Abstract
Background.
Pure laparoscopic and hand-assisted approaches are the predominant techniques for living donor nephrectomy, yet high-quality multicenter comparisons remain limited.
Methods.
Using prospectively collected data from the American College of Surgeons National Surgical Quality Improvement Program Transplant pilot (from March 2017 to July 2020), we compared outcomes between pure laparoscopic and hand-assisted donor nephrectomy. Outcomes included operative duration, postoperative length of stay (LOS), and 30-d unplanned readmission. Mixed-effects linear, Poisson, and logistic regression models with hospital-level random intercepts quantified center variation and the independent association of surgical approach with outcomes.
Results.
Among 1542 donors, 890 (57.7%) underwent pure laparoscopic and 652 (42.3%) hand-assisted nephrectomies. Donors were predominantly female (63%), mean age 43.4 y, and 61.8% were overweight or obese. Pure laparoscopic procedures had longer operative times (180 versus 150 min; P < 0.001). Median LOS was similar (2 d for both), although pure laparoscopy had more extended-stay cases (P < 0.001). Readmission was rare and comparable (2.4% versus 2.9%; pure laparoscopic versus hand-assisted; P = 0.50). Center-level variation was substantial for operative duration (intraclass correlation coefficient = 0.51), and notable for LOS (median rate ratio [RR] = 1.25) and readmission (median odds ratio = 1.60). In unadjusted and adjusted models, pure laparoscopy was not associated with differences in operative duration relative to hand-assisted (β = 5.05 min; 95% confidence interval [CI], –4.56 to 14.66 and adjusted β = 5.59; 95% CI, –3.71 to 14.88), LOS (RR = 0.99; 95% CI, 0.87-1.13 and adjusted RR = 0.98; 95% CI, 0.86-1.12), or readmission (odds ratio = 0.63; 95% CI, 0.28-1.44).
Conclusions.
In this national, multicenter analysis using prospectively collected data, pure laparoscopic and hand-assisted donor nephrectomy demonstrated similar perioperative outcomes and very low complication rates. Surgical approach did not independently influence operative duration or LOS. Readmission was rare. Substantial center-level variation suggests institutional practice patterns may play a larger role than technique selection.
INTRODUCTION
Over the past 2 decades, living donor nephrectomy has undergone a major evolution, with minimally invasive techniques—primarily pure laparoscopic and hand-assisted approaches—now representing the standard of care in most transplant centers.1-3 These methods have largely replaced open nephrectomy because of their association with reduced postoperative pain, shorter hospital stays, and faster recovery. Both techniques demonstrate excellent donor safety, low morbidity, and comparable short- and long-term outcomes. The choice between them is generally guided by surgeon expertise and institutional protocols, as definitive evidence of superiority remains limited.2,4,5
Donor outcomes following pure laparoscopic nephrectomy are characterized by low perioperative complication rates, minimal mortality, and rapid convalescence, with stable long-term renal function and quality of life.1-3 Hand-assisted nephrectomy similarly offers low perioperative and long-term complication rates, with comparable safety and recovery profiles.2-5 Comparative studies suggest that both techniques yield equivalent overall outcomes, with only modest procedural differences. Hand-assisted nephrectomy may be associated with shorter operative and warm ischemia times (WITs), while pure laparoscopic nephrectomy may offer slightly less blood loss and shorter hospitalization.2-5 Recipient graft function and survival are also comparable across approaches.2-5 However, most available evidence comes from single-center, retrospective studies that are inherently limited by small sample sizes, heterogeneous follow-up, and institutional bias. Consequently, the current understanding of how surgical approach influences donor outcomes remains incomplete, highlighting the need for robust, multicenter, prospectively collected data.
The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) has emerged as both a platform for quality improvement and a robust source of surgical outcomes data. NSQIP Transplant—a collaboration between the ACS and the American Society of Transplant Surgeons—extends this model to transplantation, offering standardized, high-fidelity data across multiple centers.6,7 Leveraging this resource, we sought to evaluate whether pure laparoscopic or hand-assisted living donor nephrectomy confers a measurable advantage in perioperative donor outcomes.
MATERIALS AND METHODS
Data Source
The data supporting this study’s findings are from the ACS, NSQIP Transplant Pilot.6 This study was conducted at the ACS to allow center-level analysis. Sites were recruited on a rolling basis into the NSQIP Transplant pilot project. Only current ACS NSQIP participating sites were invited to join. Each site was overseen by a physician champion and data were entered prospectively by data abstractors who underwent formal training and abstracted data based on predefined variables. This study was determined to be exempt from institutional review board review, and informed consent was not required, as it involved retrospective analysis of de-identified data from an established quality improvement database with minimal risk to participants.
Study Population
From a pool of 2181 kidney living donors, we excluded donors <18 y old, cases not performed at the NSQIP transplant pilot center entering the case data, cases with approaches other than pure laparoscopic or hand-assisted laparoscopic, and any duplicate entries (Figure 1). There were a total of 8 laparoscopic converted to open cases over the study period that were excluded, as NSQIP Transplant captures “laparoscopic converted to open” as a separate approach type and does not distinguish between type of index case (ie, hand-assisted versus pure laparoscopic). All live donor nephrectomy operations occurred between March 1, 2017, and July 31, 2020, and data were extracted in September 2020. The variables collected focused on preoperative patient demographic data and risk factors, intraoperative data, and postoperative outcomes.
FIGURE 1.
Flow chart detailing inclusion and exclusion criteria.
Exposure
The primary exposure of interest was the surgical approach, either pure laparoscopic or hand-assisted laparoscopic donor nephrectomy. Robotic-assisted, planned open procedures and other donor nephrectomy procedures were excluded because of low volume.
Outcomes
We explored the following surgical outcomes: operative duration, postoperative length of stay (LOS), unplanned readmissions within 30 d postoperatively, surgical site infection (SSI), and incisional hernia. Operative duration was defined as the difference in minutes between the recorded operation/surgery start time and operation/surgery end time. LOS was defined as the number of midnights, postoperatively, that the patient remained in the hospital before discharge. Finally, unplanned readmissions were defined as any recorded unplanned hospital readmission within 30 d after surgery. Additional secondary exploratory outcomes included WIT, defined as the interval from renal artery clamping to initiation of cold perfusion, and additional 30-d outcomes of any reoperation, urinary tract infection, pneumonia, venous thromboembolism, and donor creatinine at 30 d. Only donors with complete 30-d follow-up were included.
Statistical Analysis
To compare baseline characteristics of donors between approach arm, we used the chi-square test or Fisher exact test for categorical variables, Student t test for normally distributed continuous variables, and the Kruskal-Wallis test for nonnormally distributed continuous variables. Operative duration between centers that perform only pure laparoscopic, only hand-assisted, and a mix of the 2 approaches was described. To quantify between-center differences and evaluate the independent effect of surgical approach, multilevel mixed-effects models with random intercepts accounting for patient clustering within hospitals were constructed for each outcome.8,9
Operative duration was modeled as a continuous variable, LOS as a count-based outcome (Poisson), and unplanned readmission as a binary outcome (logistic). Between-center variation was summarized using the intraclass correlation coefficient for operative duration, the median rate ratio (RR) for LOS, and the median odds ratio (OR) for unplanned readmission. Three sequential models were fit: a null (intercept-only) model estimating baseline hospital-level variability, an unadjusted model incorporating surgical approach, and an adjusted model controlling for patient and operative covariates. Adjusted models accounted for the following variables: donor sex, race, health status (100% versus <100%), smoking status, number of renal arteries and veins (1 versus >1), blood type (A, AB, B, O), age, body mass index (BMI continuous), hypertension, previous abdominal operation, and graft laterality (left versus right kidney). The LOS and readmission model were additionally adjusted for operative duration. Model coefficients were expressed as β-estimates for operative duration, RRs for LOS, and ORs for readmission, each with corresponding 95% confidence intervals (CIs). A 2-tailed P-value of <0.05 was considered statistically significant. All statistical analysis was performed using SAS, Version 9.4 statistical software (SAS Institute, Cary, NC).
RESULTS
Donor Demographics
A total of 1542 donor nephrectomies were studied, of which 890 cases were pure laparoscopic and 652 were hand-assisted. Donor characteristics are outlined in Table 1. Donors were most commonly female (63.0%) and White (67.1%) with a mean age of 43.4 y. Of note, 61.8% of all donors were overweight or obese. Donors had a history of hypertension in 4.3% of cases, prior abdominal surgery in 30% of cases and had a functional status of 100% in nearly all (99.4%) of cases. Compared to donors who underwent kidney donation via a pure laparoscopic approach, donors who underwent a laparoscopic hand-assisted approach were more likely to be White (75.8% versus 60.7%; P < 0.001), less likely to be Asian (2.3% versus 11.1%; P < 0.001), more likely to have >1 renal artery (24.7% versus 19.3%; P = 0.01), and more likely to be donating a left-sided graft (93.1% versus 85.6%; P < 0.001). Blood type groups differed between groups by level (hand-assisted versus pure laparoscopic: 62.4% versus 55.8% O type, 6.6% versus 11.0% B type; P < 0.01). There were no significant differences between patients with respect to sex, age, BMI, hypertension, prior abdominal surgery, prior smoking, or number of renal veins.
TABLE 1.
Donor demographics
| Approach | Total | Laparoscopic | Laparoscopic hand-assist | P |
|---|---|---|---|---|
| N | 1542 | 890 | 652 | |
| Female | 972 (63.0) | 571 (64.2) | 401 (61.5) | 0.29 |
| Age (y) | 0.24 | |||
| 18–29 | 261 (16.9) | 146 (16.4) | 115 (17.6) | |
| 30–39 | 383 (24.8) | 220 (24.7) | 163 (25.0) | |
| 40–49 | 400 (25.9) | 240 (27.0) | 160 (24.5) | |
| 50–59 | 336 (21.8) | 181 (20.3) | 155 (23.8) | |
| 60+ | 162 (10.5) | 103 (11.6) | 59 (9.0) | |
| Race | <0.001 | |||
| White | 1034 (67.1) | 540 (60.7) | 494 (75.8) | |
| African American | 84 (5.4) | 55 (6.2) | 29 (4.4) | |
| Hispanic | 217 (14.1) | 131 (14.7) | 86 (13.2) | |
| Asian | 114 (7.4) | 99 (11.1) | 15 (2.3) | |
| Other | 93 (6.0) | 65 (7.3) | 28 (4.3) | |
| BMI | 0.14 | |||
| Normal/underweight | 588 (38.1) | 330 (37.1) | 258 (39.6) | |
| Overweight | 673 (43.6) | 383 (43.0) | 290 (44.5) | |
| Obese | 281 (18.2) | 177 (19.9) | 104 (16.0) | |
| History of hypertension | 67 (4.3) | 44 (4.9) | 23 (3.5) | 0.18 |
| Prior abdominal surgery | 462 (30.0) | 271 (30.4) | 191 (29.3) | 0.61 |
| Health status | ||||
| 100% | 1533 (99.4) | 886 (99.6) | 647 (99.2) | 0.51 |
| <100% | 9 (0.6) | 4 (0.4) | 5 (0.8) | |
| Blood type | <0.01 | |||
| O | 904 (58.6) | 497 (55.8) | 407 (62.4) | |
| A | 462 (30.0) | 271 (30.5) | 191 (29.3) | |
| B | 141 (9.1) | 98 (11.0) | 43 (6.6) | |
| AB | 35 (2.3) | 24 (2.7) | 11 (1.7) | |
| Prior smoker | 120 (7.8%) | 76 (8.5%) | 44 (6.7%) | 0.19 |
| Graft laterality | <0.001 | |||
| Left | 1369 (88.8) | 762 (85.6) | 607 (93.1) | |
| Right | 172 (11.2) | 127 (14.3) | 45 (6.9) | |
| >1 Artery | 333 (21.6) | 172 (19.3) | 161 (24.7) | 0.01 |
| >1 Vein | 45 (2.9) | 23 (2.6) | 22 (3.4) | 0.36 |
Bolded entries indicate statistical significance (P < 0.05)
BMI, body mass index.
Donor Outcomes
Donor outcomes are outlined in Table 2. Operative duration was longer for pure laparoscopic compared to hand-assisted (180.0 versus 150.0 min; P < 0.001; Figure 2). Median LOS was similar between the 2 groups (2 d for both), although there was a skew toward higher extended LOS in the pure laparoscopic group (90th–99th percentile LOS; 4–8 d for pure laparoscopic versus 3–5 d for hand-assisted; P < 0.001). Readmission was rare for the overall cohort (2.6%) and did not differ between the groups (P = 0.50). Incisional hernia was also rare (2.0% overall) and was more likely in the hand-assisted group (3.2% versus 1.2%; P = 0.038). SSI was likewise rare (1.2% overall) and did not differ between the groups (P = 0.16). Secondary outcomes are shown in Table S1 (SDC, https://links.lww.com/TXD/A866). Median WIT was longer in the pure-laparoscopic group (4 versus 3 min; P < 0.001). Rates of reoperation, urinary tract infection, pneumonia, and venous thromboembolism were also rare (≤1.1% for all) in both groups. Early donor renal function was slightly different between the 2 groups but the difference was not clinically meaningful (Creatinine 1.18 versus 1.30; pure laparoscopic versus hand-assisted; P = 0.01).
TABLE 2.
Donor outcome measures
| Approach | Total | Laparoscopic | Laparoscopic hand-assist | P |
|---|---|---|---|---|
| N | 1542 | 890 | 652 | |
| Operative duration, min, median (IQR) | 166.0 (136.5–217.0) | 180.0 (147.0–226.0) | 150.0 (119.0–190.0) | <0.001 |
| LOSa, d, median (IQR) | 2.0 (2.0, 3.0) | 2.0 (2.0, 3.0) | 2.0 (2.0, 3.0) | <0.001 |
| Readmissionb, N (%) | 40 (2.6) | 21 (2.4) | 19 (2.9) | 0.50 |
| Incisional herniac, N (%) | 16 (2.0) | 6 (1.2) | 10 (3.2) | 0.038 |
| Surgical site infection, N (%) | 19 (1.2) | 14 (1.6) | 5 (0.8) | 0.16 |
Bolded entries indicate statistical significance (P < 0.05)
aLOS, postoperative, at index operation.
bUnplanned readmission within 30 d of surgery.
cIncisional hernia was assessed at 1-y follow-up, total participants assessed was 822.
IQR, interquartile range; LOS, length of stay.
FIGURE 2.
Distribution of operative duration by surgical approach.
Center Variation
A total of 24 sites performed minimally invasive donor nephrectomies during the study period. In total, our study was comprised of 20 (83%) centers that performed live donor nephrectomy via laparoscopic approach and 16 (66%) centers used the laparoscopic hand-assisted approach. Interestingly, 12 (50%) of the 24 total centers performed all cases via 1 approach, either laparoscopic or laparoscopic hand-assisted approach. Centers that exclusively performed a single surgical approach demonstrated shorter operative times for that respective approach compared with centers using both techniques. Among centers performing only pure laparoscopic donor nephrectomy, the median operative time for pure laparoscopy was 161 min (interquartile range [IQR], 140–200 min), whereas centers using both techniques had a longer median time for pure laparoscopy (208 min; IQR, 177–238 min). A similar pattern was observed for hand-assisted nephrectomy: centers performing only hand-assisted procedures had a median operative time of 134 min (IQR, 108–170 min), compared with 180 min (IQR, 153–234 min) for hand-assisted at centers that used both approaches.
In mixed-effects models evaluating center variation (Table 3), substantial between-hospital variability was observed for operative duration (intraclass correlation coefficient = 0.51 in the null model), indicating that approximately half of the variance in operative time was attributable to center-level differences. Hospital-level variability in LOS was modest (median RR = 1.25), and variability in unplanned readmission was larger (median OR = 1.60). This indicates that, for 2 otherwise similar patients treated at different hospitals, the median relative difference in LOS would be approximately 25%, while the odds of unplanned readmission could differ by 60% solely because of the treating hospital. In unadjusted analyses, pure laparoscopic donor nephrectomy was not associated with meaningful differences in operative duration compared with hand-assisted approaches (β = 5.05 min; 95% CI, –4.56 to 14.66; P = 0.30). LOS was nearly identical between groups (RR = 0.99; 95% CI, 0.87-1.13; P = 0.93), and there was no significant association with unplanned readmission (OR = 0.63; 95% CI, 0.28-1.44; P = 0.27). After adjustment for donor and operative covariates, results remained consistent: operative duration (β = 5.59 min; 95% CI, –3.71 to 14.88; P = 0.24) and LOS (RR = 0.98; 95% CI, 0.86-1.12; P = 0.79) did not differ between approaches. Adjusted models for readmission did not converge because of the low event rate.
TABLE 3.
Center variation in key outcomes: impact of pure laparoscopic versus hand-assist
| Model | Hospital variability metric | Measure of association (pure laparoscopic vs reference: hand-assist) | 95% CI | P |
|---|---|---|---|---|
| Null model | ||||
| Operative duration (min) | ICC = 0.51 | NA | NA | NA |
| LOS (RR) | MRR = 1.25 | NA | NA | NA |
| Unplanned readmission (OR) | MOR = 1.60 | NA | NA | NA |
| Unadjusted | ||||
| Operative duration (min) | ICC = 0.51 | β = 5.05 | (–4.56 to 14.66) | 0.30 |
| LOS | MRR = 1.25 | RR = 0.99 | (0.87-1.13) | 0.93 |
| Unplanned readmission (OR) | MOR = 1.61 | OR = 0.63 | (0.28-1.44) | 0.27 |
| Adjusted | ||||
| Operative duration (min) | ICC = 0.53 | β = 5.59 | (–3.71 to 14.88) | 0.24 |
| LOS (RR) | MRR = 1.24 | RR = 0.98 | (0.86-1.12) | 0.79 |
| Unplanned readmissiona (OR) | NA | NA | NA | NA |
Operative duration model adjusted for: sex, race, health status (100%, <100), smoker, number of renal arteries (1, >1), number of renal veins (1, >1), blood type (A, AB, B, O), age (continuous), BMI (continuous), hypertension, previous abdominal operation, and graft type (left kidney, right kidney).
LOS model adjusted for: all factors in operative duration model and operative duration.
aUnplanned readmission adjusted multivariable model was unable to converge because of sparsity of events.
BMI, body mass index; CI, confidence interval; ICC, intraclass correlation coefficient; LOS, length of stay; MOR, median odds ratio; MRR, median rate ratio; NA, not applicable; OR, odds ratio; RR, rate ratio; β, effect size (min).
DISCUSSION
Both hand-assisted and pure laparoscopic techniques for living donor nephrectomy are well established, safe, and effective, with no consistent or clinically meaningful advantage of 1 over the other.10,11 The choice of approach is typically guided by surgeon experience and institutional protocols rather than evidence of superiority.11 Multiple systematic reviews, randomized trials, and large cohort studies have shown that both methods provide excellent donor safety, low morbidity, and favorable recovery profiles.2-5,10-13 The Kidney Disease: Improving Global Outcomes guideline synthesizes this evidence, reporting equivalent outcomes between standard laparoscopic and hand-assisted nephrectomy, with only modest differences—such as slightly shorter hospital stays for pure laparoscopy and marginally shorter operative and WITs for hand-assisted procedures—none of which are clinically significant.2,13,14 Large retrospective studies and meta-analyses further confirm low complication rates, minimal risk of conversion to open surgery, and excellent donor outcomes for both techniques.2-5,10-12
Some reports suggest hand-assisted procedures reduce operative and WITs, while pure laparoscopic approaches may offer marginal benefits in blood loss and LOS.4,10-12 These differences, however, are small and do not translate into meaningful variations in donor or recipient outcomes. Multicenter studies show comparable complication, readmission, and serious adverse event rates, reinforcing their shared safety and efficacy.3,12,13 Current guidelines recommend minimally invasive techniques over open nephrectomy because of lower morbidity and faster recovery but do not favor 1 laparoscopic approach over another.2 As these operations have matured, the field has shifted from demonstrating feasibility toward ensuring reproducibility and long-term donor well-being.2
In this context, our study represents the first national, multicenter analysis comparing pure laparoscopic and hand-assisted donor nephrectomy using prospectively collected, standardized data from NSQIP Transplant. By capturing standardized variable definitions across diverse institutions, this analysis provides the most generalizable comparison to date. Our findings reinforce the excellent safety of minimally invasive donor nephrectomy for both approaches. Both techniques demonstrated low complication and readmission rates, minimal serious adverse events, and short hospital stays—consistent with prior literature.15 The absence of clinically meaningful differences in operative duration or postoperative outcomes suggests that, when performed by experienced teams within structured programs, both pure laparoscopic and hand-assisted nephrectomy achieve equally favorable results. These findings confirm and extend prior single-center and meta-analytic evidence, offering the highest-quality multi-institutional confirmation to date that both approaches are safe, standardized, and effective.
However, it is also important to note that we observed several baseline differences between the pure laparoscopic and hand-assisted group—namely, that the hand-assisted donor nephrectomy group had a higher percentage of left-sided grafts and multiple renal arteries. This finding suggests that the selection of hand-assisted donor nephrectomy is unlikely to be arbitrary in some cases and may reflect a degree of the underlying anatomic or technical complexity.16,17 In clinical practice, hand-assisted donor nephrectomy is often preferentially selected for left-sided grafts because of surgeon handedness and hand-port positioning. Similarly, multiple renal arteries are known to increase technical complexity, operative time, and donor WIT in pure laparoscopic nephrectomy, which may prompt selection of a hand-assisted approach. Thus, these baseline differences in laterality and vascular anatomy could reflect intrinsic reasons why pure laparoscopic nephrectomy was not chosen initially. With this framing, the observed comparability of outcomes may reflect appropriate case selection rather than intrinsic equivalence of the 2 techniques. With that in mind, while outcomes appear to be broadly comparable between approaches, it may not be that pure laparoscopic and hand-assisted donor nephrectomy are completely interchangeable regardless of institutional experience or case selection. The choice will ultimately depend on case selection, center experience, surgeon expertise and established practice patterns.
Beyond approach-specific comparisons, our findings also highlight potential influences of institutional practice patterns on operative duration. Centers performing only 1 surgical approach—either exclusively pure laparoscopic or exclusively hand-assisted nephrectomy—had shorter operative times compared with centers that routinely used both techniques. Pure laparoscopic cases at single-approach centers were nearly 50 min shorter than those at centers offering both approaches, with a similar pattern observed for hand-assisted procedures. While procedural standardization and consistent team workflows may contribute to these differences, other unmeasured institutional factors (eg, center volume, surgeon experience, learning curve effect, selective use of hand-assistance for more complex cases at centers that do both) could also play a role. Accordingly, these findings should be interpreted as reflective of center-level variation rather than attributable to any specific underlying cause. Importantly, despite these differences in operative efficiency, donor outcomes remained similar across center types, again providing evidence that both techniques are associated with comparable donor outcomes in diverse, appropriately selected practice settings. Again, these findings should be interpreted as descriptive given the known differences in center volume, surgeon experience, and case selection.
Although robotic donor nephrectomy was not analyzed in this study because of low case numbers, emerging evidence indicates that robotic donor nephrectomy is a safe and effective alternative to traditional laparoscopic approaches, with comparable donor and recipient outcomes.13 As robotic adoption grows, future iterations of NSQIP Transplant will allow rigorous assessment of robotic donor nephrectomy’s role and potential advantages in select donor populations.
Notably, 62% of donors in our cohort were overweight or obese, reflecting the substantial proportion of higher BMI individuals among contemporary living kidney donors. Prior multicenter studies have reported similar trends, demonstrating that elevated BMI is increasingly common in donor populations.18-20 Obese donors are at increased long-term risk for developing diabetes and hypertension and may have a modestly higher risk of end-stage kidney disease compared to nonobese donors, although the absolute risk remains low.21-23 Despite this, perioperative outcomes in donors with higher BMI—including operative time, complication rates, and early postoperative recovery—are generally comparable to those of normal-BMI donors when appropriately selected and managed.20,21,24-26 The comparable operative and postoperative outcomes observed in our study further support the safety of both pure laparoscopic and hand-assisted donor nephrectomy, even in programs serving a predominantly overweight or obese donor population. These findings reinforce that minimally invasive donor nephrectomy remains safe and effective across a broad range of body habitus when careful evaluation and counseling are performed.
Several limitations merit discussion. The NSQIP Transplant dataset in its current iteration is not able to distinguish between initial approach type (ie, hand-assisted laparoscopic versus pure laparoscopic) for laparoscopic converted to open cases as it captures such cases generally as “laparoscopic converted to open.” While NSQIP Transplant does capture conversion to open, future iterations should also capture the initial approach type. Excluding unplanned conversion to open donor nephrectomy cases may underestimate approach-specific risk, particularly if conversions occurred predominantly in 1 group (eg, if they were all in the pure laparoscopic group). That said, there were only a total of 8 such cases (0.5%, 8/1550 patients [denominator from study population of 1542 cases plus 8 conversion cases]) in the total cohort over the study period, so we can conclude that conversion is a rare event overall. NSQIP also does not distinguish between transperitoneal (intraabdominal) and retroperitoneal approaches, each of which may be performed with or without hand-assistance. Thus, the classification of procedures as pure laparoscopic versus hand-assisted likely oversimplifies real-world practice. Case mix at participating centers tended to favor 1 approach over the other, reflecting institutional preference. While this reinforces that both techniques are safe when performed within experienced programs, limited within-center variability makes it difficult to fully separate approach-specific from center-specific effects. Additionally, while analyses were performed at the center level, surgical approach selection in many transplant programs is largely determined by individual surgeon preferences and experiences. So differences attributed to centers may actually reflect difference between surgeons practicing at those centers and should be interpreted as such. The experience level of the involved surgeons (ie, below or above the learning curve for each procedure) was not available. Event rates for adverse outcomes—such as readmission, SSI, and incisional hernia—were low; although this highlights the excellent safety of minimally invasive donor nephrectomy, it constrained model convergence for rare events. The absence of statistically significant differences for these rare events should also be interpreted cautiously as there is a limited ability to detect differences for rare events. Notably, while rare in both groups, incisional hernia was significantly more likely in the hand-assisted group. Finally, although NSQIP Transplant provides granular, prospectively collected data with standardized definitions—a major strength—the institutions participating during its beta phase were predominantly academic tertiary-care centers with established NSQIP infrastructure. As a result, the cohort may not fully represent all kidney transplant programs nationally, and outcomes at smaller or community-based centers may differ.
Despite these limitations, the consistency of results across centers supports the robustness and reproducibility of these findings. Together, these data confirm that both hand-assisted and pure laparoscopic donor nephrectomy are mature, safe, and standardized operations that can be successfully performed across a wide range of programs. Institutional experience, surgical expertise, and adherence to established protocols appear to be more important determinants of outcomes than the specific minimally invasive technique chosen. As NSQIP Transplant expands, inclusion of robotic cases, greater institutional diversity, and long-term donor follow-up will further refine understanding of approach selection and guide best practices in living donor surgery.
Supplementary Material
Footnotes
D.A. is supported by the National Institutes of Health Grant Number T32AI125222.
The authors declare no conflicts of interest.
D.A., A.G., K.C., and J.R.P. participated in research design. D.F., S.G., R.H., and J.R.P. participated in data acquisition. D.A., A.G., K.C., and Y.L. participated in data analysis. D.A., A.G., K.C., and J.R.P. participated in writing of the article. All authors participated in critical review.
Supplemental digital content (SDC) is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.transplantationdirect.com).
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Contributor Information
Arielle Grieco, Email: agrieco@facs.org.
Karina Covarrubias, Email: k1covarrubias@health.ucsd.edu.
Yaoming Liu, Email: yliu@facs.org.
Peter G. Stock, Email: peter.stock@ucsf.edu.
David Foley, Email: foley@surgery.wisc.edu.
Stuart Greenstein, Email: stuart.greenstein@wmchealth.org.
Ryutaro Hirose, Email: rhirose@uw.edu.
Justin R. Parekh, Email: jparekh@health.ucsd.edu.
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