Renal transplantation is the preferred treatment for end stage renal disease (ESRD). Outcomes after transplantation of a kidney from a living donor are superior to those of organs obtained from deceased donors. Traditionally performed by means of an open incision, the last two decades have seen rapid and widespread adoption of laparoscopic donor nephrectomy (LDN), with techniques that continue to evolve and improve. Because LDN delivers donor safety and efficiency, offers excellent allograft function, is preferred by donors, potentially increases the live-donor pool, and since it is now the dominant form of live-donor surgery, a legitimate question can now be asked as to whether or not LDN has become the “gold standard” for living kidney donation.

Donor nephrectomy is a unique surgical procedure because it is performed on a healthy individual who is undergoing the procedure for altruistic motives. Because of this, the operation is truly a high-stakes endeavor with little to no room for error. The safety of the donor, the graft, and the recipient are all paramount and must be taken into consideration when considering any procedural deviation from the standard of care. For the ESRD patient, what is clearly known and documented in the literature are that (1) transplantation is better than dialysis and (2) living-donor organs are preferable to cadaveric organs.

At most centers of excellence worldwide, increasingly, donor nephrectomy is now performed laparoscopically, with traditional (open) donor nephrectomy now performed less commonly. In the United Kingdom, 6% of live-donor nephrectomies were performed laparoscopically in 2000; by 2011, this had increased to 90% [1]. This trend parallels data from the United States, where 49% of living-donor nephrectomies were performed laparoscopically in 2000, which has increased to >95% in 2016. As such, the laparoscopic technique can legitimately lay claim to now becoming the preferred option around the world.

The term “gold standard” as used today in medicine was taken from its original use in finance. As stated by Jurgen, “a gold standard in its true meaning, derived from the monetary gold standard, merely denotes the best tool available at that time to compare different measures.” This term should not be confused with a golden standard, as no suggestion is made that the test or procedure being evaluated is perfect; all that is implied is that it is a time-honored alternative that is considered to be the current standard of care or best available test/technique in a given field [2]. Gold-standard tests and procedures are not static, and the gold standard of today will someday be replaced by better and more efficient options in the future. As eloquently stated by Versi: “It is the absolute truth that is never reached; gold standards are constantly challenged and superseded when appropriate” [3].

The history of renal transplantation dates back to 1945, when the first cadaveric renal transplantation was performed, followed in 1953 by the first living-related renal transplantation [4].

The first successful living-related donor kidney transplant was performed in identical twins in Boston, Massachusetts, in 1954 [5]. During the subsequent 40-year period (1954–1995), living-donor nephrectomy was performed with the open technique through a large flank incision. Drawbacks of the open technique include but are not limited to postoperative pain requiring analgesic medications, wound complications including flank hernia, and pneumothorax necessitating tube thoracostomy as well as a prolonged hospital stay and time to full recovery.

After this 40-year period, significant developments were made in the 1990s. Clayman performed the first laparoscopic nephrectomy in 1990 [6]. Gill and colleagues were the first to show that laparoscopic donor nephrectomy could be performed in a porcine model [7]. Then, in 1995, Ratner performed the first laparoscopic living-donor nephrectomy in a 40-year-old donor; warm ischemia time (WIT) was less than 5 min and the allograft immediately produced urine, with a recipient serum creatinine of 0.7 mg/dL [8]. Laparoscopic living-donor nephrectomy has evolved and been refined tremendously since that time.

As of this writing, in 2016, 99,886 candidates are currently on the kidney transplant waiting list, the most of any currently transplanted organ [9]. This waiting list has grown significantly since 2001, when 47,830 patients were waiting for an organ. In 2015, there were 17,878 kidney transplants in the United States, of which 5628 were living-donor transplants. While the number of total kidney transplants continues to increase, the number of living-donor transplants has remained relatively static for at least the last 5 years. Deceased donor transplants outnumbered living-donor transplants by a ratio of 2.5:1 in 2015. This underscores the need to continue efforts to promote living kidney donation, as numerous previous studies have documented the overall quality of a kidney from a live donor is indeed far superior to a cadaveric organ.

Over the past 15 years, during which we have seen an almost doubling of the kidney transplant waiting list, there has also been a significant increase in the proportion of patients older than 50 years of age listed for renal transplantation. Numerous studies over the years have shown that living-donor transplants are associated with better short- and long-term kidney function, as well as with fewer technical graft failures than cadaveric donation. Because of this, over time many different strategies have been employed to increase the number of living kidney donors [10]. These include ABO-incompatible transplants with and without splenectomy, emotionally related donation, cross-over transplantation, genetically unrelated donation, and transplantation of somewhat abnormal kidneys. Laparoscopic donor nephrectomy represents another major effort to increase the overall pool of live donors by making kidney donation and its associated recovery period a more palatable experience for the donor.

Laparoscopic donor nephrectomy has been widely adopted since its development, and as a matter of practicality, it is already being performed in the vast majority of living-donor nephrectomies in current times. In a review matching integrated US transplant registry data with administrative records from an academic hospital consortium of 97 centers from 2008 to 2012, the authors identified 14,964 living kidney donations of which 93.8% were performed laparoscopically; of these, 2.4% were performed with robotic assistance, and only 3.7% were planned open procedures [11]. In this series, 16.8% of all patients had any complication, but only 2.5% of these complications were Clavien grade 4 or higher. Correlates of Clavien grade 4 or higher complications were African American race, obesity, preexisting hematologic or psychiatric illness, and robotic nephrectomy. Annual center volume higher than 50 cases per year was protective. These data attest to the fact that laparoscopic donor nephrectomy now comprises over 90% of all live-donor nephrectomies at academic medical centers in the modern era.

Laparoscopic kidney donation has been shown to result in less postoperative pain, quicker recovery, and better cosmetic outcomes. Taken together, these improvements over open surgery (with its associated larger incision) make LDN a more palatable option to the donor, which may lessen some of the disincentives to kidney donation.

Laparoscopic nephrectomy for T1 and T2 renal tumors has been widely accepted as the gold standard for at least 10 years [12]. Whether or not this standard can be applied to living kidney donation has not been widely agreed upon at least to this point. Indeed, even publications as recent as 2010 indicate that “there is no strong evidence that LLDN is better than OLDN” [13]. As such, universal consensus yet remains to be achieved on this issue.

Laparoscopic donor nephrectomy may be more attractive to potential kidney donors, who by definition are otherwise healthy and are altruistically incurring the risks of surgery and anesthesia for the benefit of the organ recipient. As expected, recovery is quicker and postoperative pain lesser in patients undergoing LDN as compared to open surgery. In one study, the duration of postoperative analgesic requirement was 7 days after LDN vs. 30 days after ODN [14]. Additionally, LDN patients required significantly lesser amounts of parenteral analgesics, with LDN patients requiring total morphine doses of 36–88 mg vs. 60–265 mg in ODN patients. Ratner et al. showed that the hospital stay was lesser following LDN at 3.3 vs. 4.7 days in ODN patients, and time to return to work was 11–36 days vs. 39–83 days in the two groups, respectively.

In a randomized study seeking to determine the effects of LDN vs. ODN on health-related quality of life, donors undergoing LDN reported less bodily pain in the first 6 weeks postdonation, and this was associated with an improved mental health component of quality of life compared with ODN (51.9 ± 7.2 vs. 45.3 ± 10.1; p = 0.0009) [15].

Ultimately, graft function can be considered the most important factor in determining whether or not laparoscopic live-donor nephrectomy can be considered to have replaced open donor nephrectomy as the “gold-standard” procedure. The first randomized clinical trial comparing these two surgical approaches showed no difference in the serum creatinine level between laparoscopic and open donor nephrectomy grafts at 3 days, 30 days, and 3 months after kidney transplantation [16]. Warm ischemia time was significantly longer in the LDN group (6.6 min vs. 2.09 min), but the long-term graft function was not affected.

At 6 months follow-up, there was no significant difference in the serum creatinine (1.64 mg/dl in the laparoscopic group vs. 1.48 mg/dl in the open group). Laparoscopic and open donor nephrectomies have also been compared in patients with multiple renal arteries, and again postoperative serum creatinine levels and graft survival rates were equivalent [17, 18]. Similarly, postoperative serum creatinine was similar among open, pure laparoscopic, and hand-assisted laparoscopic donor nephrectomies [19]. Overall, regardless of which technique is employed for donor nephrectomy, there is a 5–10% incidence of delayed graft function. However, numerous studies have demonstrated that the laparoscopic approach is not a risk factor for this baseline rate of delayed graft function.

Less is known about long-term graft performance after procurement via the laparoscopic technique. A large study utilized the OPTN database to assess 5532 patients, comprised of 2685 (49%) laparoscopic vs. 2847 (51%) open living-donor renal transplant recipients reported to the Organ Procurement and Transplantation Network between November 1999 and December 2000 [20]. Follow-up data were available through February 2006 (60+ months). At discharge and at 5 years, graft function was similar for both groups; graft survival at 5 years was 79% in the laparoscopic cohort vs. 80% in the open cohort (P = NS). Acute and chronic rejection accounted for 152 laparoscopic (51%) vs. 148 (46%) open graft losses (P = NS). These long-term data are certainly encouraging as LDN has widely overtaken ODN in the number of living-donor nephrectomies performed today.

It has been stated that surgeons need the skills used in open live-donor nephrectomy, a fundamental understanding of laparoscopy, and prior experience with laparoscopic partial and radical nephrectomies to perform LDN safely [21]. In multiple studies, the renal warm ischemia time has been shown to be consistently higher in LDN but does not correlate with incidence of delayed graft function, acute rejection, or allograft or recipient survival. As regards potential morbidity to the donor, blood loss and postoperative transfusion requirements have been similar between laparoscopic and open live kidney donation. Operative time for LDN is longer than ODN but decreases with learning curve. The rate of open conversion has ranged from 0 to 13% in several studies [10] with the most common indication being intraoperative bleeding or vascular injury (65%), followed by less common reasons such as difficult exposure, patient obesity, stapler malfunction, and loss of pneumoperitoneum. Several other LDN series have reported far lower rates of open conversion, at 1–2%.