Transition from transperitoneal to retroperitoneal approach in laparoscopic living donor nephrectomy: Team-based and individual learning curve: A cross-sectional study

Background: Laparoscopic living donor nephrectomy (LLDN) is a standard practice for kidney donor transplantation due to fewer complications associated with the treatment. Retroperitoneal approach to LLDN is thought to be more advantageous in preventing injuries to various abdominal organs. However, the transition process from transperitoneal to retroperitoneal LLDN is important to ensure the best outcome for the patients. The aim of this study was to investigate the learning curve for the retroperitoneal approach in LLDN among urologists in an individual and team-based approach Methods: A retrospective analysis of retroperitoneal LLDN was performed on procedures performed by a kidney donor team consisting of four (4) urologists from January 2019 to January 2022 at Cipto Mangunkusumo National General Hospital, Indonesia. The data were taken from pre-existing medical records. The learning curve for the operation time, warm ischemic time, and estimated blood loss were analyzed using cumulative sum (CUSUM) analysis. Phase 1 represents the initial learning curve, the phase 2 plateau represents the period of proficiency, and phase 3 represents the mastery period. Results: A total of 127 retroperitoneal LLDN procedures were done during the study period by four operators with various experience. The average procedure needed to achieve proficiency was 16.5 procedures. Meanwhile, the average procedure needed to achieve mastery was 28 procedures. A shorter learning curve was achieved by operators with more experience in other laparoscopic procedures. Conclusions: The learning curve for transition from transperitoneal to retroperitoneal approach to LLDN is relatively short and feasible for both individuals and teams of urologists. Therefore, the transition to a retroperitoneal approach is a feasible option to reduce the complication rate of LLDN.