**6. Complications**

LLDN appears to be a safe procedure or at least as safe as the open one. But serious complications including death may occur. Overall mortality rate is approximately 0.03% [34] although some large series reported no mortality [60–63]. Most of these deaths occurred in the postoperative period and were due to hemorrhage [47], CO2 gas embolism [64], and pulmonary embolism [34]. The risk of a major intraoperative hemorrhage during LLDN is between 0.6 and 1.6% [60, 63]. Conversion to open surgery has been reported to occur in 0 to 13% of cases, but in most large series, conversion rates of 1–2% are reported [4, 60–63]. Other intraoperative complications are splenic or liver laceration, ureteral and intestinal injury, and pleural laceration. The total incidence of surgical complications is 5.46% [61]. All major complications occurred in the first 100 cases [62]. This raises the question of the learning curve and how many laparoscopic nephrectomies should be done before performing the first LLDN? There is no precise answer but a number between 50 and 100 seems to be convincing for this type of surgery to be learned.

Postoperative complications of LLDN are hematomas, fever, urinary tract infection, pneumonia, pulmonary embolism, wound infection, incisional hernias, prolonged ileus, chylous ascites, and left testicular pain perhaps due to gonadal vein division or extensive mobilization of the left colon which may damage the neural plexus supplying the testis and may also disrupt lymphatic drainage [65]. Chylous leakage is a rare complication of LLDN. Prevention is assured by doing a meticulous and extensive clipping of lymphatic channels along the dissection area [52, 66].

Long-term complications are arterial hypertension, renal failure, and proteinuria, particularly in more high-risk donors, such as those with obesity, old or young donors, hypertensive donors, and those with kidney stones [67, 68]. Following kidney donation, there is a compensatory increase in function in the remaining kidney. By 3 months, remnant kidney clearance increases to a mean GFR of around 65–75% of predonation renal function [4]. The average decrease in GFR after donation was 26 mL/min/1.73 m<sup>2</sup> (range 8–50) [4, 69]. The incidence of end-stage renal disease (ESRD) in living kidney donors appears to be similar to or lower than that seen in the unselected general population despite a reduction in GFR [4, 24, 70]. The estimated lifetime risk of ESRD was 90 per 10,000 in donors, 326 per 10,000 in the general population, and 14 per 10,000 in matched healthy nondonor controls [71]. Live donor nephrectomy alone will not lead to renal failure [72].

Concerning hypertension, a large meta-analysis demonstrated that donors have an increased systolic blood pressure of 5 mmHg after 5–10 years from donation [73]. The rate of hypertension in donors was similar to that of the general population [74]. But it seems that there are no effects on kidney function and microalbuminuria at least in Caucasian population. Blacks and Hispanics may have higher risks of hypertension-associated kidney disease after donation [75, 76].

Finally, it is interesting to know that longevity of live donors remains greater compared to the general population [24, 72, 77].
