Comparison of Laparoscopic and Hand-assisted Live Donor Nephrectomy: An Analysis of NSQIP Transplant

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.