Division of Urology, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
*Corresponding author: Tawatchai Taweemonkongsap E-mail: thawatchai.taw@mahidol.ac.th
Received 18 June 2025 Revised 21 July 2025 Accepted 21 July 2025 ORCID ID:http://orcid.org/0000-0002-8969-0495 https://doi.org/10.33192/smj.v77i9.276030
All material is licensed under terms of the Creative Commons Attribution 4.0 International (CC-BY-NC-ND 4.0) license unless otherwise stated.
ABSTRACT
Results: The most common indication for right-sided nephrectomy was the presence of multiple or early-branching renal arteries on the left side (62.5%). The estimated blood loss was significantly lower in the laparoscopic group compared to the open group (80 mL vs 100 mL, p=0.004). However, operative and warm ischemic times were significantly longer in the LDN group (245 minutes vs. 180 minutes, p < 0.001 and four vs. two minutes, p < 0.001, respectively). Perioperative complication rates were comparable between the two groups. Only one case (2.22%) in the LDN group required conversion to open surgery. From the recipient’s perspective, renal graft outcomes were comparable, with no instances of acute graft loss in either group.
INTRODUCTION
The introduction of kidney transplantation nearly a century ago marked a transformative milestone in the treatment of end-stage renal disease (ESRD).1 Initially dependent on deceased donors, the field has since evolved to include living donor transplants. This advancement has been accompanied by improvements in surgical techniques, including laparoscopic procedures, and the development of more effective immunosuppressant therapies. Together, these innovations have significantly enhanced transplant success rates, resulting in better patient outcomes and quality of life.
The global rate of kidney transplantation has been steadily increasing over the years.2 In Thailand, however, this increase is primarily driven by deceased donor transplants, while the rate of living donor kidney transplantation remains low. This trend persists despite significant benefits, such as a lower risk of delayed graft function (DGF) and improved immediate graft function.3 Previous studies have shown that the introduction of less invasive surgical techniques, such as laparoscopic approaches, significantly enhances individuals’ willingness to become living kidney donors.4,5
When selecting a kidney for donation, the primary considerations are the donor’s safety and the potential long-term risk of developing end-stage renal disease. If a significant functional disparity exists between the two
kidneys, typically defined by a glomerular filtration rate (GFR) difference greater than 10%, the kidney with lower function is typically selected for donation. However, if both kidneys have comparable function, anatomical factors take precedence.6 Surgeons generally prefer the left kidney for donation due to its longer renal vein, which facilitates the transplantation process. This preference has become more pronounced with the advent of laparoscopic donor nephrectomy (LDN).7 Nonetheless, the right kidney may be selected in cases where the left kidney has unfavorable anatomical features, such as multiple or complex vascular structures, cysts, or stones.
At the Faculty of Medicine Siriraj Hospital, LDN was first introduced in 2001. Over the following decade, 129 patients underwent laparoscopic kidney donation. The results showed that LDN is both effective and safe, with outcomes comparable to open surgery nephrectomy.8 Despite the widespread adoption of LDN, concerns remain regarding donor safety and graft outcomes, particularly in right-sided nephrectomies. In real practice, most left-sided donor nephrectomies are performed laparoscopically, while right-sided procedures are more commonly done using the open technique. However, several studies have reported that right-sided LDN achieves success rates comparable to those of left-sided LDN procedures.9,10 This study aims to compare the surgical outcomes and graft function between right-sided LDN and the open
technique at our institution. The ultimate goal is to promote wider adoption of the laparoscopic approaches for right-sided donor nephrectomy, thereby enhancing donor safety and potentially increasing interest in kidney donation.
MATERIALS AND METHODS
The study protocol was approved by the Institutional Review Board of the Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand, protocol number COA no. Si 578/2024. This study retrospectively reviewed the medical records of 128 patients who underwent right-sided nephrectomy at our institution between January 2001 and May 2024, following the introduction of laparoscopic donor nephrectomy as an option at our center in 2001.
Data were collected from both donor and recipient medical records and included demographic information, indication for right-sided donor nephrectomy, perioperative outcomes, and graft outcomes. Patients were categorized into two groups: LDN and open donor nephrectomy (ODN). Indications for choosing the right kidney included the presence of multiple or early-branching vessels in the left kidney, superior function of the left kidney, or pathological findings in the right kidney. Superior function of the left kidney was defined as a glomerular filtration rate (GFR) difference of more than 10% and DGF was defined as the requirement for dialysis within the first postoperative week.
The ODN procedure was performed using a standard retroperitoneal flank approach without rib resection. LDN was performed via a transperitoneal approach using three or four ports. In the initial eight cases, the kidney
was retrieved through a low transverse incision with a hand-assist device. Subsequently, manual extraction was done through a 7–9 cm Pfannenstiel incision. In our cohort, hilar control was achieved using lockable polymer clips.
Quantitative variables such as age, body mass index (BMI), and serum creatinine levels, were reported as mean
± standard deviation for normally distributed variables or as median for non-normally distributed variables. Qualitative data, such as gender and complication rates, were expressed as frequencies and percentages. Comparisons of categorical data were performed using the Chi-square test or Fisher’s exact test. Continuous data with normal distribution were analyzed using the Student’s t-test and the Mann-Whitney U test for non-normally distributed continuous data. All analyses were conducted using SPSS Version 18 (IBM Corp., Armonk, NY), with a p-value
<0.05 considered statistically significant.
RESULTS
A total of 128 right-sided donors were included in this study, with 83 undergoing open ODN and 45 undergoing LDN. The most common indication for right-sided donor nephrectomy was the presence of multiple or early branching arteries on the left side (62.5%), followed by superior function of the left kidney in 25% of cases. Other indications included right-sided renal pathologies, such as renal cysts (6.25%) and small calyceal stones (3.13%), as summarized in Table 1.
Donor demographic data and surgical outcomes for the LDN and open ODN are presented in Table 2. There were no significant differences in baseline characteristics between the two groups, including age, sex, body mass
TABLE 1. Indications for right-sided donor nephrectomy.
Two or more arteries on left side | 72 (56.25) |
Early branching of left renal artery | 8 (6.25) |
Better function of left kidney (>10%) | 32 (25.00) |
Right renal artery stenosis | 1 (0.78) |
Right renal cyst | 8 (6.25) |
Small calyceal stone in right kidney | 4 (3.13) |
Right renal anomaly* | 3 (2.34) |
*Right double collecting system, malrotation of right kidney, scar of the lower pole of the right kidney
TABLE 2. Donor demographics and surgical outcomes.
Variables | Open nephrectomy | Laparoscopic nephrectomy | p-value |
(N=83) | (N=45) | ||
Age (mean±SD, years) | 37.90±9.42 | 36.71±10.98 | 0.617 |
Sex (M:F) | 33:50 | 19:26 | 0.786 |
BMI (mean±SD, kg/m2) | 24.11±4.20 | 22.79±3.36 | 0.071 |
Preoperative Cr (mean±SD, mL/min) | 0.79±0.19 | 0.80±0.18 | 0.632 |
Operative time (Median range, mins) | 180 (82,360) | 245 (160, 350) | <0.001 |
Estimated blood loss (Median range, ml) | 100 (20, 2,600) | 80 (10, 3,000) | 0.004 |
Warm ischemic time (Median range, mins) | 2 (0.5, 8) | 4 (1.5, 14) | <0.001 |
Length of stays, (mean±SD, days) | 5.99±1.63 | 6.09±1.71 | 0.743 |
Tube drain (N, %) | 44 (53.01) | 18 (40.00) | 0.196 |
Duration of tube drain (mean±SD, days) | 3.05±0.61 | 3.5±1.38 | 0.195 |
Immediate post-operative serum Cr (mean±SD, mL/mins) | 1.25±0.32 | 1.20±0.29 | 0.355 |
Cr at discharge (mean±SD, mL/min) | 1.12±0.29 | 1.07±0.26 | 0.360 |
Intraoperative complication (N, %) | 7 (8.43) | 3 (6.67) | 0.745 |
Postoperative complication (N,%) | 21 (25.30) | 15 (33.33) | 0.335 |
index and preoperative serum creatinine levels, indicating comparable donor profiles. However, significant differences were observed in operative parameters. The median operative time and warm ischemic time were significantly longer in the LDN group compared to the ODN group (245 vs. 180 minutes, p < 0.001 and 4 vs. 2 minutes, p < 0.001, respectively). Estimated blood loss was significantly lower in the LDN group (80 vs. 100 ml, p = 0.004).
Intraoperative complications occurred in 8.4% of ODN cases and 6.6% of LDN. Only one patient (2.22%) in the LDN group required conversion to open surgery due to technical challenges related to poor exposure in a high BMI case. In the ODN group, there were seven complications, including vascular injury, renal injury, and pleural injury; however, the difference between groups was not statistically significant (p = 0.745). Postoperative complications were observed in 25.3% of ODN cases and 33.3% of LDN cases, though the difference was not statistically significant (p = 0.335). Major postoperative complication, defined as a Clavien-Dindo score greater than three, occurred in only one case in the LDN group. This case, only the third LDN case of our series, involved postoperative bleeding from a renal vein tear that required
re-exploration. Among minor complications, fever was the most common and occurred significantly more often in the LDN group (22.2% vs. 7.2%, p = 0.023). Surgical site- related complications in ODN group, including surgical site infection and pleural injury, were more frequently observed in the ODN group. Other minor complications, including anemia requiring transfusion, paralytic ileus, acute urinary retention, electrolyte imbalances, phlebitis, and herpes zoster infection, were comparable between the groups (Table 3).
Regarding recipient outcomes, renal graft function was comparable between the two groups. The median vascular anastomosis time did not significantly differ between ODN and LDN groups (41 vs. 43.5 minutes, p = 0.685). The incidence of graft-related complications, including acute rejection and ureteric leakage, showed no significant differences. There were no cases of acute graft loss, renal artery thrombosis, or renal vein thrombosis in either group. Although the incidence of DGF was slightly higher in the ODN group, the difference was not statistically significant. Serum creatinine levels at discharge were also comparable between both groups. (Table 4)
TABLE 3. Donor perioperative complications.
Variables (n, %) | Open nephrectomy | Laparoscopic nephrectomy | p-value |
Intraoperative complications | |||
Conversion to open | 0 | 1 (2.22) | 0.352 |
Vascular injury | 3 (3.61) | 2 (4.44) | 1.000 |
Renal injury | 2 (2.41) | 0 | 0.540 |
Pleural injury | 2 (2.41) | 0 | 0.540 |
Postoperative complications | |||
Major complication | |||
Postoperative bleeding requires re-exploration | 0 | 1 (2.22) | 0.352 |
Minor complication | |||
Pneumothorax | 3 (3.61) | 0 | 0.551 |
Surgical site infection | 4 (4.82) | 1 (2.22) | 0.656 |
Anemia requiring transfusion | 3 (3.61) | 0 | 0.551 |
Paralytics ileus | 0 | 1 (2.22) | 0.352 |
Post-operative fever | 6 (7.22) | 10 (22.22) | 0.023 |
Acute urinary retention | 1 (1.29) | 1 (2.22) | 1.000 |
Electrolyte imbalances | 3 (3.61) | 0 | 0.551 |
Phlebitis | 0 | 1 (2.22) | 0.351 |
Herpes zoster infection | 1 (1.20) | 0 | 1.000 |
TABLE 4. Recipients’ graft outcomes.
Variables | Open nephrectomy | Laparoscopic nephrectomy | p-value |
Recipient anastomosis time (Median range, min) | 41 (20, 91) | 43.5 (11, 70) | 0.685 |
Acute rejection | 12 (15.00) | 5 (11.36) | 0.573 |
Delayed graft function | 8 (10.00) | 2 (4.55) | 0.492 |
Ureteric leakage | 2 (2.50) | 1 (2.27) | 1.000 |
Renal artery thrombosis | 0 | 0 | |
Renal vein thrombosis | 0 | 0 | |
Perinephric hematoma | 1 (1.25) | 0 | 1.000 |
Serum Cr at discharge (mean±SD, mL/min) | 1.41±0.78 | 1.50±0.83 | 0.559 |
DISCUSSION
The superiority of LDN over ODN has been well established in previous studies, demonstrating advantages such as reduced intraoperative blood loss, shorter hospital stays, decreased postoperative pain, and improved cosmetic outcomes.8,11-14 However, in most studies, LDN has predominantly been performed on the left side due to the anatomical advantages, including a longer renal vein and the absence of liver mobilization. In contrast, the use of laparoscopic techniques for right- sided donor nephrectomy remains a subject of ongoing debate, particularly regarding its safety and impact on graft outcomes.
Our study specifically focused on right-sided donor nephrectomies, comparing laparoscopic and open approaches. We found that, even on the right side, LDN offered the advantage of significantly reduced blood loss (80 mL vs 100 mL, p = 0.004), highlighting one of the key benefits of minimally invasive surgery. Although LDN was associated with longer WIT and operative duration, the WIT remained within an acceptable range (4 minutes), and the operative time observed in our study was consistent with previous literature.15 Moreover, recent studies have also reported that the operative time for right-sided LDN may be shorter than that for left-sided procedures.16 In our LDN cohort, the conversion rate to open surgery was 2.22% (1 case), which is consistent with previously reported conversion rates for right-sided LDN, ranging from 1.79% to 6.25%.17,18 This conversion was due to poor intraoperative exposure. The patient in this case had a BMI of 24.38. Notably, a study by Jacobs et al.19 showed that markedly obese patients (BMI > 35) undergoing LDN were more likely to require conversion to open nephrectomy compared to donors with ideal body size (7.3% vs. 0%). In our series, we performed LDN in two obese patients (defined as BMI > 30), and neither required conversion or experienced any intraoperative complications. This suggests that the conversion observed in our study was likely attributable to the surgeon’s experience.
One of the primary concerns in right-sided LDN is achieving adequate renal vein length while ensuring secure pedicle control. Two commonly employed methods for ligating the renal pedicle include non-transfixing techniques, such as lockable polymer clips, and transfixing techniques like surgical staplers. Although the safety of polymer clips for pedicle control has been questioned, recent studies have demonstrated that they are both safe and effective, and offer additional advantages such as increased vascular length and cost efficiency.20,21 In our cohort, polymer ligating clips were used for vascular
control in all cases, and no instances of clip dislodgement or clip-related complications were observed. As donor safety remains paramount, future developments in surgical instruments like staples designed to preserve greater venous length at a reasonable cost may further optimize outcomes in right-sided LDN.
Previous studies have reported perioperative complication rates ranging from 5% to 30% for LDN, and from 0% to 35% for ODN.22 In our study, which specifically focused on right-sided donor nephrectomies, the perioperative complication rate for LDN was 40.31%, compared to 33.73% for ODN. Furthermore, we observed no major laparoscopy-specific complications, such as intraabdominal organ injury. Our results demonstrated comparable postoperative complication rates between the two surgical approaches. Most complications in the LDN group were minor, including fever, paralytic ileus, and phlebitis. Only one major complication was observed in the LDN group — postoperative bleeding in the third case, which required re-operation. This may be attributed to our learning curve associated with performing right-sided LDN.
In contrast, the ODN group was associated with more surgical site-related complications, including surgical site infections and pleural injuries. Three cases in the ODN group developed pneumothorax, one of whom required intercostal drainage (CDC grade 3a). Additionally, three cases experienced anemia requiring transfusion. Notably, neither pneumothoraxnortransfusion- requiring anemia occurred in the LDN group. There were no cases of mortality among donors undergoing right-sided nephrectomy. While previous studies have reported significantly shorter hospital stays for LDN14, our cohort showed no significant difference in length of stay between the two approaches. This is likely due to local clinical practice in Thailand, where most patients prefer to remain hospitalized for approximately one week to ensure full recovery before discharge.
In terms of recipient outcomes, concerns have been raised that the laparoscopic approach could compromise graft function due to factors such as pneumoperitoneum, longer WIT, and shorter renal vein length. Although LDN in our study was associated with significantly longer operative time and WIT, the latter remained within an acceptable range of four minutes. Importantly, graft function did not differ significantly between the LDN and ODN groups. Also, anastomosis times were comparable, suggesting that the technical difficulty of vascular anastomosis was not markedly different between the two approaches. Additionally, there were no cases of acute graft loss, renal artery thrombosis, or renal vein
thrombosis in either group. A recent systematic review in 2025 demonstrated that right-sided living donor kidney transplantation is associated with a higher risk of DGF and graft loss compared to left-sided transplantation.16 However, in our study, the incidence of thrombosis, acute rejection, graft loss, and DGF were all comparable between surgical approaches. The technique of pain management for improving recipient outcomes was also previously reported.23 Nevertheless, the importance of long-term recipients’ outcomes in right-sided donors still needs further investigation.
Nevertheless, the retrospective design of our study presents several limitations. Notably, data on postoperative pain and cosmetic outcomes, which are likely to be more favorable in the LDN — were not available. Additionally, the study was conducted at a single center, where surgeon preference and experience could have influenced the outcomes. The sample size for both surgical approaches was also small. However, to our knowledge, this represents the largest report comparing right-sided donor nephrectomy using both surgical approaches in the Thai population.
CONCLUSION
Our findings suggest that right-sided LDN is as safe as the open approach, given its comparable complication profile. Although LDN is associated with longer operative and warm ischemia times, recipient graft outcomes remain unaffected. Moreover, LDN provides the added benefits of reduced intraoperative blood loss. Therefore, the laparoscopic approach should be considered a viable option even for right-sided nephrectomies. However, further research is needed to validate these findings and to assess long-term outcomes, particularly with respect to postoperative pain, convalescence data, and cosmetic outcomes.
The data supporting this study are available from the corresponding author upon reasonable request.
ACKNOWLEDGEMENT
The authors would like to thank Ms. Jitsiri Chaiyatho and all coordinators of the Siriraj Hospital for their important contributions to this study.
DECLARATION
None.
The authors declare no conflict of interest.
None.
Conceptualization and methodology: N.W., T.W., T.H.; Investigation: N.W., V.W.; Formal analysis: N.W., P.L.; Visualization and writing—original draft: N.W., T.W.; Writing-review and editing: T.W., E.C., S.J.; Supervision: T.W.
No artificial intelligence tools or technologies were used in the analysis of the manuscript.
The study protocol was approved by the Siriraj Institutional Review Board (SIRB) (COA no. Si 578/2024).
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