The practice of live renal donation remains a competition between minimization of the risk to the healthy donor and the ease of reimplantation of the donated kidney. One of the bedrock principles underpinning the practice of live renal donation is leaving the donor with the better kidney, whenever a discrepancy exists between the 2. If both are equal, the left kidney is generally preferred by recipient surgeons owing to the increased length and often thicker wall of the renal vein compared with the right. This facilitates reanastomosis to the iliac vessels, especially in recipients with a deep pelvis or a high body mass index. However, the wide application of laparoscopic donor nephrectomy has created strong incentives to bend these rules. Before laparoscopy, about 30%-40% of donor kidneys were right kidneys. Some even advocated the preferential use of right kidneys in fertile women, to avoid the possibility of physiologic hydronephrosis of pregnancy. With widespread laparoscopic nephrectomy, only 5%-10% of donor kidneys are the right kidney. In addition to the anatomic reasons mentioned, laparoscopic surgeons are reluctant to remove a cuff of vena cava with the right donor kidney, preferring to divide the right renal vein with a staple line on several millimeters of vein. This makes the right donor kidney less desirable for transplantation. When decisions are made regarding which kidney to remove, the ease of laparoscopy often becomes the primary consideration.
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