Laparoscopic Live Donor Nephrectomy: A Technical Road Map

Abstract

Laparoscopic live donor nephrectomy is a safe, minimally invasive alternative to the customary open approach. During the past two decades, laparoscopic renal surgery has increased the availability of renal allograft specimens for transplantation. Specifically, the laparoscopic approach has minimized postoperative pain and duration of recovery, making it a more attractive option for potential altruistic organ donors. Here we detail the techniques, challenges, and troubleshooting approaches necessary for this technically challenging, yet valuable operation.

Introduction

R enal transplantation is the best available option for treating patients with end-stage renal disease.^1,2 Renal transplantation from living donors is superior to cadaveric donation, providing greater graft survival, shorter waiting times, greater chance for a perfect human leukocyte antigen (HLA) match, less cold ischemia, improved long-term patient survival, better quality of life, more rapid renal function, and lower cost.^3

–7

Potential live donors face several barriers, however. A significant time commitment is needed to donate a kidney, and many lack the financial and social support necessary to pursue such an endeavor.⁸ In addition, cosmetic concerns that are associated with the traditional flank incision and fear of pain can militate against kidney donation.¹

Laparoscopic nephrectomy was introduced in 1990, as a minimally invasive alternative to removing diseased kidneys.⁹ Subsequently in 1995, Drs. Louis R. Kavoussi and Lloyd Ratner modified this technique and performed the first laparoscopic live donor nephrectomy (LLDN). This advent carried the potential to overcome many of the disincentives that donors faced.¹⁰ Since the introduction of LLDN, new modifications in the surgical technique and equipment used have been developed with the goal of improving patient safety and outcomes. Several studies have since compared open with laparoscopic donor nephrectomy and have demonstrated that LLDN offers donors less postoperative pain, quicker convalescence, and a better cosmetic outcome while preserving donor safety and allograft function in the hands of experienced surgeons.^{1
–3,5

–8,10

–14}

LLDN has become an attractive option for altruistic organ donors who wish to participate in directed donation of their kidney to a friend or family member, thus increasing the pool of available organs for transplantation.¹²

Attention to donor well-being and safety is paramount, and surgical technique must be continually optimized to minimize the risk to donors.

In the following article, we will outline the indications and contraindications to LLDN, the preoperative work-up and patient preparation, detail the instrumentation used and the surgical steps involved, as well as discuss the postoperative care and management of intraoperative and postoperative complications that may arise.

Indications and Contraindications

Prospective kidney donors are otherwise healthy persons with an altruistic motive in undergoing a major operation with potential morbidity. They represent unique surgical candidates for whom extreme care must be used by all providers involved to minimize potential risks.¹⁴ The surgical indications for laparoscopic donor nephrectomy, as well as preparation of the patient, are generally no different than for the traditional open surgical approach.¹ Indications for LLDN include: Successful completion of the preoperative workup including medical, physical, and psychological assessments, and two functional kidneys with the likelihood of maintaining normal renal function after nephrectomy for donation.

Absolute contraindications to LLDN include: Solitary kidney, ABO incompatibility, pregnancy, certain blood-borne infectious diseases, significant renal arterial occlusive disease, renal parenchymal diseases such as malignancy or polycystic kidney disease, uncorrectable coagulopathy, and horseshoe kidney.^1,2,13
–15

Depending on surgical experience and comfort level, relative contraindications to LLDN include: Underlying medical conditions (extremes of age, hypertension, diabetes mellitus, nephrolithiasis), inability to tolerate general anesthesia or pneumoperitoneum, retroperitoneal inflammatory processes (diverticulitis, retroperitoneal fibrosis), severe morbid obesity, ascites, and a history of multiple intra-abdominal operations.^{1,2,13

–16}

LLDN is most commonly performed as a transperitoneal procedure.¹ Thus, donors who have had previous upper abdominal surgery should be approached cautiously, because they are at increased risk for injury to the bowel or adjacent organs because of adhesions. Multiplicity of renal vessels is not a contraindication; this procedure has been performed on donors with as many as four renal arteries.^17
–19 The surgeon, however, must thoughtfully assess each person's vascular anatomy to determine whether successful ex vivo reconstruction is feasible.

Preoperative Workup

All potential donors must go through extensive preoperative medical and psychological evaluation in accordance with guidelines published by the American Society of Transplant Physicians.^10,20 This includes a comprehensive history and physical examination, complete blood cell count, metabolic panel, and ABO and HLA histocompatibility testing. In addition, radiographic studies including three-dimensional CT of the abdomen and pelvis, chest radiography, and electrocardiography should be performed.

LLDN needs accurate preoperative imaging to identify any anatomic or vascular variations that may influence the operative approach and/or exclude a potential patient as a donor.^2,14,20,21 In comparison with its open counterpart, LLDN needs a higher degree of resolution of venous anatomy on preoperative evaluation and, therefore, it may be advantageous to obtain a dual-phase spiral CT with three-dimensional angiography or magnetic resonance (MR) angiography to optimally delineate the venous anatomy.^1,2,14,22 While the left kidney is generally preferred for LLDN because of greater renal vein length and technical ease of dissection compared with right-sided nephrectomies, right-sided nephrectomies are occasionally necessary because of relative renal function, presence of stones, or unique vascular configuration. In determining which kidney to remove, the same criteria are used as for open donation. The goal is to leave the donor with the better kidney and, if there is a size discrepancy between kidneys, the smaller kidney is removed for transplantation.^1,2

It is recommended that all transplant centers organize a transplant committee to oversee and discuss all cases of live organ donation. These committees carefully evaluate the donor's emotional stability and motivation for donating.^2,14 Sufficient time should be provided between the initial discussion and the actual surgery to provide potential donors ample time to reflect on their decision. The importance of the psychological evaluation cannot be stressed enough. Both family and interpersonal relationships may have long-term consequences on the donor and the recipient.¹⁴ The Organ Donor Consensus Group published recommendations for organ donation emphasizing the need for full informed consent from the donor regarding the procedure they are undergoing, including all immediate possible perioperative, unforeseeable, or long-term complications. If there is any evidence of possible coercion, a donor is rendered ineligible.¹⁴

Patient Preoperative Preparation

Before surgery, patients should avoid taking any anticoagulants, antiplatelet agents, or medications that would increase risk of bleeding. These should be avoided about 1 week before surgery. Every patient is unique and his or her list of medications should be discussed with the prescribing physician before discontinuation of any medications.

Only clear fluids should be ingested during the 24-hour period before surgery. The afternoon before surgery, patients are instructed to drink one bottle of magnesium citrate, and patients should not eat or drink anything after midnight the night before their surgery.

Instrumentation

There is a wide variety of available instrumentation, and surgeon preference dictates the selection of appropriate instruments that enable the safe and effective performance of LLDN. Table 1 delineates a list of preferred instruments categorized as reusable, disposable, and optional.

Table 1.

Preferred Instruments

Reusable Instruments

• Laparoscopic minor tray (includes 5-mm Debakey grasper, 5-mm right angle dissector, 5-mm Maryland dissector, 5-mm bipolar paddle forceps, 5-mm suction tip, suture passer, bipolar cord, two Bonnie forceps with teeth, two Richardson retractors, monopolar cord, two cleaning brushes, a 11-mm basket valve, a 6-mm basket valve, 6-mm endo tip trocar, two 11-mm seals and two 6-mm seals)

• 30-degree laparoscope set, camera, and video system

• Thompson retractor set (includes one table post, one clamp, and one scope holder)

• Thermos

• Open major/genitourinary tray (a standard open surgery tray that is available in the operating room if there is need for conversion to an open procedure)

• Bookwalter retractor

• Long small gel rolls × 2

• Flat small gel pad × 1

• Pillow × 1

• Blankets × 4

• Operating room table 3600 slider or 6500 Skytron or 6600 Skytron

• Weighing scale

Disposable Instruments/Supplies

• 3 in silk tape × 4

• Towels × 1 pack

• Ulnar protector × 4

• Argon Bovie with monopolar and bipolar foot pedals

• Auto Suture clip applier ML

• Auto Suture 14G Veress needle

• Auto Suture VersaStep trocar

• Valleylab LigaSure 10-mm × 1

• Auto Suture Endo Shears × 1

• Auto Suture Multifire GIA × 1

• Auto Suture GIA reload × 6

• Stryker PneumoSure tubing × 1

• Argon Bovie hand piece and laparoscopic tip

• Isolation drape

• Specimen containers

• Sterile towels

• 18G hypodermic needle

• 10-mL, 20-mL, and 60-mL syringes

• 1/4 inch Penrose drain

• Sutures: 1 Polysorb GS 21, 2-0 Polysorb GS 21, 2-0 Polysorb V 20, 4-0 Caprosyn P12, 2-0 Polysorb long ties, 2-0 silk short tie, 3-0 short silk ties, 4-0 silk short tie

• Medications: 0.25% Sensorcaine, mannitol 25 g, furosemide 40 mg, bacitracin 50,000 U for irrigation

• 3 L of sterile water

Optional Instruments/Supplies

• SurgiQuest trocar

• SurgiQuest tubing

• SurgiQuest AirSeal generator

• Valleylab LigaSure generator

• Papaverine 240 mg

Surgical Steps

Patient preparation

The patient is brought into the operating room and placed supine onto the operating table. After induction of general endotracheal anesthesia and the administration of preoperative intravenous antibiotic prophylaxis, a Foley catheter is inserted. An orogastric tube is placed, which remains throughout the duration of the procedure to decompress the stomach.

The patient is then repositioned into a modified flank position (with the planned extraction site facing upward). A gel roll is placed underneath the left shoulder blade extending to the lower flank, which elevates the torso to a 45-degree lateral decubitus position. The hips are rolled slightly posterior, and a pillow is placed posterior to the knees.^1,2,23 The left arm is flexed and folded across the chest on top of a gel pad or egg crate cushion, while the right arm is extended to the side on an arm board. Compression stockings are placed on the legs, and the patient is secured to the table using cloth tape across the hips, chest, and lower legs. Great care must be taken to ensure that appropriate axillary and extremity padding is placed at all pressure points to avoid paresthesia, neuropraxia, or irreversible neuromuscular injury. The patient should be test rolled to verify secure positioning to the table before commencing the operation to ensure safety during the case when exaggerated table positioning may be necessary. The patient is then draped and prepped in routine sterile fashion, and a time out is performed.

Unique management issues, troubleshooting, and tips

While this procedure may be performed retroperitoneal, transperitoneal, or hand-assisted, the transperitoneal approach is the most commonly used and provides maximal working space for dissection, as well as the ability to address potential intraperitoneal pathology, if needed.

Pneumoperitoneum and trocar placement

Pneumoperitoneum is established using a Veress needle placed at the umbilicus. A 10- to 12-mm port is placed at the umbilicus. Recently, we have used the Airseal (Surgiquest) trocar at this position, which allows for a more constant maintenance of intraperitoneal pressure via its mechanism of rapidly recycling CO₂ to and from the pneumoperitoneum with continuous monitoring of pressures.²⁴ A laparoscopic survey is performed. Additional ports are placed under direct vision including a 10- to 12-mm port placed lateral to the rectus muscle at the level of the umbilicus, and a 5-mm port placed in the midline at a subxiphoid position. The umbilical port is used primarily as the camera port, and a fixed 30-degree lens is used for visualization throughout the entire procedure.^2,14,23 A 5- to 6-cm Pfannenstiel incision is made at this time through the skin and subcutaneous tissues down to the level of the fascia, maintaining the pneumoperitoneum. This will be used later as the site of kidney extraction.

Unique management issues, troubleshooting, and tips

In patients with previous abdominal surgery, posing a risk of adhesions at the umbilicus, Veress needle insertion subcostally is an option. Once access is obtained, the peritoneal cavity is insufflated to a pressure of 15 mm Hg. A second Veress needle may be inserted to ensure an area is free from adhesions or bowel loops to help map out trocar insertion safely.

Pneumoperitoneum causes increased intra-abdominal pressure, which decreases renal blood flow and may subsequently decrease urine output. Therefore, it is important to keep the patient volume expanded during the procedure and insufflated with the lowest pressure to safely proceed with the operation. The variability of port placement relates to the size of the donor. In smaller patients, the distance from the rib cage increases, while in larger patients, it is decreased.²³ Ports should always be a minimum of 90 degrees apart to prevent instrument collision during the procedure. Also, in obese patients, the “midline” umbilical and subxiphoid trocars should be lateralized toward the side of the allograft kidney. If adhesions are encountered during the initial survey scan, they should be carefully taken down systematically, using a cold scissor before introducing more trocars.

Dissection and mobilization of the colon

Dissection begins with incising the white line of Toldt (the lateral peritoneal reflection) and subsequent medial mobilization of the colon. The splenocolic, splenorenal, and splenodiaphragmatic ligaments are divided to allow the spleen to be reflected medially and superiorly.^2,14,23 The phrenocolic ligaments as well as the colorenal ligaments are divided, and the Gerota fascia is exposed. The dissection continues at the level of the Gerota fascia and extends down into the true pelvis where the psoas muscle, ureter, and gonadal vessels are identified. The ureter is exposed at its crossing over the iliac vessels and followed superiorly until the renal hilum is encountered.

Unique management issues, troubleshooting, and tips

Electrocautery is used as necessary during dissection for hemostasis. Caution should be used, however, to avoid thermal injury to the colon and surrounding organs and vasculature. If difficulties arise with identifying the ureter, this portion of the dissection may be postponed, and the surgeon may focus dissection on the renal hilum first to identify the ureter at its junction with the renal pelvis.²³

If a large amount of perinephric fat exists, the gonadal vein can be dissected and followed cranially to identify the renal vein.²³ In a right-sided donor nephrectomy, the duodenum must be kocherized medially to avoid injury during renal hilar dissection.¹⁴

Ureteral dissection

At this point, the dissection is focused around the ureter, preserving the periureteral tissue and keeping the ureteral vessels intact. Just below the renal hilum, the gonadal vein is identified, and a plane is created medially toward the side wall proceeding inferiorly to identify the ureter. The ureter is visualized and dissected where it crosses over the iliac vessels. Using a gastrointestinal anastomosis (GIA) stapler, the gonadal vessels are reflected medially off the ureter at the midureteral level. The ureter is then dissected proximally from the iliac artery and vein.

Unique management issues, troubleshooting, and tips

Some surgeons prefer taking the gonadal vein with the ureter en bloc to reduce ureteral compromise. Care should be taken when preserving the periureteral tissue to avoid problems with ureteral ischemia in the recipient.¹

Renal and hilar dissection

The next step is hilar dissection and freeing the upper pole of the kidney. Once the superior extent of the kidney is identified, gentle elevation of the upper pole with a blunt retractor, such as the tip of the 5-mm suction-irrigation device through the 5-mm port, can facilitate dissection of medial upper pole attachments.² Blunt and sharp dissection is used to free these upper pole attachments and expose the hilar vessels at their cranial aspect. We use the LigaSure device to mobilize the cephalad portion of the upper pole of the kidney, with attention to spare the ipsilateral adrenal gland by maintaining close proximity to the kidney in the medial region of the upper pole. The renal vein is then exposed by excising the Gerota fascia on the medial aspect of the kidney. In thin patients, it may be readily apparent and used as a landmark. After the renal vein is clearly visualized, it is carefully dissected from its adventitial attachments, and the gonadal, adrenal, and associated lumbar veins are identified and clipped, placing two clips in opposite directions to assure complete occlusion.² Alternatively, the vessels can be occluded with the LigaSure device.

The renal artery, which most commonly lies posterior to the vein, is now identified. The artery should be dissected up to its proximal origin at the aorta. Sharp dissection of the lymphatic tissue will enable this and expose the artery adequately.² Clips may be used during the dissection to prevent lymphatic leakage. At this time, 12.5 g of mannitol and 40 mg of furosemide are administered intravenously.²

The lateral, posterior, and inferior attachments to the kidney are maintained intact, which serves to limit the mobility of the kidney and prevent torsion about its vascular pedicle. The inferior and lateral attachments of the kidney are now taken down. By carefully elevating the lower pole of the kidney, divide the remaining posterior renal and ureteral attachments using a combination of sharp and blunt dissection.²

Unique management issues, troubleshooting, and tips

Freeing the upper pole of the kidney is one of the most technically challenging steps in the procedure. Lobulations can easily be mistaken for the border of the upper pole, and great care must be taken to avoid injury to the renal parenchyma, hilar structures, and spleen.² If the renal vein is difficult to visualize, after identifying the upper and lower poles of the kidney, meticulous blunt and sharp dissection through the Gerota fascia and perihilar fat can reveal the renal vein in its presumed location.²³ The right angle clip applier may facilitate placement of clips on the gonadal and adrenal veins. It is important to note that, if dissection is too aggressive along the renal vein, avulsion of the adrenal vessels may occur. Furthermore, when dissecting the renal artery, to prevent vasospasm, a topical solution of papaverine can be applied to the artery.² Care should be taken to preserve the arterial branches.

Transecting the ureter and vessels

Take care in preserving the pneumoperitoneum during this step, which is eased with the use of the Airseal trocar system. Before dividing the vascular pedicle, the laparoscope may be moved to the left lower quadrant port to allow for a perpendicular approach to the renal hilar vessels.² A 10-mm titanium clip applier is used to clip the ureter proximally and distally before transecting the ureter using endoshears.²

Attention is now directed to the vessels. The renal artery and vein are sequentially divided using the endovascular GIA stapler.

Unique management issues, troubleshooting, and tips

When performing a right-sided donor nephrectomy, the GIA stapler has been shown to decrease the renal vessel length as much as 1.5 cm.²⁵ To preserve renal vessel length, several modifications can be used. Vein ligation is often performed across its confluence with the inferior vena cava (IVC), in part resecting the IVC wall with the Endo-GIA device. The port placement may be relocated so that the GIA stapler transects the right renal vein in a plane parallel to the IVC; or the incision site can be relocated for extracting the kidney after complete laparoscopic dissection of the vasculature, creating a 5- to 6-cm right subcostal margin incision.²⁶

For maximal arterial length, an intra-aortocaval dissection is performed; five metal clips are placed proximally on the right renal artery, and it is divided using cold scissors. In donors with multiple renal arteries, attention must be paid to the feasibility of ex vivo reconstruction before transplantation into the allograft recipient. Hsu and associates^18,19 reported equivalent outcomes in donors and recipients in cases where multiple renal arteries were dissected with the transplant kidney.

Kidney extraction

Once the pedicle has been divided, under direct vision, the perirenal adipose tissue is used to manipulate the kidney and ureter into the bag.² Care should be taken to ensure that the entirety of the resected ureter is within the bag before closure. The bag is secured, and the kidney is extracted with care through the peritoneum. The incision should be lengthened if necessary to prevent trauma to the kidney during extraction through the Pfannenstiel incision. Once the kidney is removed, it is immediately transferred to the transplant recipient surgical team.^2,14,23

Closure

The fascia of the allograft extraction site is closed with #1 polyglactin suture in a running fashion. Pneumoperitoneum is reestablished, and under low pressure the abdomen is reinspected to verify that complete hemostasis has been achieved. The 10- to 12-mm trocar sites are closed under direct vision with double-stranded 2-0 polyglactin sutures passed with a Carter-Thomason (CloseSure^®) device. The skin of all ports is closed using 4-0 Caprosyn™ sutures. Steri-strips and benzoin are used for dressing. The patient is taken out of the left flank position and repositioned supine. A Penrose drain is placed in the subcutaneous pocket created for extraction.

Postoperative Care

At completion of the procedure, the orogastric tube is removed, and the patient is awoken from general anesthesia and extubated. Patients are brought to the postanesthesia care unit where after routine observation, they are transferred to a standard urology floor or general surgical floor. On the first postoperative day, patients begin a clear liquid diet that is advanced as tolerated. The Foley catheter is also removed, and a metabolic panel and complete blood cell count are obtained. Patients may be discharged to home if blood work and vital signs are stable, they are tolerating a regular diet, are ambulating without assistance, and have adequate pain control on oral analgesics. The median length of hospitalization is 2 to 3 days.^27,28

Management of Intraoperative Complications

Complications can arise from any laparoscopic procedure. Using safe and careful technique is paramount. While uncommon, the most commonly reported intraoperative complications include vascular injuries resulting in bleeding or hemorrhage, mechanical complications (splenic capsular injury and bowel injury), injuries caused by the GIA stapler, or problems with kidney retrieval using the specimen bag.^{15,16,29

–33} Inadequate hilar dissection and bleeding are reportedly the most common reasons for open conversion, shown to correlate with surgeon experience.^{16,30,32

–35} Most of the intraoperative complications can be managed laparoscopically or with the application of a hand-assisted approach.³²

A left-sided LLDN necessitates mobilization of the spleen. Injuries to the spleen may occur during the dissection and can typically be controlled with an argon beam coagulator, a topical hemostatic agent, or direct pressure. Rarely, a splenectomy may be necessary in extensive injury if bleeding cannot be controlled with conservative measures.¹⁵

The tail of the pancreas will also be encountered during visceral mobilization. If the pancreas is inadvertently transected during dissection, copious amounts of normal saline should be used to irrigate the area, followed by repair with an Endo-GIA stapler running across the most distal portion of the pancreas. Alternatively, the pancreas can be plicated with an absorbable suture in a running fashion and covered with an omental patch. A drain is placed adjacent to the repair, and serial amylase levels are followed postoperatively.¹⁵

If the mesentery is opened, elevating and retracting the colon laterally will expose the defect and allow closure with an Endo Stitch™ device or surgical clips. Vigilance is needed when mobilizing the colon to prevent and identify defects early. Failure to recognize and repair bowel injury can result in postoperative hernia, bowel obstruction, perforation or ischemia.^15,29

During a right-sided LLDN, injuries to the liver and gallbladder may occur during retraction or dissection. The argon beam coagulation can control liver bleeding while injury to the gallbladder necessitates a cholecystectomy.¹⁵

Management of Postoperative Complications

Postoperative complications are uncommon and no different than those encountered from an open donor nephrectomy.³⁶ The most commonly reported postoperative complications include bowel obstruction, internal hernia, prolonged ileus, pancreatitis, wound complications (infection, abscess, hematoma), and bleeding.^{15,16,29,30,32

–35,37,38} Depending on the complication, the patient may need reoperation or nonoperative management during a prolonged hospital stay.

Mortality that arises from LLDNs is extremely low, estimated at 0.02%,^16,38,39 and the potential for life-threatening or debilitating complications is estimated to be 0.23%.⁴⁰ In general, the benefits of LLDN are greater than the risks to the informed donor, and as surgical techniques improve and experience grows, morbidity is expected to further decline.^15,40

Conclusion

LLDN has been a major advancement in the procurement of living kidneys for donation. During the past decade, modifications in the surgical technique and equipment of LLDN have evolved with the aim of improving patient outcomes. LLDN has been shown to be similar to open live donor nephrectomy in terms of donor safety, complication rates, and allograft functional outcomes. LLDN has been shown to be superior in regard to providing the donor with less postoperative pain, quicker convalescence, and a better cosmesis.^{1

–7,14,16,30} Future directions for further enhancement of LLDN are at laparoendoscopic single-site donor nephrectomy, which have been reported in early feasibility studies to date.^27,28

While there has never been a long-term randomized controlled trial assessing the long-term outcomes of LLDN, the last 20 years have shown LLDN to be an acceptable alternative and evolving to the “gold-standard” approach to renal transplantation in the United States (Table 2).

Table 2.

Laparoscopic Live Donor Nephrectomy Study Series

Study	Year	Patient sample	Notes
Ratner¹⁰	1995	1	The first LLDN case
Flowers¹³	1997	70	An initial series comparing LLDN to ODN
Schulam⁴⁴	1996	3	A report on the initial 3 LLDN cases
Ratner⁴¹	1999	NA	A 4 year review of the Johns Hopkins experience performing LLDN
Merlin¹¹	2000	10 studies	A systematic review comparing safety and efficacy of LLDN to OLDN
Chan⁴³	2000	175	A review of the first 175 LLDN cases
Ratner⁴²	2001	NA	A review of the first 5 years of LLDN.
Mandal²⁶	2001	227	An experience with LLDN is reviewed to determine whether the right kidney should be procured laparoscopically.
National Institute for Clinical Excellence⁵⁰	2002	NA	An overview for the Interventional Procedures Advisory Committee on the safety and efficacy of LDN reviewed by SERNIP
Velidedeoglu⁴⁵	2002	150	Comparison of a series of open, laparoscopic and hand-assisted live donor nephrectomies
Hsu¹⁸	2002	353	A retrospective review evaluating renovascular complications of LLDN
Hsu¹⁹	2003	353	Review on the impact of multiple renal arteries on LLDN
Tooher³⁰	2004	2726	A systematic review assessing safety and efficacy of LLDN compared with open Live donor nephrectomies
Jacobs⁴⁶	2004	738	A review of the University of Maryland: 6 year experience of LLDN
Su⁴⁷	2004	381	A 6 year experience reviewing complications, outcomes and trends in LLDN donors and recipients.
Sundaram⁴⁸	2007	253	A retrospective review of complications of LLDN after a 5 year experience at Indiana University.
Shokeir¹⁶	2007	69 studies	A review of 69 studies evaluating donor safety and graft efficacy of LLDN compared to OLDN
Permpongkosol³¹	2007	2775	A 12 year review of complications of urological laparoscopic surgery from 1993–2005
Duchene and Winfield¹⁴	2008	NA	A review of the current indications, selection criteria, surgical approaches, outcomes, and complications of LDN.
Mjoen³³	2009	1022	Living Donor Registry assessment of postoperative complications of LDN from 1997–2008
Leventhal³²	2010	1200	Large single center experience of LLDN, its associated complications, and their management
Dols⁴	2010	169 studies	A review of evidence for surgical technique of live donor nephrectomy
Nicholson⁴⁹	2010	84	A randomized controlled trial evaluating the safety and efficacy of LLDN compared with ODN

Footnotes

Disclosure Statement

No competing financial interests exist.

Abbreviations Used

References

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