# Laparoscopic Living Donor Nephrectomy: Learning Curve Analysis Through 1446 Cases and Outcomes from 200 Consecutive Mastery-Phase Procedures—How I Do It

## TL;DR

This study analyzes the learning curve and outcomes of laparoscopic living donor nephrectomy across 1446 cases, showing improved efficiency and safety over time.

## Contribution

The study provides a detailed learning curve analysis using CUSUM methodology and reports outcomes from a mastery-phase cohort of 200 consecutive cases.

## Key findings

- Operative time decreased by 37.4% from 154.6 to 96.8 minutes as surgeons progressed through learning phases.
- The mastery phase (1001–1446 cases) had no conversions to open surgery and a 0.5% major postoperative complication rate.
- Left kidney procurement was performed in 99.5% of cases, with orchalgia prevalence declining over time in male donors.

## Abstract

Background: Laparoscopic living donor nephrectomy is a standard approach for kidney procurement, yet optimal technique and learning curve trajectories remain incompletely characterized. We present a high-volume single-center experience with standardized transperitoneal laparoscopic donor nephrectomy and CUSUM-based learning curve analysis. Methods: Retrospective analysis of 1446 consecutive laparoscopic living donor nephrectomies performed by six surgeons between January 2015 and December 2024. Learning curve analysis used the cumulative sum (CUSUM) methodology to identify proficiency phases. The most recent 200 consecutive cases, representing mature institutional performance, were analyzed for detailed outcomes. The surgical technique employed a transperitoneal approach with the GelPOINT® Advanced Access Platform for kidney extraction via an offset Pfannenstiel incision. Results: CUSUM analysis identified case 669 as the inflection point, defining four phases: Phase I (initial learning, cases 1–250, n = 250, 154.6 ± 35.9 min), Phase II (rapid improvement, cases 251–669, n = 419, 136.7 ± 32.6 min), Phase III (consolidation, cases 670–1000, n = 331, 118.0 ± 30.1 min), and Phase IV (mastery, cases 1001–1446, n = 446, 101.5 ± 26.2 min). Overall operative time decreased from 154.6 to 96.8 min (37.4% reduction, p < 0.001). In the 200-case mastery-phase cohort, mean operative time was 96.8 ± 25.5 min with warm ischemia time of 3.8 ± 1.2 min. There were no conversions to open surgery (0%), no intraoperative complications, and one major postoperative complication (0.5%, Clavien–Dindo ≥ IIIa). Left kidney procurement was performed in 99.5% of cases. Among male donors (n = 86), systematic orchalgia surveillance demonstrated 46.5% prevalence at 1 month, declining to 36.0% at 1 year, and 7.0% at a 5-year follow-up. Conclusions: This high-volume single-center experience demonstrates favorable outcomes in laparoscopic living donor nephrectomy with CUSUM-defined proficiency phases extending beyond 1000 cases. The outcomes observed likely reflect the combined effects of institutional volume, team experience, and standardized technique. Multi-center validation is required before generalizing these results.