Innovations in living kidney donor surgery.

PURPOSE OF REVIEW: Living donor kidney transplantation is an important avenue to address persistent shortage of deceased donor organs. Although transplantation offers superior survival and quality-of-life outcomes compared to dialysis, living donation rates have declined from their mid-2000s peak despite ongoing demand.

RECENT FINDINGS: Innovations in surgical techniques, expanded living donor acceptance criteria, and growth of paired kidney donation programs represent opportunities to improve and expand living donor kidney transplantation. The transition from open donor nephrectomy to minimally invasive laparoscopic approaches significantly reduced perioperative morbidity, postoperative pain, and recovery time. Robotic-assisted techniques offer enhanced visualization and ergonomics, with comparable clinical outcomes to conventional laparoscopy, though cost and resource constraints remain barriers to widespread adoption. Concurrently, transplant centers have broadened donor eligibility to include older individuals, donors with obesity, controlled hypertension, and more complex renal anatomy. Paired kidney donation has enabled incompatible donor-recipient pairs to undergo transplantation through multicenter exchanges and chain-based mechanisms. Despite logistical and resource challenges limiting universal participation, these programs now account for a growing proportion of living donor transplants.

SUMMARY: Continued innovation in surgical practice, donor selection, and exchange networks is essential to expand living kidney transplantation and mitigate organ shortage.