Introduction

Renal transplantation is the ideal solution to end-stage renal disease. It has had a major impact on the survival and quality of life of those suffering from kidney failure, affording these patients an independent lifestyle free from dialysis and its significant morbidity. Unfortunately, the annual supply of renal allografts has continued to fall short of the increasing number of patients seeking renal transplantation.

Live donor nephrectomy has long been viewed as an underused alternative in renal replacement therapy. Live donor kidney transplantation offers substantially superior graft function and survival compared to cadaveric renal transplantation (1,2). Other advantages over cadaveric renal allografts include shorter time waiting for transplantation, the ability to schedule it as an elective procedure and therefore optimize the medical status of the recipient, and overall reduced immunosuppression requirements (3). The large discrepancy between the supply and demand for renal allografts, coupled with the advantages of live versus cadaveric renal transplantation, has prompted efforts to increase the pool of live renal donors.

Prior to 1995, the standard method of kidney procurement was open donor nephrectomy performed through a flank or subcostal incision. Although this procedure can be performed safely and produces an allograft of excellent quality with minimal warm ischemia, it is associated with considerable perioperative morbidity for the renal donor. Postoperative pain, prolonged hospitalization and convalescence, lost wages, and poor cosmesis have been identified as significant disincentives for organ donation (4). As a result, the number of live renal transplants that were performed accounted for only a small fraction of the total number of transplants performed.

The first series of laparoscopic live donor nephrectomies were performed in 1995, specifically intended to decrease the morbidity of renal donation for the healthy donor and thus reduce disincentives and expand the pool of live donor candidates (3,4). Since its inception, technical modifications that have come with surgeon experience have led to a substantial reduction in total donor complications, as well as a progressive decline in the rate of recipient complications including delayed graft function or loss, ureteral stricture and necrosis, and vascular thrombotic events (5-9).

Computed tomography angiography is highly accurate and specific for the delineation of renal vascular anatomy in these patients, including detection of multiple renal vessels.

Laparoscopic live donor nephrectomy is now the standard technique at many transplant centers, resulting in less postoperative pain and convalescence for the living donor while maintaining equivalent allograft function and recipient outcomes as compared with results from traditional open donor nephrectomy. Despite technical modifications, improved instrumentation, and increased surgeon experience, laparoscopic live donor nephrectomy remains a technically challenging operation with a steep learning curve.

Psychologic evaluation includes a complete evaluation of the donor's emotional stability and determination if an altruistic motivation for donation exists.

Radiologic imaging is a crucial component of the preoperative assessment of potential live renal donors. Precise pre-operative mapping of the number and location of the main renal vessels, and the presence of accessory vessels is crucial for obtaining safe hilar dissection and minimizing vascular complications.

Laparoscopic live donor nephrectomy is now the standard technique at many transplant centers, resulting in less postoperative pain and convalescence for the living donor while maintaining equivalent allograft function and recipient outcomes as compared with results from traditional open donor nephrectomy (5,10-13). Despite technical modifications, improved instrumentation, and increased surgeon experience, laparo-scopic live donor nephrectomy remains a technically challenging operation with a steep learning curve.

With no margin for error, it requires an advanced level of laparoscopic skill and meticulous technique, as well as a detailed knowledge of renal vascular anatomy. It must replicate the standards set by traditional open donor nephrectomy—optimize the safety of the donor and procure a healthy functioning allograft for transplantation.

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