title: Introducing hand-assisted retroperitoneoscopic live donor nephrectomy: learning curves and development based on 413 consecutive cases in four centers.
abstract: BACKGROUND
  Hand-assisted and retroperitoneoscopic techniques reduce the risk of bleeding and intraabdominal complications in living donor nephrectomy (LDN). This study reports on our four-center experience, development, and learning curves from the first 413 LDNs using a hand-assisted retroperitoneoscopic (HARS) technique.
  
  
  METHODS
  The first 413 consecutive donors operated on using HARS were included in the study. Donor demographics, perioperative and postoperative data, complications, and recipient outcomes have been compiled. The data were analyzed as a whole and separately for each center, looking at center differences and learning curves over time.
  
  
  RESULTS
  Significant differences were found in donor demographics between centers for the variables: age, body mass index, number of arteries, and side of operation. Mean operating time was 170.2 min, with significant differences between centers. Operating time was also significantly influenced by learning curves, sex/body mass index, and side of operation. Warm ischemia time differed significantly between centers and was influenced by center-wise learning and number of arteries. Overall conversion rate was 2.4% and differed significantly between centers. There was no mortality and no intraabdominal complications. Apart from the conversions and one pulmonary embolism, there were no major intraoperative or postoperative complications. Overall 3-month graft survival was 99%, with 96% immediate onset of function and 1% ureteral complications.
  
  
  CONCLUSIONS
  The HARS technique reduces the risk of intraabdominal complications. It can be implemented with excellent donor and recipient outcomes despite different population demographics and center/surgeon-related tradition and experience. On the basis of our experience, we recommend the technique to increase the safety margin of LDN.
authors.affiliation: Department of Surgery, Uppsala University Hospital, Uppsala, Sweden. jonas.wadstrom@akademiska.se
authors.forename: Jonas
authors.initials: J
authors.lastname: Wadström
authors.forename: Alireza
authors.initials: A
authors.lastname: Biglarnia
authors.forename: Henrik
authors.initials: H
authors.lastname: Gjertsen
authors.forename: Atsushi
authors.initials: A
authors.lastname: Sugitani
authors.forename: Jiri
authors.initials: J
authors.lastname: Fronek
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D058733:Hand-Assisted Laparoscopy / Q000379:methods*; D006801:Humans; D016030:Kidney Transplantation / Q000379:methods*; D059032:Learning Curve; D007902:Length of Stay; D019520:Living Donors; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000379:methods*; D011183:Postoperative Complications / Q000453:epidemiology; D020858:Tissue and Organ Harvesting / Q000379:methods*; D016896:Treatment Outcome; D055815:Young Adult