Safety of Right-Sided Minimally Invasive Living Donor Nephrectomy: A Contemporary National Registry Analysis of 29,874 Transplants.

OBJECTIVE: To compare donor and recipient outcomes after minimally invasive living donor nephrectomy based on kidney laterality. METHODS: We performed a retrospective cohort study of living donor kidney transplants recorded in UNOS (2021-2025). Donor and recipient demographic, perioperative, and functional outcomes were analyzed. Continuous and categorical variables were compared using adequate statistical tests. Graft survival was assessed using Kaplan-Meier and Cox regression analysis. Multivariable logistic models were constructed. RESULTS: We analyzed 29,874 transplants. Right-sided minimally invasive living donor nephrectomy was associated with longer cold ischemia time (1.9 [IQR:1.1-4.4] vs. 1.6 [IQR:1.0-3.8] hours; p<0.001) and higher rates of delayed graft function (4.7% vs. 2.5%;p<0.001). In the overall cohort, right-sided kidneys demonstrated higher rates of graft thrombosis, early graft loss, and lower 4-year graft survival. However, these differences were dependent on procurement technique and not observed in non-hand-assisted laparoscopic cases. Donor and recipient creatinine levels at last follow-up were clinically comparable. CONCLUSIONS: Right-sided minimally invasive living donor nephrectomy is associated with greater cold ischemia times and delayed graft function rates but otherwise yields comparable outcomes when stratified by procurement technique. Despite registry follow-up constraints and combined non-hand-assisted classification (pure laparoscopic/robotic), these findings suggest right-sided procurement remains a reasonable option in experienced centers using non-hand-assisted laparoscopy.