The anterior extraperitoneal approach was compared to the flank approach for living donor nephrectomy in a series of 36 familial donors. The former procedure (23 cases) not only afforded superior visualization of renal vessels but also was probably at least as safe as the latter (13 cases) for donors with risk factors of obesity, age more than 45 years and pulmonary disease. Anterior extraperitoneal nephrectomy appears to be indicated for donors with multiple renal arteries and skeletal deformities, including thoracolumbar arthritis.