Background: The optimal surgical approach for managing multiple renal arteries in living donor kidney transplantation remains unclear. This study compared outcomes between separate anastomoses (SA) and pantaloon anastomosis (PA). Methods: A retrospective cohort study was conducted from November 2018 to August 2024. In total, 117 patients were included (SA, 67; PA, 50). The primary outcome was arterial complications. Secondary outcomes included renal function, graft and patient survival at 1 year, and intraoperative variables. Statistical analyses utilized the t-test, the Mann-Whitney U-test, and Kaplan-Meier survival curves. Results: The mean warm ischemia time was similar between groups (105.48±35.64 vs.103.92±33.51 min; P=0.811). Cold ischemia time was also comparable (75.90±14.36 vs.80.68±17.85 min; P=0.111). However, anastomosis time was significantly longer in the SA group (39.00 [35.00–43.00] min) compared with the PA group (34.00 [28.50–39.50] min; P<0.001). The immediate postoperative creatinine reduction was slightly greater in the SA group (46.83%±20.68% vs. 39.78%±19.04%; P=0.090). Vascular complications requiring re-exploration were infrequent in both groups (1.5% vs. 2.0%). At 1 year posttransplant, creatinine levels were comparable between the SA (1.20 [0.95–1.45] mg/dL) and PA (1.20 [1.05–1.35] mg/dL) groups (P=0.337). Regression analysis confirmed that postoperative creatinine levels were independently associated with SA (P=0.006). Graft survival was similarly high (97% vs. 98%), as was patient survival (100% vs. 96%). Conclusions Both anastomosis techniques are safe and effective for transplanting kidneys with anatomical anomalies. SA offers surgical efficiency and provides superior early renal recovery.