis

Sensitivity analysis and publication bias model was used (I2 = 34%). The statistical analysis showed a
No significant heterogeneity was found in the results. lower incidence of catheter migration in the laparoscopic
Sensitivity analysis was performed to evaluate the stabil- group than in the conventional open group (OR: 0.42, 95%
ity of our results. The results showed that no individual CI: 0.19 to 0.90, P: 0.03), as presented in Table 3 and Fig. 2.
studies significantly affected the heterogeneity.
Omentum adhesion
Catheter-related complications Only 2 studies [18, 20] reported an incidence of omen-
Migration tum adhesion involving 166 per patient-years, with 83
Five studies [10, 12, 18–20] assessed catheter migration in a assigned to laparoscopic groups and 83 assigned tocon-
total of 440per patient-years, with 217 assigned to laparoscopic ventional open groups. Because there was no significant
groups and 223 assigned to conventional open groups. Be- heterogeneity, the fixed-effects model was used (I2 = 0%).
cause there was no significant heterogeneity, the fixed-effects The statistical analysis showed no significant difference

Table 1 Main characteristics of the included studies

Study Country Design Sample Size (n) Age (year) Follow-up (month) Outcomes
Laparoscopic Conventional Laparoscopic Conventional Early Late
Gadallah 1999 [16] USA RCT 76 72 45.0 ± 1.8 47.2 ± 2.4 0.5 0.5–8 complications
Wright [14] 1999 UK RCT 24 21 46.4 ± 14.8 49.3 ± 20.2 1.5 1.5–26 complications
Tsimoyiannis 2000 [10] Greece RCT 25 25 53.7 ± 12.2 61.4 ± 6.1 36 complications
Jwo 2010 [12] Taiwan RCT 37 40 56.6 ± 13.4 54.4 ± 16.5 1 1–8 complications
Laanen 2018 [17] Netherlands RCT 46 44 62.6 ± 14.1 64.5 ± 14.1 8 complications
Qiao 2012 [18] China RCT 58 58 47.64 ± 13.73 24 complications
Qu 2017 [19] China RCT 35 35 39.4 ± 11.3 39.8 ± 11.2 12 complications
Xu 2010 [20] China RCT 25 25 53.6 ± 14.6 59.2 ± 16.8 18 complications
Sun et al. BMC Nephrology (2020) 21:60 Page 4 of 10

Table 2 Risk of bias in published randomized control trials

Study Random sequence Allocation Blinding of participants Blinding of Incomplete outcome Selective Other Score
generation concealment and personnel outcome data reporting bias
assessment
Gadallah 1999 [16] UC UC Low risk Low risk Low risk (Loss to Low risk Low 5
follow-up: 0) risk
Wright 1999 [14] Low risk Low risk Low risk Low risk Low risk (Loss to Low risk Low 5
follow-up: 0) risk
Tsimoyiannis 2000 [10] Low risk Low risk Low risk Low risk Low risk (Loss to Low risk Low 7
follow-up: 3/50) risk
Jwo 2010 [12] UC UC Low risk Low risk Low risk (Loss to Low risk Low 5
follow-up: 0) risk
Laanen 2018 [17] Low risk Low risk Low risk Low risk Low risk (Loss to Low risk Low 7
follow-up: 5/95) risk
Qiao 2012 [18] UC UC Low risk Low risk Low risk (Loss to Low risk Low 5
follow-up: 6/116) risk
Qu 2017 [19] UC UC Low risk Low risk Low risk (Loss to Low risk Low 5
follow-up: 0) risk
Xu 2010 [20] UC UC Low risk Low risk Low risk (Loss to Low risk Low 5
follow-up: 0) risk
UC unclear

between the 2 groups (OR: 0.32, 95% CI: 0.05 to 2.10, P: conventional open groups. Because there was no signifi-
0.24), as presented in Table 3 and Fig. 2. cant heterogeneity, the fixed-effects model was used
(I2 = 45%). The statistical analysis showed no significant
difference between the 2 groups (P: 0.23, OR: 0.69, 95%
Hernia
CI: 0.38 to 1.26), as presented in Table 3 and Fig. 2.
Three studies [12, 18, 19] assessed the incidence of inci-
sional hernias in a total of 243 per patient-years, with
120 assigned to laparoscopic groups and 123 to conven-
Bleeding
tional open groups. Because there was no significant het-
The incidence of bleeding was reported in 4 studies
erogeneity, the fixed-effects model was used (I2 = 0%).
[12, 17–19] involving 353 per patient-years, with 176
The statistical analysis showed no significant difference
assigned to laparoscopic groups and 177 assigned to
between the 2 groups (OR: 0.38, 95% CI: 0.09 to 1.68, P:
conventional open groups. Because there was no sig-
0.20), as presented in Table 3 and Fig. 2.
nificant heterogeneity, the fixed-effects model was
used (I2 = 0%). Compared with patients in the conven-
Leakage tional open groups, patients in the laparoscopic
The incidence of leakage was reported in 6 studies [10, groups showed a statistically significant increase in
12, 14, 16, 18, 19] involving 731 per patient-years, with the incidence of bleeding ((OR: 3.25, 95% CI: 1.18 to
368 assigned to laparoscopic groups and 363 assigned to 8.97, P: 0.02), as assigned in Table 3 and Fig. 2.

Table 3 The results of catheter-related complications in observational studies

Infections Results Heterogeneity
Parameter N/Pt-yr Effects Model Pooled Estimate 95% CI P-value Chi2 I2 P-value
Migration [10, 12, 18–20] 5/440 Fixed 0.42 0.19 to 0.90 0.03 7.55 34% 0.18
Omentum adhesion [18, 20] 2/166 Fixed 0.32 0.05 to 2.10 0.24 0.94 0% 0.33
Hernia [12, 18, 19] 3/243 Fixed 0.38 0.09 to 1.68 0.20 0.29 0% 0.20
Leakage [10, 12, 14, 16, 18, 19] 8/731 Fixed 0.69 0.38 to 1.26 0.23 12.83 45% 0.08
Bleeding [12, 17–19] 4/263 Fixed 3.88 1.28 to 11.77 0.02 0.08 0% 0.96
Intestinal obstruction [16, 18–20] 5/532 Fixed 0.96 0.48 to 1.91 0.90 2.54 0% 0.64
Catheter removal [10, 16] 2/198 Fixed 0.41 0.21 to 0.79 0.008 0.06 0% 0.80
Perforation [16] 1/148 Fixed 0.95 0.06 to 15.42 0.97 Not applicable
N/Pt-yr: No. of studies/Patient-years
Sun et al. BMC Nephrology (2020) 21:60 Page 5 of 10

Fig. 2 Forest plot of catheter-related complications in observational studies. The follow-up times of “early” and “late” are defined in Table 2
Sun et al. BMC Nephrology (2020) 21:60 Page 6 of 10

Intestinal obstruction 30%). The statistical analysis showed no significant differ-

Four studies [16, 18–20] assessed the incidence of intes- ence in early (OR: 0.39, 95% CI: 0.06 to 2.36, P: 0.30), late
tinal obstruction in a total of 532 per patient-years, with (OR: 1.35, 95% CI: 0.78 to 2.33, P: 0.16) or total (OR: 1.20,
270 assigned to laparoscopic groups and 262 assigned to 95% CI: 0.71 to 2.02, P: 0.17) tunnel or exit-site infections
conventional open groups. Because there was no signifi- between the 2 groups, as presented in Table 4 and Fig. 4.
cant heterogeneity, the fixed-effects model was used
(I2 = 0%). The statistical analysis showed no significant Discussion
difference between the 2 groups (OR: 0.96, 95% CI: 0.48 In 1959, Richard Ruben [23] successfully used peritoneal
to 1.91, P: 0.90), as presented in Table 3 and Fig. 2. dialysis (PD) for the first time. Popovich and Moncrief
developed continuous ambulatory PD, which promoted
Catheter removal the use of PD. [24] Subsequently, the method of introdu-
Only 2 studies [10, 16] reported the incidence of cath- cing catheters into the abdominal cavity was modified,
eter removal in a total of 198 per patient-years, with 101 and then an open operation, percutaneous puncture,
assigned to laparoscopic groups and 97 assigned to con- peritoneoscopy and laparoscopic techniques were intro-
ventional open groups. Because there was no significant duced [14, 25, 26]. Several authors favour laparoscopic
heterogeneity, the fixed-effects model was used (I2 = 0%). catheter placement over conventional surgery and dem-
The statistical analysis showed a lower incidence of cath- onstrate the obvious advantages of laparoscopic PD-
eter removal in the laparoscopic group than in the con- catheter in non-randomized trials [4, 9, 27]. However,
ventional open group (OR: 0.41, 95% CI: 0.21 to 0.79, P: due to the lack of RCTs with high quality and large sam-
0.008), as presented in Table 3 and Fig. 2. ple sizes, this conclusion is still controversial.
Recently, a few RCTs examining the two techniques
Perforation have been published. Gadallah et al. conducted an RCT
Only 1 study [16] reported the incidence of perforation, with 148 patients addressing the use of the laparoscope
and it involved 148 per patient-years, with 76 assigned for dialysis catheter implantation and provided us with
to laparoscopic groups and 72 assigned to conventional some suggestions for catheter placement [16]. Later, Jwo
open groups. Because there was only 1 study describing et al. conducted an RCT with 77 patients for comparison
perforation, heterogeneity analysis was not applicable. of conventional placement with laparoscopic-assisted
The statistical analysis showed no significant difference placement of a Tenckhoff PD catheter; they wrote a re-
between the 2 groups (OR: 0.95, 95% CI: 0.06 to 15.42, port and concluded that laparoscopic-assisted catheter
P: 0.97), as presented in Table 3 and Fig. 2. placement exhibited no superiority to the conventional
operation technique [12]. A previous meta-analysis com-
Infections pared the two surgical methods. They also found that
Infections were divided into “early” and “late”. The defi- laparoscopic catheter placement had no superiority to
nitions of “early” and “late” are shown in Table 1. Early the traditional operation, but only four RCTs were in-
infections are usually related to catheter placement; late cluded in the meta-analysis. As several new RCTs have
infections are usually related to multiple factors other been published recently, a number of different views
than the surgical procedure [12]. A measure of early and have emerged. Therefore, we performed a meta-analysis
late infections was reported in 3 [12, 14, 16] of the 8 to make it convenient for clinicians to select the appro-
trials. priate surgical approach.
In this study, we conducted a meta-analysis to com-
Peritonitis pare the complications of laparoscopic versus conven-
Seven studies [10, 12, 14, 16, 18–20] assessed the inci- tional catheter placement in PD patients. Our results
dence of peritonitis in a total of 749 per patient-years. showed that laparoscopic insertion could significantly
Because there was no significant heterogeneity, the decrease the probability of migration and catheter re-
fixed-effects model was used (I2 = 41%). The statistical moval. However, laparoscopic PD-catheter has a higher
analysis showed no significant difference in early (OR: risk of bleeding than conventional open catheterization.
0.44, 95% CI: 0.15 to 1.33, P: 0.15), late (OR: 0.89, 95% Jwo et al. reported that the higher incidence of bleeding
CI: 0.41 to 1.90, P: 0.76) or total (OR: 0.68, 95% CI: 0.42 in the laparoscopic group may be due to the fact that
to 1.12, P: 0.13) peritonitis infections between the 2 the puncture procedure lacks sufficient monitoring of
groups, as presented in Table 4 and Fig. 3. bleeding [12]. No significant difference was found in
Tunnel or exit-site infections: Three studies [12, 14, 16] other complications, such as omentum adhesion, hernia,
assessed the incidence of tunnel or exit-site infections in a leakage, intestinal obstruction and perforation. No statis-
total of 315 per patient-years. Because there was no signifi- tically significant difference was found in the incidence
cant heterogeneity, the fixed-effects model was used (I2 = of peritonitis or exit-site/tunnel infection.
Sun et al. BMC Nephrology (2020) 21:60 Page 7 of 10

Table 4 The results of infections in observational studies

Infections Results Heterogeneity
Parameter N/Pt-yr Effects Model Pooled Estimate 95% CI P-value Chi2 I2 P-value
Peritonitis
Early [14, 16] 2/193 fixed 0.44 0.15 to 1.33 0.15 3.56 72% 0.15
Late [12, 14, 16] 3/270 fixed 0.89 0.41 to 1.90 0.76 5.02 60% 0.76
Total [10, 12, 14, 16, 18–20] 9/749 fixed 0.68 0.42 to 1.12 0.13 12.61 37% 0.13
Tunnel /exit-site infection
Early [14] 1/45 fixed 0.39 0.06 to 2.36 0.30 Not applicable
Late [12, 14, 16] 3/270 fixed 1.35 0.78 to 2.33 0.16 3.68 46% 0.29
Total [12, 14, 16] 4/315 fixed 1.20 0.71 to 2.02 0.49 5.00 40% 0.17
N/Pt-yr: No. of studies / Patient-years

Fig. 3 Forest plot of peritonitis in observational studies. The follow-up times of “early” and “late” are defined in Table 2
Sun et al. BMC Nephrology (2020) 21:60 Page 8 of 10

Fig. 4 Forest plot of tunnel (exit-site) infections in observational studies. The follow-up times of “early” and “late” are defined in Table 2

Compared with laparoscopic minimally invasive PD laparoscopic or conventional catheter placement, and
catheterization, conventional PD catheterization has the fol- were followed up for 6 months after the operation. The re-
lowing disadvantages: 1) a long operation time, strong pain sults showed that the probability of transabdominal tube
(laparoscopy PD catheterization is a general anesthesia op- displacement and blockage in patients who received trad-
eration, while conventional PD catheterization is under itional laparotomy was 12%. However, no drift or blockage
local or epidural anesthesia. Therefore, patients often have of the peritoneal tube occurred in patients undergoing
“strong pain” during the conventional PD catheterization), laparoscopic peritoneal catheterization. There are other
a long incision length and a slow recovery [28]; 2) a limited reports of laparoscopic PD catheter placement describing
field of vision, as it is not as open as the laparoscopic min- excellent results. Ko J et al. reported [30] that the success
imally invasive operation, and blindcatheter placement by rate of laparoscopic PD-catheter was 100%. Other re-
hand leads to inaccurate catheter placement, easy catheter searchers have used stitches to fix the catheter in place
movement or catheter obstruction by the greater omentum during laparoscopy, with reported success rates of 94 to
[3]; 3) the incision infection rate is high, with ESRD often 100% [27, 31]. A study by Ko et al. also showed a
associated with a variety of diseases, poor resistance, and favourable outcome when fixing the catheter to the lower
traditional PD catheterization associated with a longer inci- abdominal wall. In their report, only 1 late migration
sion length and a high infection rate that often lead to sur- (2.6%) of the catheter occurred. Regretfully, patient details
gical failure [3]; and 4) the operation is more difficult for were not provided in the study [30].
obese patients [3]. Zhang et al. reported that the failure rate There are several limitations of our meta-analysis that
of conventional open PD catheter placement could reach should be taken into account. First, the information in
10.0 to 22.0%. Therefore, accurate intraoperative position- several studies was incomplete because of the lack of suffi-
ing and fixation and prevention of postoperative infection cient data, and subgroup analysis based on study type or
are important for successful PD treatment. study region was not conducted. Second, the follow-up
Lee et al. reported [29] that 102 patients who received times in some studies were different and could have af-
PD were divided into two groups, which received either fected our conclusions. Third, as mentioned in the
Sun et al. BMC Nephrology (2020) 21:60 Page 9 of 10

individual studies, the conditions and techniques investi- Consent for publication
gated in the studies varied widely. The RCTs in this meta- N/A.

analysis had key methodological limitations, particularly

due to participant attrition and unclear blinding methods, Competing interests
The authors declare that they have no competing interests.
which reduced our confidence in the conclusions drawn
from the contributing data. Finally, the inevitable result of Author details
1
these practice trials was that there were so many laparo- Department of Blood Purification Center, The First Affiliated Hospital of
Yangtze University, Jingzhou, Hubei, China. 2Department of Nephrology,
scopic techniques used by surgeons for catheter placement, Jianli People’s Hospital, Jingzhou, Hubei, China. 3Department of Ultrasonic
and these different PD-catheter techniques may have af- Imaging, Affiliated Renhe Hospital of China Three Gorges University, Yichang,
fected the final results. Despite these limitations, our results Hubei, China. 4Department of Nephrology, The First Affiliated Hospital of
Yangtze University, Jingzhou, Hubei, China. 5Department of Nephrology,
are very meaningful for understanding the differences in Nanjing General Hospital of Nanjing Military Command, Nanjing, Jiangsu,
outcomes between laparoscopic catheter placement and China. 6Department of Nephrology, The Central Hospital of Wuhan, Tongji
conventional open operation catheter placement. These Medical College, Huazhong University of Science and Technology, Wuhan,
Hubei, China.
limitations also encourage researchers to design stricter
RCTs in the future. Received: 11 July 2019 Accepted: 12 February 2020

Conclusions
Qie et al. reported [1] that PD-catheter related complica- References
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