A Cost-effectiveness Analysis of Antibiotic Prophylaxis versus No Antibiotic Prophylaxis for Postoperative Infectious Complications for Hand-assisted Laparoscopic Donor Nephrectomy

Abstract

Objectives:

Individuals who volunteer to undergo hand-assisted laparoscopic donor nephrectomy (HALDN) to help those needing renal transplants, face postoperative infection complications (POICs) risks for no corresponding clinical benefit. Prophylactic antibiotics often control POIC risk; however, there is no clear consensus on their use in HALDN. Considering the incidence of POICs, National Health Service (NHS) resource constraints, and antimicrobial stewardship priorities, a cost-effectiveness analysis (CEA) was conducted to evaluate the economic impact of prophylactic antibiotic use in HALDN.

Methods:

A CEA was conducted using data from the UK multicenter, double-blinded, randomized controlled POWAR (Prophylaxis of Wound Infections-antibiotics in Renal Donation) trial. The primary outcome was the cost per POIC avoided within 30 days post-HALDN. Effectiveness was defined as the absence of POICs. The incremental cost-effectiveness ratio (ICER) was calculated in British pounds. Four sensitivity analyses examined variability in drug costs, length of stay, POIC severity, and cost thresholds.

Results:

The ICER for antibiotic prophylaxis compared with no prophylaxis was –£4,709.71, indicating that prophylaxis was cost-saving. Sensitivity analyses under all 4 scenarios confirmed the robustness of this cost-saving finding under varying assumptions.

Conclusion:

Antibiotic prophylaxis in HALDN is a cost-saving intervention. These findings support the need to review UK guidelines for antibiotic use in living donor renal transplant surgery, specifically regarding prophylactic measures for donors. Further clarification on whether HALDN should be classified as a ‘clean’ or ‘clean-contaminated’ procedure may enhance consistency in national practice and inform evidence-based antibiotic stewardship and policy aligned with NHS goals for safe and sustainable surgical care.

INTRODUCTION

Chronic kidney disease (CKD) affects over 7.2 million people in the UK, exceeding 10% of the population,¹ with over 70,000 treated for kidney failure (CKD stage 5).² Managing CKD costs the National Health Service (NHS) £6.4 billion annually, 3.2% of the NHS budget.³ While kidney transplantation is the gold standard for end-stage renal failure, it often relies on healthy living donors who face surgical risks without clinical benefits. One such risk includes postoperative infectious complications (POICs), including surgical site infections (SSIs), urinary tract infections (UTIs), and lower respiratory tract infections (LRTIs). Therefore, ensuring the health and comfort of these altruistic individuals is crucial in enhancing confidence in the donation decision-making and outcomes, considering the shortage of donated organs.⁴

When comparing surgical techniques for living donor nephrectomy, current evidence suggests that hand-assisted laparoscopic donor nephrectomy (HALDN) may carry a slightly higher risk of postoperative infection than total laparoscopic donor nephrectomy (LDN). A 2022 study reported UTI and wound infection rates of 0.7% and 1.7% for HALDN, compared to 0.3% and 0.8% for LDN, respectively—though these differences were not statistically significant. Overall complication rates were also higher for HALDN (9.9%) versus LDN (7%).⁵ Despite this, the British Transplantation Society (BTS) supports the use of either technique, based on surgeon expertise, with HALDN being the more common procedure due to the combination of its minimally invasive approach with tactile feedback and faster kidney removal.⁶

These findings have important implications for the use of prophylactic antibiotics, which are commonly used to prevent POICs and associated human and economic costs.^7,8 However, there is no clear clinical consensus on their necessity in HALDN. The National Institute for Health and Care Excellence (NICE) currently recommends against antibiotic use for ‘clean’ surgeries⁹—defined as procedures where no inflammation is present and the respiratory, gastrointestinal, genital, or urinary tracts are not entered. Whether HALDN fits this classification remains debated due to ureteric transection, which may introduce contamination and thus may shift its classification towards ‘clean-contaminated.’ The BTS guidelines similarly offer no definitive recommendation.¹⁰

Given the ambiguity in guidance, considerable incidence of postoperative infections, and the risks associated with routine antibiotic usage, it is crucial to assess the impact of prophylactic antibiotics in living kidney donation. The NHS long-term plan and the UK Government’s 20-year vision emphasize reducing unnecessary antibiotic use to combat antimicrobial resistance (AMR).^11,12 AMR costs the NHS £180 million yearly, with over 700,000 annual deaths from untreatable infections.¹³ Published data relating to the incidence of AMR in donors who have had POIC remains very limited. Although this limits the analytical potential of the current study, the presence and severity of AMR should not be underestimated. This remains an area in need of further research.

The cost-effectiveness of antibiotic prophylaxis for preventing POICs remains uncertain due to insufficient research. This study aims to address this gap by providing valuable insights into optimizing NHS resources amidst AMR challenges.

Competing alternatives

The comparator in this economic evaluation is the absence of preoperative antibiotic prophylaxis. Other methods for preventing POICs include preoperative showering, nasal decolonization, patient and staff theater wear, and removal of hand jewelry, artificial nails, and nail polish, based on NICE guidelines.⁹ However, these methods are often ineffective or inconclusive due to insufficient evidence¹⁴:

1. Preoperative showering: A Cochrane systematic review including 7 trials did not show conclusive evidence for preoperative showering improving SSI outcomes.¹⁵ Chlorohexidine washing has also been shown to not be cost-effective.¹⁶

2. Nasal decolonization: Five randomised controlled trials (RCTs) concluded no significant reduction in SSIs with mupirocin or chlorhexidine^,17–21 though an economic evaluation indicated a 50% likelihood of nasal decolonization being a cost-effective approach.²²

3. Patient theater wear: No studies were identified to determine the effectiveness of patients wearing clean clothing in reducing rates of SSIs.

4. Staff theater wear: No studies have confirmed the effectiveness of scrub suits; head attire or overshoes to prevent SSIs. Two quasi-RCTs concluded no significant difference in SSIs when wearing face masks during clean surgery.^23,24

5. Removal of hand jewelry: Insufficient evidence to conclude the effectiveness of removing nail polish, hand jewelry, or artificial nails to reduce SSI rates. One RCT showed no significant difference in colony-forming units upon removal of finger rings and nail polish.²⁵

Due to the lack of definitive evidence on the clinical and cost-effectiveness of these alternative methods, this study will evaluate the potential of antibiotic prophylaxis in preventing POICs.

Objectives

The study aimed to perform a cost-effectiveness analysis (CEA) of antibiotic prophylaxis versus no antibiotic prophylaxis in healthy patients who undergo HALDN in the UK. This economic evaluation aims to understand whether antibiotic prophylaxis is economically justifiable for HALDN in the NHS to inform the NICE guidelines.

METHODS

The POWAR (Prophylaxis of Wound Infections-antibiotics in Renal Donation) RCT²⁶ looked at the effectiveness of a preoperative single dose of 1.2 g of intravenous co-amoxiclav for those undergoing HALDN on reducing 30-day POICs, including SSIs, UTIs, and LTRIs. Definitions for SSI, UTI, and LRTI can be found in the POWER trial “Outcome Measures” section.²⁶ It was a multicenter, double-blinded RCT across 5 UK tertiary hospitals with transplant centers, involving 293 kidney donors. Adult patients undergoing HALDN with no documented history of penicillin allergy were able to participate in the study. Exclusion criteria included patients with known allergies or adverse reactions to antibiotics, documentation of methicillin-resistant Staphylococcus aureus colonization, or a documented history of penicillin allergy. Patient demographics and intraoperative parameters were similar between placebo and antibiotic groups, except for a slight predominance of white ethnicity in the antibiotic group. Participants were randomized either to a single-dose antibiotic prophylaxis group (n = 148) or no-prophylaxis group (n = 145). The primary outcome was the absence of POIC within 30 days of surgery. The primary outcome concluded that antibiotic prophylaxis significantly reduces 30-day POIC rates, particularly for SSIs and LRTIs, by 17.7% [95% confidence interval (CI) = 7.2–28.1%] with 6 donors requiring treatment to prevent 1 POIC. The study highlighted the importance of providing antibiotic prophylaxis to improve patient outcomes as well as illustrating the prevalence of POICs in living kidney donors.

A cost-effectiveness analysis, quantifying costs in British pounds and benefits as the absence of POICs, was chosen. The 30-day time horizon was chosen to mirror the time used to assess the primary endpoint—POICs. By definition, SSIs occur within 30 days postsurgery; thus, this was adequate for evaluation.²⁷ The economic evaluation was conducted from an NHS perspective to align with the POWAR trial, contributing to the UK’s evidence base to optimize NHS guidelines and budget allocation. Managing POICs results in more complex treatments and extended hospital stays, straining resources. POICs cost an average of $18,626 (£14,780.19) and increase hospital stays by 9.3 days, according to 1 US study.²⁸ Combined with the challenge of AMR, this presents a multifaceted dilemma, underscoring the need for a cost-effectiveness study to navigate these intertwined healthcare challenges efficiently. This is the first study to evaluate the cost-effectiveness of antibiotic prophylaxis for the HALDN procedure within the NHS.

This study adheres to the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 guidelines to ensure comprehensive and transparent reporting of the economic evaluation. A completed CHEERS checklist is included as Supplemental Data, Supplemental File 2: CHEERS Checklist, https://links.lww.com/AOSO/A518.

Modeling of Data

A decision tree, as seen in Supplemental Appendix 4A, https://links.lww.com/AOSO/A514, was constructed to compare the incidence of POICs in patients undergoing HALDN with and without preoperative antibiotic prophylaxis. Probabilities related to POICs were obtained from the POWAR trial, based on the intention-to-treat data analysis, to include in the decision tree. Due to limitations within the data, each POIC outcome extending from a chance node was assumed to be mutually exclusive. A breakdown of further assumptions for the modeling of data is included in Supplemental Appendix 1, https://links.lww.com/AOSO/A514.

At the decision node of renal donation admission, patients either received antibiotic prophylaxis (Arm 1) or no antibiotic prophylaxis (Arm 2). Following the HALDN, interventions were considered successful if they did not develop any POICs within 30 days and unsuccessful if they developed POICs. POICs were stratified into SSIs: superficial site infection, deep site infection, and organ space infection; LRTIs and UTIs. From the POWAR trial, a breakdown of complications is summarized in Supplemental Appendix 3, https://links.lww.com/AOSO/A514. Other infections were not explicitly stratified in the POWAR trial and, therefore, were excluded from the analysis due to the lack of granular data required to assign reliable cost estimates.

Costs

All costs of units were expressed in British pounds and were taken from UK national sources: NHS National Tariff Payment System 2022/2023²⁹ and British National Formulary (BNF).³⁰ National tariffs include factors, such as duration of hospital stay, cost of required staff, tests, procedures, and medications into their total price.²⁹ View Appendix 2 https://links.lww.com/AOSO/A514 for a full cost breakdown. Cost values at decision nodes were found by calculating backward from terminal nodes by using probabilities from the POWAR trial. Discounting is used in health economic assessments to account for the timings of cash flows. Since all costs in this study were taken from 2023 databases, discounting was not required.

Nephrectomy

Based on 2023 NHS tariffs, a HALDN combined day case or ordinary elective spell costs the NHS £6368. This tariff includes all standard costs incurred from admission to discharge for the procedure. Following a HALDN procedure, 2-week, 6–12-week, and 6-month appointments are typically scheduled, followed by annual checkups.³¹ Since the costs of follow-up appointments occur in both arms equally, these expenses were excluded from the analysis. This is because our research question focuses on understanding the cost differences between both arms. Thus, costing and discounting for follow-up appointments were not required.

After kidney donation, apart from short-term analgesia, no long-term medications are required to be taken.¹⁰ In this case, the ‘combined day case/ordinary elective spell’ NHS tariff was chosen, as the HALDN procedure takes only 1 day. We used the average length of stay (LOS) (3.7 days) and chose not to use the specific LOS for both arms due to the lack of statistical significance (P = 0.21). The median time to SSI diagnosis was 14 days (IQR, 10–20), indicating that most occurred postdischarge and thus were unlikely to impact LOS. LOS, therefore, more likely reflects standard perioperative recovery, institutional protocols, and patient mobilization rather than infection-related complications. LOS (3.7 days) was multiplied by the ‘Admission related to Donation of Organ or Tissue’ price/day of £537 to give the cost of postoperative ward admission of £1986.90.

Antibiotic Prophylaxis

The POWAR trial outlined that the antibiotic prophylaxis intervention involved a single dose of 1.2 g of intravenous Co-amoxiclav as the antibiotic of choice, conforming to the surgical prophylaxis guidelines provided by the BNF.³⁰ Among the 4 Co-amoxiclav manufacturers authorized by the BNF, Sandoz Ltd has been chosen for this protocol as it presents the lowest price point of £10.60 per unit cost among the available options. This price has been used as the NHS negotiates the lowest price for its drugs to alleviate the tax burden on the population.³² The price for Co-amoxiclav was added to the costings at each terminal node.

Complications

Costs have been assigned for all 5 types of POICs based on NHS national tariffs. As the UK guidelines lack detailed management strategies tailored to various types of SSIs, superficial and deep wound infections have been categorized based on the healthcare resource group codes or tariff payments most closely associated with them. Organ/space infection was depicted as an intra-abdominal abscess since this condition closely resembles the description provided by the POWAR trial. Following the NICE guidelines and the trial protocol, the management approach for this condition involves percutaneous drainage alongside antibiotic therapy.³³ LRTIs were assigned to the tariff for ‘acute lower respiratory infection’ and UTIs were assigned to the ‘kidney or urinary tract infections’ tariff.

Tariffs with the lowest complication and comorbidity (CC) score were used as all participants were healthy patients, except for deep SSIs which used a CC of 2–3 (see Supplemental Appendix 1 and 2, https://links.lww.com/AOSO/A514). For each infective complication treatment, the ‘combined day case/ordinary elective spell’ price was used because the HALDN procedure is elective; thus, the patient would be under the elective team when complications require treatment.

Given the trial did not specify the duration of hospital stays for individual POICs, a ‘best-case scenario’ was adopted, assuming that all POICs were managed within the trim point (the LOS after which the excess bed day tariff is applied) specified by their respective tariffs. The ‘combined day case/ordinary elective spell’ price (£) was multiplied by the ‘ordinary elective long stay trim point’ (days) to find the total treatment cost of SSIs.

When applicable, tariffs categorized as ‘without intervention’ were preferred over those requiring interventions. This is because it was not made explicitly clear in the POWAR trial that all complications required interventions. The exception here is organ space (intra-abdominal) infections, which require intervention, as per NICE guidelines.^9,33 However, this assumption is tested and addressed in the sensitivity analyses where costings ‘with interventions’ are trialed.

Benefits and Effectiveness

The primary effectiveness outcome of the study is the absence of POICs within 30 days post-HALDN following the interventions (antibiotic prophylaxis or no antibiotic prophylaxis). We allocated a numerical value of 0 or 1 to the end outcomes; 0 for no POICs and 1 for POICs. The overall effectiveness of having antibiotic prophylaxis versus no prophylaxis was calculated by working from the terminal nodes backward, resulting in the effectiveness of 0.770 for antibiotic prophylaxis and 0.607 for no prophylaxis. Discounting the effectiveness measure was not required, as all outcomes were measured at the endpoint of 30 days and were independent of the time period in which they occurred.

RESULTS

Cost Outcomes

Patients in the antibiotic prophylaxis group accessed healthcare resources costing an estimated £9,168.46, in comparison to the nonprophylaxis group, where expected costs were £9,936.14. The cost breakdown can be seen in Supplemental Appendix 4A, https://links.lww.com/AOSO/A514. Therefore, this represents an average cost-saving of £767.68 per patient, directly decreasing NHS expenditure on healthcare resources.

Effectiveness Outcomes

With regard to effectiveness outcomes, the measure chosen was the proportion of POICs prevented post-HALDN. A breakdown of the rates of specific POIC types in the antibiotic prophylaxis and nonprophylaxis groups is reported in the POWAR trial.²⁶ The effectiveness in the antibiotic prophylaxis group was 77% of POICs prevented, compared to 60.7% for the nonprophylaxis group. Therefore, utilizing the antibiotic prophylaxis was more effective, with an average of 16.3% lower chance of having POICs. Thus, this improves patient outcomes and could lower the utilization of NHS resources. Notably, there were no significant differences in POIC rates across demographic variables or surgical factors, including age, sex, BMI, ethnicity, smoking status, operating time, hand-port site, operative approach, or type of skin preparation used.

Cost-effectiveness

Overall, antibiotic prophylaxis is proven to be cost-saving, thus the economically dominant regimen, reflected in our calculated incremental cost-effectiveness ratio (ICER) of £−4709.71. Overall, the ICER shows potential cost savings for the NHS if antibiotic prophylaxis is utilized. See Supplemental Appendix 5, https://links.lww.com/AOSO/A514 to view the calculated ICER portrayed on a cost-effectiveness plane diagram. Due to the antibiotic prophylaxis regimen representing the dominant strategy, it is not required to establish a willingness-to-pay threshold. Therefore, monetary net benefit and health net benefit ratios were not calculated.

$${\displaystyle \begin{array}{l}{\displaystyle \mathrm{I}\mathrm{C}\mathrm{E}\mathrm{R}=\frac{Cost\left(AntibioticProphylaxis\right)-Cost\left(NoProphylaxis\right)}{Effectiveness\left(AntibioticProphylaxis\right)-Effectiveness\left(NoProphylaxis\right)}}\end{array}}$$

$${\displaystyle \begin{array}{l}{\displaystyle \mathrm{I}\mathrm{C}\mathrm{E}\mathrm{R}=\frac{\text{£}9168.46-\text{£}9936.14}{0.770-0.607}}\end{array}}$$

= −£4709.71.

Sensitivity Analysis

Sensitivity Analysis 1

In the original CEA, the cheapest drug manufacturer was used to reflect NHS cost-saving decisions when choosing medications, although, this does not offer a cost analysis based on a ‘worst-case scenario’. Therefore, a sensitivity analysis was conducted using the highest unit cost of Co-amoxiclav (£50/unit). Even under this scenario, the ICER remained negative (–£4467.99), indicating that antibiotic prophylaxis continues to be cost-effective.

Sensitivity Analysis 2

In the original ICER, we used an average LOS for both arms (3.7 days); however, postoperative LOS was 3.63 days for the antibiotic group and 3.82 for the no-prophylaxis group. Despite the high P-value of 0.21 and statistical insignificance, it is important to consider the increased resource costs of extended admission and hospital stay. Therefore, ‘admission related to donation per day’ costs are multiplied by 3.63 and 3.82 to provide an overall admission cost of £1949.31 and £2051.34 for the antibiotic prophylaxis group and no prophylaxis group, respectively. This results in a more negative ICER (−£5338.46), reinforcing the cost-effectiveness of antibiotic prophylaxis.

Sensitivity Analysis 3

The third sensitivity analysis determines the necessary alteration in the percentage of prevented POICs for antibiotic prophylaxis to reach a point where it is neither cost-effective nor cost-ineffective (ICER = 0). The calculation demonstrates that the probability of POICs in the antibiotic prophylaxis group must increase by 95.61% from 0.23 to 0.450 for ICER = 0. The probability of POICs in the no prophylaxis group must decrease by 48.55% from 0.393 to 0.202 for ICER = 0. This shows that the POICs rate needs to change hugely to change the outcome of this cost-effectiveness study, validating our conclusion.

Sensitivity Analysis 4

The POWAR trial does not address the severity of each complication or whether interventions were necessary. Previously, we have assumed that interventions were not required; however, this may not be accurate. Therefore, in the fourth sensitivity analysis, when applicable, tariffs are categorized as ‘with single intervention’ rather than ‘without intervention’ to assess the impact on cost-effectiveness. The ICER became markedly more negative (–£68,143.32), suggesting continued cost-effectiveness of antibiotic prophylaxis, even when accounting for potential intervention-related costs.

Sensitivity Analysis 5

This sensitivity analysis considers the societal and long-term costs of antibiotic prophylaxis. Increasing antibiotic usage has been shown to lead to a greater burden of antibiotic-resistant infections.^34,35 The consequences of antibiotic-resistant infections are both human and financial. The rising risk of AMR has been shown to negatively affect morbidity, mortality, and readmission rates,^36,37 causing a significant issue for patients. AMR also causes considerable expense to healthcare providers due to the greater need for healthcare provisions.³⁸ According to a 2023 systematic review, the costs attributable to an episode of resistant infections range from −$2371.4 (−£1,866.8) to +$29,289.1 (£23,056.4) with a mean excess LOS of 7.4 days.³⁸ Antibiotic prescribing increased by 8.4% in the UK from 2021 to 2022, with a 4% antibiotic-resistant infection rate rise in the same period.³⁹ Thus, it is clear to see that AMR poses a real and serious threat to patients, whilst also creating a significant economic burden for healthcare providers.

It is difficult to predict the exact effect that antibiotic prophylaxis in HALDN procedures will have on the growing issue of AMR in the UK. One could argue that substantially decreasing the incidence of 30-day POICs, while simultaneously decreasing immediate financial costs, would be a significant enough benefit to warrant antibiotic prophylaxis. However, there is no way of entirely knowing that these immediate benefits outweigh the potential long-term societal costs associated with growing AMR.

DISCUSSION

The POWAR trial concluded that preoperative antibiotic prophylaxis significantly decreases POICs in patients undergoing HALDN. The results of this CEA indicate that antibiotic prophylaxis emerges as the superior approach through reducing NHS costs and improving patient outcomes by lowering POIC occurrence when compared with no prophylaxis. The conclusion that antibiotics are cost-effective, shown in the negative ICER, can be attributed to the combination of the affordability of antibiotics and their role in significantly decreasing POICs. Extensive sensitivity analyses further suggest that prophylaxis remains cost-effective.

There are no CEAs comparing antibiotic prophylaxis to no prophylaxis for the HALDN procedure from an NHS perspective. Nevertheless, our findings support previous systematic reviews^40,41 that concludes with the recommendation of preoperative antibiotic prophylaxis in reducing POICs in surgeries, including liver transplants. However, the comparability to our CEA is limited as the studies above review different surgical procedures (eg liver transplantation) and focus on OECD countries (countries/organizations for economic cooperation and development), many of which may not have a comparable universal healthcare system.

Generalisability

The large sample size of the POWAR trial (n = 293) enhances internal validity,⁴² and the multicenter UK setting using NHS cost data supports generalizability within the NHS. However, the trial was conducted in a controlled environment, therefore, findings may not fully translate to the UK population, those undergoing donor nephrectomy outside of trial settings, or to healthcare systems with different infrastructure, costs, and prescribing patterns. Additionally, the exclusion of penicillin-allergic patients and the use of a 1.2 g Co-amoxiclav regimen may further limit applicability to broader donor populations.

Study Limitations

This economic evaluation has limitations. Some treatments lacked matching to specific NHS tariffs, potentially causing inaccuracies in cost calculations and ICER outcomes, where the ICER may become more negative with a higher tariff, and vice versa. The POWAR trial did not provide confidence intervals for POICs, limiting the ability to conduct a sensitivity analysis reviewing worst-case probabilities of infection. Antibiotic prophylaxis showed significant reductions in superficial SSIs and LRTIs but not in other infections; therefore, the probabilities of infection for the other POICs may be higher, thereby decreasing the cost-effectiveness of antibiotics. Assumptions about mutually exclusive complications and a 30-day timeframe may underestimate long-term costs. Antibiotic overuse could increase AMR,⁴³ costing up to $29,289.10 (£23,241.63) per patient episode of resistant infection, thus a very costly ramification of increased antibiotic prophylaxis not accounted for in this study.³⁷ Moreover, the study focused on HALDN, limiting its generalizability to pure laparoscopic nephrectomies. However, an RCT from the Netherlands, which has a similar universal healthcare service to the UK, has shown that there is not a significant difference in healthcare and societal costs between a HALDN and pure laparoscopic nephrectomy.⁴⁴ Patients who were allergic to penicillin were excluded from the study, therefore, guideline recommendations will need to determine the appropriate antibiotic prophylaxis for these individuals which will have a clinical and cost-effectiveness benefit. Finally, while ICER is a widely used metric in economic evaluations, it has limitations. It compares only 2 interventions, may be sensitive to input variability (especially from a single RCT), and its ratio format can be misinterpreted. Alternative frameworks—such as net monetary benefit, cost-benefit analysis, or probabilistic sensitivity analysis—may complement or address some of these limitations. Future evaluations could consider incorporating these methods to enhance robustness.

CONCLUSION

To conclude, this economic evaluation suggests that preoperative single-dose antibiotic prophylaxis to reduce the rate of POICs after HALDN is more cost-effective than no prophylaxis. Our findings support a reevaluation of the current NICE guidelines to include the use of antibiotic prophylaxis in laparoscopic donor nephrectomy and to confirm the classification of this procedure—whether it is considered a ‘clean’ or ‘clean-contaminated’ procedure.

Our study supports the recommendations outlined by the BTS,¹⁰ suggesting that antibiotic prophylaxis, as indicated by the POWAR trial findings, is likely to become standard practice in laparoscopic living donor nephrectomy. Since antibiotic prophylaxis is readily employed in select surgical procedures according to NICE guidelines,⁹ the associated costs related to training and administration will be limited. Nevertheless, it is essential to note that these recommendations may be subject to change considering the potential cost implications arising from AMR prevalence, an aspect not accounted for in our study.

ACKNOWLEDGMENTS

The authors would like to express our gratitude to Dr. Laure de Preux for her guidance.

Supplementary Material

as9-6-e592-s001.pdf ^{(59.7KB, pdf)}

as9-6-e592-s002.pdf ^{(1.3MB, pdf)}