Introduction:Laparoscopic donor nephrectomy has become the standard of care due to multiple benefits. Transperitoneal laparoscopic (TLDN) approach is currently being widely adopted in most transplant centres. However, a systematic review has shown that an alternative retroperitoneoscopic (RLDN) approach is associated with fewer complications due to the anatomical advantage by avoidance of manipulation of the intraperitoneal organs. There was limited data available in assessing the learning curve for transition to RLDN. The aims of this study were to compare the outcomes of RLDN and TLDN by a case control study. The learning curve for transition from TLDN to RLDN was analyzed
Materials and Methods: From Dec 2012, the authors have changed the surgical technique for live donor nephrectomy from TLDN to RLDN after a mentorship.  Sixty two cases of live donor nephrectomy have been performed by RLDN up to Oct 2017. For an efficient analysis, another 60 cases of live donor nephrectomy by TLDN were included retrospectively in this study. Data on patient demographics, peri-operative parameters, analgesia consumption, pain scores and kidney graft function were collected and analyzed.  Statistical analyses were performed with a student’s t-test or Mann-Whitney test. A CUSUM analysis was also performed to explore the learning curve by setting the mean operative goal time of TLDN as a target.
Results: All these 122 donor nephrectomies were successful with no conversion to open surgery. There was no blood transfusion, readmission or mortality. There were no post-operative complications which were graded over Clavien II. The kidney graft function was comparable in both groups. The follow-up period ranged from 2 to 86 months. The CUSUM analysis demonstrated that approximately 30 cases are required for the surgeon to be proficient in the transition from TLDN to RLDN.
Conclusion: RLDN is a safe approach with comparable results to TLDN. It has an anatomical advantage as it avoids manipulating the intraperitoneal organs and retains a virgin abdomen and hence translates to a lower peri-operative complication risk. The learning curve of transitioning from TLDN to RLDN of about 30 cases is acceptable.