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

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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 retroperitoneal approach in LLDN among urologists in an individual and team-based approach. Methods A prospective analysis of retroperitoneal LLDN was performed on procedures performed by a kidney donor team consisting of four 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 was analyzed using cumulative sum (CUSUM) analysis. Phase 1 represents the initial learning curve, the phase 2 plateau represents the period of proficiency, while 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. 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, transition to retroperitoneal approach is a feasible option to reduce the complication rate of LLDN. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/12-464", "name": "Transition from transperitoneal to retroperitoneal approach in laparoscopic..." } } ] } Home Browse Transition from transperitoneal to retroperitoneal approach in laparoscopic... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Wahyudi I, Adriansyah IA, Yonathan K et al. Transition from transperitoneal to retroperitoneal approach in laparoscopic living donor nephrectomy: team-based and individual learning curve: a cross-sectional study [version 2; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 12 :464 ( https://doi.org/10.12688/f1000research.129479.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Revised Transition from transperitoneal to retroperitoneal approach in laparoscopic living donor nephrectomy: team-based and individual learning curve: a cross-sectional study [version 2; peer review: 1 approved, 1 approved with reservations] Irfan Wahyudi 1 , Ilham Azka Adriansyah 1 , Kevin Yonathan https://orcid.org/0000-0002-3089-0652 1 , Fina Widia 1 , Agus Rizal A Hamid https://orcid.org/0000-0002-7538-2811 1 , Chaidir Arif Mochtar 1 Irfan Wahyudi 1 , Ilham Azka Adriansyah 1 , [...] Kevin Yonathan https://orcid.org/0000-0002-3089-0652 1 , Fina Widia 1 , Agus Rizal A Hamid https://orcid.org/0000-0002-7538-2811 1 , Chaidir Arif Mochtar 1 PUBLISHED 10 Feb 2026 Author details Author details 1 Department of Urology, University of Indonesia, Jakarta, DKI Jakarta, 10430, Indonesia Irfan Wahyudi Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Ilham Azka Adriansyah Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Software, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Kevin Yonathan Roles: Conceptualization, Data Curation, Methodology, Project Administration, Resources, Writing – Original Draft Preparation, Writing – Review & Editing Fina Widia Roles: Conceptualization, Formal Analysis, Resources, Validation, Writing – Review & Editing Agus Rizal A Hamid Roles: Conceptualization, Formal Analysis, Resources, Writing – Review & Editing Chaidir Arif Mochtar Roles: Conceptualization, Investigation, Methodology, Resources, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract 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 retroperitoneal approach in LLDN among urologists in an individual and team-based approach. Methods A prospective analysis of retroperitoneal LLDN was performed on procedures performed by a kidney donor team consisting of four 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 was analyzed using cumulative sum (CUSUM) analysis. Phase 1 represents the initial learning curve, the phase 2 plateau represents the period of proficiency, while 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. 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, transition to retroperitoneal approach is a feasible option to reduce the complication rate of LLDN. READ ALL READ LESS Keywords kidney donor, laparoscopy, nephrectomy, transplantation Corresponding Author(s) Irfan Wahyudi ( [email protected] ) Close Corresponding author: Irfan Wahyudi Competing interests: No competing interests were disclosed. Grant information: The funding for this study was partially fulfilled by Universitas Indonesia with International Indexed Publication Grant Program (PUTI) [grant number NKB-1235/UN2.RST/HKP.05.00/2022] Copyright: © 2026 Wahyudi I et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Wahyudi I, Adriansyah IA, Yonathan K et al. Transition from transperitoneal to retroperitoneal approach in laparoscopic living donor nephrectomy: team-based and individual learning curve: a cross-sectional study [version 2; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 12 :464 ( https://doi.org/10.12688/f1000research.129479.2 ) First published: 04 May 2023, 12 :464 ( https://doi.org/10.12688/f1000research.129479.1 ) Latest published: 10 Feb 2026, 12 :464 ( https://doi.org/10.12688/f1000research.129479.2 ) Revised Amendments from Version 1 In this revision, we incorporated specific feedback from reviewers to enhance the clarity and accuracy of the study. In the Abstract section, the background was refined to clarify that surgeons typically start with transperitoneal approaches because they are more familiar, providing better context for the transition to retroperitoneal techniques. In the Text and Methods sections,, now details of the 1-2 year fellowships undertaken at external centers were included. We also clarified that this is a prospective study and explained that the alternating nature of surgeons in the team-based model is why more procedures are needed to reach proficiency compared to individual analysis. Additionally, we added the suggested citation regarding the acquisition of laparoscopic skills. The limitations section was expanded to explicitly address the study's retrospective design, the lack of randomization in surgeon assignment, constraints on nephrectomy indications (right vs. left), and the surgeons' significant pre-existing experience. Finally, we updated the References to include more current literature, ensuring that a greater proportion of citations are recent. In this revision, we incorporated specific feedback from reviewers to enhance the clarity and accuracy of the study. In the Abstract section, the background was refined to clarify that surgeons typically start with transperitoneal approaches because they are more familiar, providing better context for the transition to retroperitoneal techniques. In the Text and Methods sections,, now details of the 1-2 year fellowships undertaken at external centers were included. We also clarified that this is a prospective study and explained that the alternating nature of surgeons in the team-based model is why more procedures are needed to reach proficiency compared to individual analysis. Additionally, we added the suggested citation regarding the acquisition of laparoscopic skills. The limitations section was expanded to explicitly address the study's retrospective design, the lack of randomization in surgeon assignment, constraints on nephrectomy indications (right vs. left), and the surgeons' significant pre-existing experience. Finally, we updated the References to include more current literature, ensuring that a greater proportion of citations are recent. See the authors' detailed response to the review by Mustafa Suat Bolat See the authors' detailed response to the review by Luis Garcia-Covarrubias READ REVIEWER RESPONSES Introduction Kidney transplantation is the best available option for the management of end stage renal disease (ESRD). 1 Transplantation reduces the risk of cardiovascular and mortality events, while also improving quality of life compared to chronic hemodialysis. 2 Living donor transplantation is preferred over deceased donor, as it has better survival rates and less delayed graft function. 3 , 4 Laparoscopic living donor nephrectomy (LLDN) is the standard surgical practice due to fewer complications associated with the treatment. 5 This technique includes standard laparoscopic, hand-assisted laparoscopic, hand-assisted retroperitoneoscopic, pure retroperitoneoscopic, and robot-assisted live donor nephrectomy. 6 – 9 Usually, surgeons will initially use transperitoneal approach for laparoscopic procedure due to its familiarity and natural orientation, then use retroperitoneal approach afterward. However, previous studies have shown that the retroperitoneal approach to LLDN has more advantages than the transperitoneal approach; namely shorter access to renal arteries and veins, better visualization during donor nephrectomy, and prevention of injuries of the liver, spleen, and bowel. 10 – 14 However, some adjustments to the techniques require additional training for the operators performing the technique. Evaluation of surgical practice performances could be done using the learning curve. 15 However, there has only a few studies regarding the learning curve of the retroperitoneal approach of LLDN. Moreover, a previous study only analyzed learning curve on a single operator, although LLDN is usually performed by a team, alternating between operators. 16 Therefore, this study aims to investigate the learning curve for retroperitoneal approach in LLDN among urologists in an individual and team-based approach. Methods A prospective analysis of laparoscopic living donor nephrectomy (LLDN) procedures was done on four different urologists (operators) with different levels of experience from January 2019 to January 2022 at Cipto Mangunkusumo National General Hospital, Indonesia. All of the operators in our kidney donor team were included in this study. Total sampling method was performed on all the procedures performed during the time limit. The date was determined as the first LLDN in our center was performed in January 2019 while the endpoint was the most recent date that the yearly review of the procedure was carried out. Ethical Approval to conduct this study was issued by the ethics committee of the Faculty of Medicine Universitas Indonesia–Cipto Mangunkusumo Hospital (KET-720/UN2.F1/ETIK/2018). All patients had received detailed preoperative counselling and their decision to undergo the procedure was taken with written informed consent prior to the surgery. Meanwhile, the data used in this study were collected from the medical records of the patients. The written permission was granted by the ethics committee of the Faculty of Medicine Universitas Indonesia–Cipto Mangunkusumo Hospital for the publication of the study results. Demographical data was collected from the electronic medical record, including age, sex, and body mass index (BMI, calculated as weight in kilograms divided by square of height in meters). Preoperative data included number of arteries involved and side of the donor kidney. Intraoperative data included surgery duration, warm ischemic time (WIT), and estimated blood loss (EBL). Surgery duration was determined as the length of time from the first incision to renal artery clamping, as the final closure was sometimes done by the residents due to the study location being a teaching hospital. WIT was documented as the length of time from clamping to cold ischemic time. Postoperative complication was documented in accordance to the pre-existing data in the medical records. Operative technique The operative technique used in this study has been reported in other publications and become the routine technique used in our center, including for the subjects in this study. 8 , 17 The LLDN was done under general anesthesia and the donor was positioned in the lateral decubitus position. First incision was then made one finger below the 12 th rib with open approach (Hasson technique) to reach access to retroperitoneal space. Retroperitoneal space was created using balloon dilator. Afterward, an 11 mm trocar was then inserted into retroperitoneal space for camera. Other two incisions were made in line: one at the costovertebral angle and one the above anterior superior iliac spine. Pneumoretroperitoneum was created using a carbon dioxide (CO 2 ) insufflation and the pressure maintained at 12 mmHg. The psoas muscle was identified and the Gerota fascia was incised to expose the ureter. Furthermore, the gonadal vein was identified, and its course was followed upward to find the renal vein. Each renal pedicle was identified individually and dissected. Perirenal fat was then dissected from renal parenchyma and the kidney was mobilized. Further dissection was performed to renal artery until its base at aorta and renal vein until below gonadal and adrenal tributaries. The ureter was dissected until the distal part near its crossing to iliac vessel. Retrieval of the kidney was done via suprapubic access created through a modified Pfannenstiel incision. Operators In this study, the procedures were performed by four urologists, namely surgeon 1 (S1), surgeon 2 (S2), surgeon 3 (S3) and surgeon 4 (S4). S1 was a urologist with more than 15 years of laparoscopy experience, S2 was a urologist with more than nine years of laparoscopy experience, S3 was a urologist with more than eight years of experience, while S4 was a urologist with more than four years of experience. All of the urology surgeons had performed more than 100 transperitoneal approach LLDN with limited experiences in retroperitoneal approach for other laparoscopic urology procedures, such as partial nephrectomy, adrenalectomy, unroofing renal cyst and proximal ureterolithotomy. The learning method for retroperitoneal approaches used was done by viewing the video and visiting urology centers which are familiar with retroperitoneal approach of laparoscopy procedures, either for LLDN or for other nephrectomy procedures. The urology centers visited for the study were The Academic Medical Center, University of Amsterdam (Amsterdam, Netherlands), Radboud University Medical Center (Nijmegen, Netherlands), and SLK Kliniken Heilbronn GmbH (Heilbronn, Germany). The operators acted as fellows in those centers for 1-2 years. The average of LLDN surgery in our hospital was between two and three surgeries per week. As per the protocol in our center, all the surgeons were arranged to have fair and similar opportunity to perform retroperitoneal approach LLDN regularly, including in the transition process. Statistical analysis Cumulative sum (CUSUM) analysis was performed with SPSS version 20 (RRID:SCR_016479)(IBM Corp, 2011) 18 to investigate individual surgeon operative time learning curves to reach optimal performance. Team-based analysis was separately performed to analyze the operative time by all of the four urologists. Three indicators, namely duration of surgery, WIT, and EBL were collected from pre-existing medical records and evaluated to represent the learning process taking place as the surgery repetition occurred. The CUSUM is the running total of differences between the individual data points and the mean of all data points, thus it can be performed recursively. The cases were ordered chronologically from the earliest to the most recent. The surgery duration for each case was defined as x i and the mean surgery duration of all cases was defined as μ. Therefore, the CUSUM at surgery duration n (CUSUM SDn ) might be calculated as follow: CUSUM SDn = ∑ i = 1 n x i − μ The CUSUM SD1 of the first case was the difference between the duration of surgery for the first case and the μ. The CUSUM SD2 of the second case was the previous case’s CUSUM SD added to the difference between the duration of surgery for the second case and the μ. The process then continued until the CUSUM SD for the last case was calculated. 19 All of the surgeons in this study experienced three learning phases as described in a previous study. 19 The three phases of the learning curve were identified by the inflection point of the CUSUM curve. Phase 1 (learning period) showed an expected incline in CUSUM curve which was the initial learning curve, phase 2 (proficiency) showed a decline in CUSUM curve, with a plateau which was the proficient phase with additional experience obtained leading to the achievement of expert competence. Phase 3 was defined as the post-learning (mastery) period, as seen in typical learning curve studies in which there was steeper decline of the CUSUM curve. To determine the difference of characteristics and outcomes between phases, the Chi-square test was used to analyze categorical data and Wilcoxon test was used to analyze numerical data. All statistical tests were 2-tailed, and a p-value of < 0.05 was considered to as statistical significance. The statistical analyses were performed with SPSS version 20 (RRID:SCR_016479) (IBM Corp, 2011). Results A total of 127 patients underwent LLDN during the three years [30], with 31 operations done by S1, 30 operations by S2, 38 operations by S3, and 28 operations by S4. There was no conversion to open nephrectomy during the surgeries performed in this study. Individual learning curve of retroperitoneal LLDN operator CUSUM analysis of LLDN operative time is shown in Figure 1 . Based on the analysis of each surgeons, the average number of procedures needed to achieve proficiency (phase 2) was 16.5. Meanwhile, the average number of procedures needed to achieve mastery (phase 3) was 28. However, S4 did not achieve mastery during the study, thus the average number of procedures needed to achieve mastery was calculated only for S1, S2, and S3. Figure 1. Cumulative SUM (CUSUM) for operation time of Laparoscopic Living Donor Nephrectomy (LLDN). (a) Surgeon 1 (15+ years of exp), (b) Surgeon 2 (9+ years of exp), (c) Surgeon 3 (8+ years of exp), (d) Surgeon 4 (4+ years of exp). Team-based learning curve of retroperitoneal LLDN operator Based on the analysis, it can be assumed that the number of procedures needed as a team to achieve proficiency (phase 2) was 66 procedures, while the number of procedures needed as a team to achieve mastery (phase 3) was 106 procedures ( Figure 2 ). Figure 2. Team-based learning curve of retroperitoneal Laparoscopic Living Donor Nephrectomy (LLDN) Operator. Clinical outcome compared to experience There was a significant reduction in operative time after proficiency and mastery of LLDN (P < 0.001). Meanwhile, intraoperative WIT, EBL, and postoperative complication shows no significant difference between phases ( Table 1 ). Table 1. Clinical outcome of donors in each phase. Variables Phase 1 (n = 66) Phase 2 (n = 40) Phase 3 (n = 21) p Age (years), median (min-max) 47 (22-71) 41.5 (22-65) 37 (23-68) 0.073 Sex 0.189 Male 26 (39.4%) 19 (47.5%) 13 (61.9%) Female 40 (60.6%) 21 (52.5%) 8 (38.1%) BMI (kg/m 2 ), median (min-max) 25.2 (15.6-32.8) 24.3 (17.0-36.1) 24.5 (17.4-32.5) 0.626 Side of donor kidney transplanted 1.000 Left 66 (100%) 40 (100%) 21 (100%) Right 0 0 0 Arteries 0.347 Single 55 (83.3%) 37 (92.5%) 19 (90.5%) Multiple 11 (16.7%) 3 (7.5%) 2 (9.5%) Surgery duration (min), median (min-max) 186 (110-345) 150 (85-289) 140 (90-230) < 0.001 WIT, median (min-max) 4.05 (2.12-13.32) 4.02 (2.33-11.65) 3.53 (3.07-7.43) 0.315 EBL (mL), median (min-max) 70 (10-340) 50 (30-200) 75 (20-300) 0.876 Complications 0.223 None 62 (93.9%) 34 (85.0%) 20 (95.2%) Clavien-Dindo I 3 (4.6%) 4 (10.0%) 1 (3.6%) Clavien-Dindo II 1 (1.5%) 2 (5.0%) 0 Discussion Minimally invasive techniques are the preferred technique for donor nephrectomy compared to open nephrectomy. Studies found that a minimally invasive approach is associated with perioperative lower blood loss, lower morbidity, 20 reduced analgesia use, shorter length of stay, and faster recovery. 5 Retroperitoneal approach or retroperitoneoscopic provides direct access to renal hilum without moving abdominal organs. Therefore, injury or bleeding of the organs could be avoided and bowel function may return rapidly following the surgery. 10 , 21 The crucial disadvantage of this procedure was the difficulty to orient the landmark due to the limited working space of the retroperitoneal approach in LLDN. 22 In terms of the learning curve, retroperitoneal approach is more technically demanding and has a steeper learning curve than the transperitoneal approach. 23 – 25 Learning curves represent the relationship between learning repetition and practice performance. 26 There are several methods that can be used to analyze the learning curves other than CUSUM analysis, such as graphical visual inspection, split-group method, and regression techniques. CUSUM method is considered the sensitive method adopted by surgical practice for self-and supervisor assessment. This method uses plotted graph and gives accurate progression and level of performance, thus, it can be used to show a process of achieving and maintaining a surgical technique proficiency. 15 A comparison study of retroperitoneoscopic donor nephrectomy by a single surgeon between a high volume and a low volume hospital by van der Merwe et al . describes the learning curve differences in surgery time and WIT. This study shows the improvement based on the graph decline. 11 Meanwhile, a learning curve study of retroperitoneoscopic donor nephrectomy by Pal et al . analyzes the performance changes between three groups using the split-group method. However, this method has several biases based on its arbitrary group size option and uncertain changes. 27 In our CUSUM analysis study, on an individual level, an average of 16.5 procedures was needed to achieve proficiency and 28 procedures to acquire mastery in the transition from transperitoneal to retroperitoneal approach. There were some differences between the results of this study and other learning curve studies of the retroperitoneal approach of LLDN. Pal et al . 27 found a significantly reduced surgery time after 34 pure laparoscopic retroperitoneal nephrectomies. Chin et al ., 16 though, observed a substantial difference in surgery time after 150 cases, although this study did not use the CUSUM model analysis. The second reduction of operation time or mastery is found after 300 laparoscopic nephrectomies in a study by Nakajima et al . 28 However, the procedures needed to achieve both proficiency and mastery in our study differed on each operator. Operator 1 who had more experience in other surgeries only needed 12 procedures before achieving proficiency, while other operators needed more procedures in accordance with their prior experiences. Based on the CUSUM analysis, it was found that 66 procedure was needed to achieve proficiency (phase 2) and 106 procedures to acquire mastery (phase 3) for team-based approach of the transition from transperitoneal to retroperitoneal LLDN. Team-based analysis shows a more gradual improvement in operation time compared an individual surgeon-based analysis. A study by van der Merwe et al . shows that the subgroup analysis of a single surgeon shows a more graphically evident improvement in operation time than the team-based analysis. 25 However, LLDN is usually approached by several operators, as it is technically demanding and require a significant amount of time. Several variables could affect the learning curve of the retroperitoneal approach of LLDN. The technical skills of each surgeon are related to shorter surgery time and lesser complications. The advantages of the retroperitoneal approach may relate to the surgeon’s experience as the vessel injury, or surgical complications were lower in the more experienced surgeon. 10 , 20 In this study, urologists that have more experience achieve proficiency in operation time in fewer procedures. A study by Zhang et al . showed that senior surgeons had a better learning curve for laparoscopic procedures. Operation time was also significantly faster, with a lower conversion rate to open surgeries. 29 Proficiency-based guidance, part-task training, and assigning practice over time might optimize the learning curve. 30 There were other problematic factors, such as obese donors prolonged the surgery time then affected the learning curve. 6 A few millimeters of perinephric fat would significantly prolong the surgery time. 31 A limitation of the study is in the methodology as it is a study based on pre-existing medical records and done in a single center, with limitation of indication of nephrectomy side (whether left or right) and no random assignment of surgeons to the cases. Therefore, information bias may occur due to the data input, processing, and collection. Moreover, being a teaching hospital, the performance of urology residents as the operative assistant may create another bias, especially for the operative time. Furthermore, regardless of whether it was transperitoneal or retroperitoneal, the surgeons had previous extensive experience in laparoscopic surgery. However, we have limited the calculated operative time to only from the first incision to renal artery clamping, as the final closure was sometimes done by the residents. Conclusions Transition from transperitoneal to retroperitoneal approach in laparoscopic living donor nephrectomy has a certain learning curve time to achieve proficiency and mastery, both on the individual and team-based analysis. Prior experience and focused training may improve the learning process. The transition to retroperitoneal approach is a feasible option to improve the outcome of LLDN. Authors’ contributions IW involved in conceptualization, protocol development, administration of the study, data collection, funding, manuscript writing, and manuscript finalization. IAA involved in conceptualization, protocol development, administration of the study, data collection, and manuscript finalization. KY involved in conceptualization, protocol development, administration of the study, data collection, and manuscript finalization. FW involved in protocol development, study conceptualization, patient recruitment, and manuscript editing and finalization. ARAH contributed in protocol development, study conceptualization, patient recruitment, and manuscript editing and finalization. CAM contributed in protocol development, study conceptualization, patient recruitment, and manuscript editing and finalization. All authors read and approved the final manuscript. Ethics approval and consent to participate Ethical Approval to conduct this study was issued by the ethics committee of the Faculty of Medicine Universitas Indonesia–Cipto Mangunkusumo Hospital (KET-720/UN2.F1/ETIK/2018). Written informed consent was obtained from the patient for the surgery performed in this study. Written informed consent was obtained from a guardian for participants under 18 years old. Written permission was granted by the ethics committee of the Faculty of Medicine Universitas Indonesia–Cipto Mangunkusumo Hospital for the publication of the study results. Data availability Underlying data The data used in this study were provided from pre-existing medical records of kidney donor patients in Cipto Mangunkusumo National Hospital, Indonesia. The authors obtained the data by submitting the ethical clearance to the research ethics of Faculty of Medicine, University of Indonesia, and requesting the written research permit for the data to the Innovation and Intellectual Property Management Installation of Cipto Mangunkusumo National Hospital, Indonesia. The access to the same data will be provided following the formal ethical clearance request to the research ethics of Faculty of Medicine, University of Indonesia, and formal research permit request to the the Innovation and Intellectual Property Management Installation of Cipto Mangunkusumo National Hospital, Indonesia. Extended data Drayad: Transition from transperitoneal to retroperitoneal approach in laparoscopic living donor nephrectomy: Team-based and individual learning curve: A cross-sectional study https://doi.org/10.5061/dryad.3tx95x6kq . 32 This project contains the following extended data: - Dataset.sav (SPSS file containing all aggregated data in this study). Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication). 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Publisher Full Text Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 04 May 2023 ADD YOUR COMMENT Comment Author details Author details 1 Department of Urology, University of Indonesia, Jakarta, DKI Jakarta, 10430, Indonesia Irfan Wahyudi Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Ilham Azka Adriansyah Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Software, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Kevin Yonathan Roles: Conceptualization, Data Curation, Methodology, Project Administration, Resources, Writing – Original Draft Preparation, Writing – Review & Editing Fina Widia Roles: Conceptualization, Formal Analysis, Resources, Validation, Writing – Review & Editing Agus Rizal A Hamid Roles: Conceptualization, Formal Analysis, Resources, Writing – Review & Editing Chaidir Arif Mochtar Roles: Conceptualization, Investigation, Methodology, Resources, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The funding for this study was partially fulfilled by Universitas Indonesia with International Indexed Publication Grant Program (PUTI) [grant number NKB-1235/UN2.RST/HKP.05.00/2022] Article Versions (2) version 2 Revised Published: 10 Feb 2026, 12:464 https://doi.org/10.12688/f1000research.129479.2 version 1 Published: 04 May 2023, 12:464 https://doi.org/10.12688/f1000research.129479.1 Copyright © 2026 Wahyudi I et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Wahyudi I, Adriansyah IA, Yonathan K et al. Transition from transperitoneal to retroperitoneal approach in laparoscopic living donor nephrectomy: team-based and individual learning curve: a cross-sectional study [version 2; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 12 :464 ( https://doi.org/10.12688/f1000research.129479.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 2 VERSION 2 PUBLISHED 10 Feb 2026 Revised Views 0 Cite How to cite this report: Bolat MS. Reviewer Report For: Transition from transperitoneal to retroperitoneal approach in laparoscopic living donor nephrectomy: team-based and individual learning curve: a cross-sectional study [version 2; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 12 :464 ( https://doi.org/10.5256/f1000research.188901.r457290 ) The direct URL for this report is: https://f1000research.com/articles/12-464/v2#referee-response-457290 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 05 Mar 2026 Mustafa Suat Bolat , Department of Urology, Atilim University, Ankara, Ankara, Turkey Approved VIEWS 0 https://doi.org/10.5256/f1000research.188901.r457290 Dear Editor, I checked the revised form of the manuscript. The authors fully ... Continue reading READ ALL Dear Editor, I checked the revised form of the manuscript. The authors fully addressed my previous recommendations. With its present form, the manuscript is acceptable. My decision is: Accept. Sincerely yours, Competing Interests: No competing interests were disclosed. Reviewer Expertise: Urology, metabolic syndrome, endourology, andrology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Bolat MS. Reviewer Report For: Transition from transperitoneal to retroperitoneal approach in laparoscopic living donor nephrectomy: team-based and individual learning curve: a cross-sectional study [version 2; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 12 :464 ( https://doi.org/10.5256/f1000research.188901.r457290 ) The direct URL for this report is: https://f1000research.com/articles/12-464/v2#referee-response-457290 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 04 May 2023 Views 0 Cite How to cite this report: Garcia-Covarrubias L. Reviewer Report For: Transition from transperitoneal to retroperitoneal approach in laparoscopic living donor nephrectomy: team-based and individual learning curve: a cross-sectional study [version 2; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 12 :464 ( https://doi.org/10.5256/f1000research.142165.r196411 ) The direct URL for this report is: https://f1000research.com/articles/12-464/v1#referee-response-196411 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 12 Oct 2023 Luis Garcia-Covarrubias , Surgery, Hospital de Especialidades Centro Medico Nacional Siglo XXI, Mexico City, Mexico City, Mexico Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.142165.r196411 1. Of the references, only 30% are 5 years old or less, recommending that at least 50% of the references be updated. 2. With respect to the design and in order to allow its reproducibility, I suggest ... Continue reading READ ALL 1. Of the references, only 30% are 5 years old or less, recommending that at least 50% of the references be updated. 2. With respect to the design and in order to allow its reproducibility, I suggest being explicit in the definitions, as well as in the inclusion and exclusion criteria and performing a sample size calculation based on Cohen's D obtained from previous studies. I would suggest including the Clavien scale to compare complications or other variables, not just time such as hemorrhage, ischemia time, and whether or not the graft suffered any damage, for example. 3. Mention the limitations of the study before reaching the conclusions, as it is a retrospective study and is limited by the indication for nephrectomy (right or left) and the assignment of surgeons to the cases, which is not commented on. Furthermore, regardless of whether it was transperitoneal or retroperitoneal, the surgeons had extensive experience in laparoscopic surgery. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? No If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: Methodology , surgical techniques I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Garcia-Covarrubias L. Reviewer Report For: Transition from transperitoneal to retroperitoneal approach in laparoscopic living donor nephrectomy: team-based and individual learning curve: a cross-sectional study [version 2; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 12 :464 ( https://doi.org/10.5256/f1000research.142165.r196411 ) The direct URL for this report is: https://f1000research.com/articles/12-464/v1#referee-response-196411 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 10 Feb 2026 Kevin Yonathan , Department of Urology, University of Indonesia, Jakarta, 10430, Indonesia 10 Feb 2026 Author Response 1. Of the references, only 30% are 5 years old or less, recommending that at least 50% of the references be updated. Thank you for the review, we ... Continue reading 1. Of the references, only 30% are 5 years old or less, recommending that at least 50% of the references be updated. Thank you for the review, we have added some references to the manuscript 2. With respect to the design and in order to allow its reproducibility, I suggest being explicit in the definitions, as well as in the inclusion and exclusion criteria and performing a sample size calculation based on Cohen's D obtained from previous studies. This study used total sampling method in order to include the study subjects. Added in the manuscript for clarity I would suggest including the Clavien scale to compare complications or other variables, not just time such as hemorrhage, ischemia time, and whether or not the graft suffered any damage, for example. We thank you for the addition. Added to the manuscript 3. Mention the limitations of the study before reaching the conclusions, as it is a retrospective study and is limited by the indication for nephrectomy (right or left) and the assignment of surgeons to the cases, which is not commented on. Furthermore, regardless of whether it was transperitoneal or retroperitoneal, the surgeons had extensive experience in laparoscopic surgery. Added to the manuscript 1. Of the references, only 30% are 5 years old or less, recommending that at least 50% of the references be updated. Thank you for the review, we have added some references to the manuscript 2. With respect to the design and in order to allow its reproducibility, I suggest being explicit in the definitions, as well as in the inclusion and exclusion criteria and performing a sample size calculation based on Cohen's D obtained from previous studies. This study used total sampling method in order to include the study subjects. Added in the manuscript for clarity I would suggest including the Clavien scale to compare complications or other variables, not just time such as hemorrhage, ischemia time, and whether or not the graft suffered any damage, for example. We thank you for the addition. Added to the manuscript 3. Mention the limitations of the study before reaching the conclusions, as it is a retrospective study and is limited by the indication for nephrectomy (right or left) and the assignment of surgeons to the cases, which is not commented on. Furthermore, regardless of whether it was transperitoneal or retroperitoneal, the surgeons had extensive experience in laparoscopic surgery. Added to the manuscript Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 10 Feb 2026 Kevin Yonathan , Department of Urology, University of Indonesia, Jakarta, 10430, Indonesia 10 Feb 2026 Author Response 1. Of the references, only 30% are 5 years old or less, recommending that at least 50% of the references be updated. Thank you for the review, we ... Continue reading 1. Of the references, only 30% are 5 years old or less, recommending that at least 50% of the references be updated. Thank you for the review, we have added some references to the manuscript 2. With respect to the design and in order to allow its reproducibility, I suggest being explicit in the definitions, as well as in the inclusion and exclusion criteria and performing a sample size calculation based on Cohen's D obtained from previous studies. This study used total sampling method in order to include the study subjects. Added in the manuscript for clarity I would suggest including the Clavien scale to compare complications or other variables, not just time such as hemorrhage, ischemia time, and whether or not the graft suffered any damage, for example. We thank you for the addition. Added to the manuscript 3. Mention the limitations of the study before reaching the conclusions, as it is a retrospective study and is limited by the indication for nephrectomy (right or left) and the assignment of surgeons to the cases, which is not commented on. Furthermore, regardless of whether it was transperitoneal or retroperitoneal, the surgeons had extensive experience in laparoscopic surgery. Added to the manuscript 1. Of the references, only 30% are 5 years old or less, recommending that at least 50% of the references be updated. Thank you for the review, we have added some references to the manuscript 2. With respect to the design and in order to allow its reproducibility, I suggest being explicit in the definitions, as well as in the inclusion and exclusion criteria and performing a sample size calculation based on Cohen's D obtained from previous studies. This study used total sampling method in order to include the study subjects. Added in the manuscript for clarity I would suggest including the Clavien scale to compare complications or other variables, not just time such as hemorrhage, ischemia time, and whether or not the graft suffered any damage, for example. We thank you for the addition. Added to the manuscript 3. Mention the limitations of the study before reaching the conclusions, as it is a retrospective study and is limited by the indication for nephrectomy (right or left) and the assignment of surgeons to the cases, which is not commented on. Furthermore, regardless of whether it was transperitoneal or retroperitoneal, the surgeons had extensive experience in laparoscopic surgery. Added to the manuscript Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Bolat MS. Reviewer Report For: Transition from transperitoneal to retroperitoneal approach in laparoscopic living donor nephrectomy: team-based and individual learning curve: a cross-sectional study [version 2; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 12 :464 ( https://doi.org/10.5256/f1000research.142165.r178114 ) The direct URL for this report is: https://f1000research.com/articles/12-464/v1#referee-response-178114 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 29 Jun 2023 Mustafa Suat Bolat , Department of Urology, Atilim University, Ankara, Ankara, Turkey Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.142165.r178114 Abstract Background The authors state that the transition process from transperitoneal to retroperitoneal LLDN is important to ensure the best outcome for the patients. I wonder if there is a transition process in real. According ... Continue reading READ ALL Abstract Background The authors state that the transition process from transperitoneal to retroperitoneal LLDN is important to ensure the best outcome for the patients. I wonder if there is a transition process in real. According to their experience and educational program, surgeons use their individual techniques. Therefore they only can state that they decided to convert their technique to Retro. Otherwise, it could be misunderstood that nephrectomy should primarily be managed by transperitoneal and it might be converted to retro. Methods How did the authors identify Phase 1, 2 and 3? Introduction Second paragraph: Preferentially, l advise the authors to cite paper 1 . This citation is about to gain experience of laparoscopy. Thus it may improve quality of the manuscript. If authors read it, they will find data supporting their hypothesis. Sixth Paragraph: What were the time period for three centers? Were the authors observer or fellow? Discussion In second paragraph, CUSUM analysis should be given in detail. The authors should remember that many readers might not know about CUSUM analysis. Fifth paragraph - What is the reason for higher procedure experience need for team-based surgery compared to individual one? Please support it in the light of literature. Last paragraph - I supposed this paper should be a prospective one? Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? I cannot comment. A qualified statistician is required. Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes References 1. Gozen AS, Gherman V, Akin Y, Bolat MS, et al.: Evaluation of the complications in laparoscopic retroperitoneal radical nephrectomy; An experience of high volume centre. Arch Ital Urol Androl . 2017; 89 (4): 266-271 PubMed Abstract | Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: Urology, andrology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Bolat MS. Reviewer Report For: Transition from transperitoneal to retroperitoneal approach in laparoscopic living donor nephrectomy: team-based and individual learning curve: a cross-sectional study [version 2; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 12 :464 ( https://doi.org/10.5256/f1000research.142165.r178114 ) The direct URL for this report is: https://f1000research.com/articles/12-464/v1#referee-response-178114 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 10 Feb 2026 Kevin Yonathan , Department of Urology, University of Indonesia, Jakarta, 10430, Indonesia 10 Feb 2026 Author Response Abstract Background The authors state that the transition process from transperitoneal to retroperitoneal LLDN is important to ensure the best outcome for the patients. I wonder if there ... Continue reading Abstract Background The authors state that the transition process from transperitoneal to retroperitoneal LLDN is important to ensure the best outcome for the patients. I wonder if there is a transition process in real. According to their experience and educational program, surgeons use their individual techniques. Therefore they only can state that they decided to convert their technique to Retro. Otherwise, it could be misunderstood that nephrectomy should primarily be managed by transperitoneal and it might be converted to retro. Response : It is true that usually the surgeons will initially use transperitoneal approach for laparoscopic procedure due to its familiarity and natural orientation, then use retroperitoneal approach afterward. The statement will be added for clarity Methods How did the authors identify Phase 1, 2 and 3? Response: The three phases of the study are explained in the methodology section using the CUSUM analysis, as stated “The three phases of the learning curve were identified by the inflection point of the CUSUM curve. Phase 1 (learning period) showed an expected incline in CUSUM curve which was the initial learning curve, phase 2 (proficiency) showed a decline in CUSUM curve, with a plateau which was the proficient phase with additional experience obtained leading to the achievement of expert competence. Phase 3 was defined as the post-learning (mastery) period, as seen in typical learning curve studies in which there was steeper decline of the CUSUM curve.” Introduction Second paragraph: Preferentially, l advise the authors to cite paper 1 . This citation is about to gain experience of laparoscopy. Thus it may improve quality of the manuscript. If authors read it, they will find data supporting their hypothesis. Response: Added to the manuscript Sixth Paragraph: What were the time period for three centers? Were the authors observer or fellow? Response: The authors were fellow for 1-2 years on the centers. Added to the manuscript Discussion In second paragraph, CUSUM analysis should be given in detail. The authors should remember that many readers might not know about CUSUM analysis. Response: The analysis is already explained in the methods section (paragraph 2) Fifth paragraph - What is the reason for higher procedure experience need for team-based surgery compared to individual one? Please support it in the light of literature. Response: It is due to the alternating operators on the surgery, thus reducing the exposure of the case compared to surgery performed by a single operator Last paragraph - I supposed this paper should be a prospective one? Response: We concur with the comment. Revised accordingly Abstract Background The authors state that the transition process from transperitoneal to retroperitoneal LLDN is important to ensure the best outcome for the patients. I wonder if there is a transition process in real. According to their experience and educational program, surgeons use their individual techniques. Therefore they only can state that they decided to convert their technique to Retro. Otherwise, it could be misunderstood that nephrectomy should primarily be managed by transperitoneal and it might be converted to retro. Response : It is true that usually the surgeons will initially use transperitoneal approach for laparoscopic procedure due to its familiarity and natural orientation, then use retroperitoneal approach afterward. The statement will be added for clarity Methods How did the authors identify Phase 1, 2 and 3? Response: The three phases of the study are explained in the methodology section using the CUSUM analysis, as stated “The three phases of the learning curve were identified by the inflection point of the CUSUM curve. Phase 1 (learning period) showed an expected incline in CUSUM curve which was the initial learning curve, phase 2 (proficiency) showed a decline in CUSUM curve, with a plateau which was the proficient phase with additional experience obtained leading to the achievement of expert competence. Phase 3 was defined as the post-learning (mastery) period, as seen in typical learning curve studies in which there was steeper decline of the CUSUM curve.” Introduction Second paragraph: Preferentially, l advise the authors to cite paper 1 . This citation is about to gain experience of laparoscopy. Thus it may improve quality of the manuscript. If authors read it, they will find data supporting their hypothesis. Response: Added to the manuscript Sixth Paragraph: What were the time period for three centers? Were the authors observer or fellow? Response: The authors were fellow for 1-2 years on the centers. Added to the manuscript Discussion In second paragraph, CUSUM analysis should be given in detail. The authors should remember that many readers might not know about CUSUM analysis. Response: The analysis is already explained in the methods section (paragraph 2) Fifth paragraph - What is the reason for higher procedure experience need for team-based surgery compared to individual one? Please support it in the light of literature. Response: It is due to the alternating operators on the surgery, thus reducing the exposure of the case compared to surgery performed by a single operator Last paragraph - I supposed this paper should be a prospective one? Response: We concur with the comment. Revised accordingly Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 10 Feb 2026 Kevin Yonathan , Department of Urology, University of Indonesia, Jakarta, 10430, Indonesia 10 Feb 2026 Author Response Abstract Background The authors state that the transition process from transperitoneal to retroperitoneal LLDN is important to ensure the best outcome for the patients. I wonder if there ... Continue reading Abstract Background The authors state that the transition process from transperitoneal to retroperitoneal LLDN is important to ensure the best outcome for the patients. I wonder if there is a transition process in real. According to their experience and educational program, surgeons use their individual techniques. Therefore they only can state that they decided to convert their technique to Retro. Otherwise, it could be misunderstood that nephrectomy should primarily be managed by transperitoneal and it might be converted to retro. Response : It is true that usually the surgeons will initially use transperitoneal approach for laparoscopic procedure due to its familiarity and natural orientation, then use retroperitoneal approach afterward. The statement will be added for clarity Methods How did the authors identify Phase 1, 2 and 3? Response: The three phases of the study are explained in the methodology section using the CUSUM analysis, as stated “The three phases of the learning curve were identified by the inflection point of the CUSUM curve. Phase 1 (learning period) showed an expected incline in CUSUM curve which was the initial learning curve, phase 2 (proficiency) showed a decline in CUSUM curve, with a plateau which was the proficient phase with additional experience obtained leading to the achievement of expert competence. Phase 3 was defined as the post-learning (mastery) period, as seen in typical learning curve studies in which there was steeper decline of the CUSUM curve.” Introduction Second paragraph: Preferentially, l advise the authors to cite paper 1 . This citation is about to gain experience of laparoscopy. Thus it may improve quality of the manuscript. If authors read it, they will find data supporting their hypothesis. Response: Added to the manuscript Sixth Paragraph: What were the time period for three centers? Were the authors observer or fellow? Response: The authors were fellow for 1-2 years on the centers. Added to the manuscript Discussion In second paragraph, CUSUM analysis should be given in detail. The authors should remember that many readers might not know about CUSUM analysis. Response: The analysis is already explained in the methods section (paragraph 2) Fifth paragraph - What is the reason for higher procedure experience need for team-based surgery compared to individual one? Please support it in the light of literature. Response: It is due to the alternating operators on the surgery, thus reducing the exposure of the case compared to surgery performed by a single operator Last paragraph - I supposed this paper should be a prospective one? Response: We concur with the comment. Revised accordingly Abstract Background The authors state that the transition process from transperitoneal to retroperitoneal LLDN is important to ensure the best outcome for the patients. I wonder if there is a transition process in real. According to their experience and educational program, surgeons use their individual techniques. Therefore they only can state that they decided to convert their technique to Retro. Otherwise, it could be misunderstood that nephrectomy should primarily be managed by transperitoneal and it might be converted to retro. Response : It is true that usually the surgeons will initially use transperitoneal approach for laparoscopic procedure due to its familiarity and natural orientation, then use retroperitoneal approach afterward. The statement will be added for clarity Methods How did the authors identify Phase 1, 2 and 3? Response: The three phases of the study are explained in the methodology section using the CUSUM analysis, as stated “The three phases of the learning curve were identified by the inflection point of the CUSUM curve. Phase 1 (learning period) showed an expected incline in CUSUM curve which was the initial learning curve, phase 2 (proficiency) showed a decline in CUSUM curve, with a plateau which was the proficient phase with additional experience obtained leading to the achievement of expert competence. Phase 3 was defined as the post-learning (mastery) period, as seen in typical learning curve studies in which there was steeper decline of the CUSUM curve.” Introduction Second paragraph: Preferentially, l advise the authors to cite paper 1 . This citation is about to gain experience of laparoscopy. Thus it may improve quality of the manuscript. If authors read it, they will find data supporting their hypothesis. Response: Added to the manuscript Sixth Paragraph: What were the time period for three centers? Were the authors observer or fellow? Response: The authors were fellow for 1-2 years on the centers. Added to the manuscript Discussion In second paragraph, CUSUM analysis should be given in detail. The authors should remember that many readers might not know about CUSUM analysis. Response: The analysis is already explained in the methods section (paragraph 2) Fifth paragraph - What is the reason for higher procedure experience need for team-based surgery compared to individual one? Please support it in the light of literature. Response: It is due to the alternating operators on the surgery, thus reducing the exposure of the case compared to surgery performed by a single operator Last paragraph - I supposed this paper should be a prospective one? Response: We concur with the comment. Revised accordingly Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 04 May 2023 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 2 (revision) 10 Feb 26 read Version 1 04 May 23 read read Mustafa Suat Bolat , Atilim University, Ankara, Turkey Luis Garcia-Covarrubias , Hospital de Especialidades Centro Medico Nacional Siglo XXI, Mexico City, Mexico Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Bolat M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 05 Mar 2026 | for Version 2 Mustafa Suat Bolat , Department of Urology, Atilim University, Ankara, Ankara, Turkey 0 Views copyright © 2026 Bolat M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Dear Editor, I checked the revised form of the manuscript. The authors fully addressed my previous recommendations. With its present form, the manuscript is acceptable. My decision is: Accept. Sincerely yours, Competing Interests No competing interests were disclosed. Reviewer Expertise Urology, metabolic syndrome, endourology, andrology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Bolat MS. Peer Review Report For: Transition from transperitoneal to retroperitoneal approach in laparoscopic living donor nephrectomy: team-based and individual learning curve: a cross-sectional study [version 2; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 12 :464 ( https://doi.org/10.5256/f1000research.188901.r457290) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/12-464/v2#referee-response-457290 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2023 Garcia-Covarrubias L. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 12 Oct 2023 | for Version 1 Luis Garcia-Covarrubias , Surgery, Hospital de Especialidades Centro Medico Nacional Siglo XXI, Mexico City, Mexico City, Mexico 0 Views copyright © 2023 Garcia-Covarrubias L. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions 1. Of the references, only 30% are 5 years old or less, recommending that at least 50% of the references be updated. 2. With respect to the design and in order to allow its reproducibility, I suggest being explicit in the definitions, as well as in the inclusion and exclusion criteria and performing a sample size calculation based on Cohen's D obtained from previous studies. I would suggest including the Clavien scale to compare complications or other variables, not just time such as hemorrhage, ischemia time, and whether or not the graft suffered any damage, for example. 3. Mention the limitations of the study before reaching the conclusions, as it is a retrospective study and is limited by the indication for nephrectomy (right or left) and the assignment of surgeons to the cases, which is not commented on. Furthermore, regardless of whether it was transperitoneal or retroperitoneal, the surgeons had extensive experience in laparoscopic surgery. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? No If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Partly Competing Interests No competing interests were disclosed. Reviewer Expertise Methodology , surgical techniques I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 10 Feb 2026 Kevin Yonathan, Department of Urology, University of Indonesia, Jakarta, 10430, Indonesia 1. Of the references, only 30% are 5 years old or less, recommending that at least 50% of the references be updated. Thank you for the review, we have added some references to the manuscript 2. With respect to the design and in order to allow its reproducibility, I suggest being explicit in the definitions, as well as in the inclusion and exclusion criteria and performing a sample size calculation based on Cohen's D obtained from previous studies. This study used total sampling method in order to include the study subjects. Added in the manuscript for clarity I would suggest including the Clavien scale to compare complications or other variables, not just time such as hemorrhage, ischemia time, and whether or not the graft suffered any damage, for example. We thank you for the addition. Added to the manuscript 3. Mention the limitations of the study before reaching the conclusions, as it is a retrospective study and is limited by the indication for nephrectomy (right or left) and the assignment of surgeons to the cases, which is not commented on. Furthermore, regardless of whether it was transperitoneal or retroperitoneal, the surgeons had extensive experience in laparoscopic surgery. Added to the manuscript View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Garcia-Covarrubias L. Peer Review Report For: Transition from transperitoneal to retroperitoneal approach in laparoscopic living donor nephrectomy: team-based and individual learning curve: a cross-sectional study [version 2; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 12 :464 ( https://doi.org/10.5256/f1000research.142165.r196411) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/12-464/v1#referee-response-196411 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2023 Bolat M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 29 Jun 2023 | for Version 1 Mustafa Suat Bolat , Department of Urology, Atilim University, Ankara, Ankara, Turkey 0 Views copyright © 2023 Bolat M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Abstract Background The authors state that the transition process from transperitoneal to retroperitoneal LLDN is important to ensure the best outcome for the patients. I wonder if there is a transition process in real. According to their experience and educational program, surgeons use their individual techniques. Therefore they only can state that they decided to convert their technique to Retro. Otherwise, it could be misunderstood that nephrectomy should primarily be managed by transperitoneal and it might be converted to retro. Methods How did the authors identify Phase 1, 2 and 3? Introduction Second paragraph: Preferentially, l advise the authors to cite paper 1 . This citation is about to gain experience of laparoscopy. Thus it may improve quality of the manuscript. If authors read it, they will find data supporting their hypothesis. Sixth Paragraph: What were the time period for three centers? Were the authors observer or fellow? Discussion In second paragraph, CUSUM analysis should be given in detail. The authors should remember that many readers might not know about CUSUM analysis. Fifth paragraph - What is the reason for higher procedure experience need for team-based surgery compared to individual one? Please support it in the light of literature. Last paragraph - I supposed this paper should be a prospective one? Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? I cannot comment. A qualified statistician is required. Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes References 1. Gozen AS, Gherman V, Akin Y, Bolat MS, et al.: Evaluation of the complications in laparoscopic retroperitoneal radical nephrectomy; An experience of high volume centre. Arch Ital Urol Androl . 2017; 89 (4): 266-271 PubMed Abstract | Publisher Full Text Competing Interests No competing interests were disclosed. Reviewer Expertise Urology, andrology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 10 Feb 2026 Kevin Yonathan, Department of Urology, University of Indonesia, Jakarta, 10430, Indonesia Abstract Background The authors state that the transition process from transperitoneal to retroperitoneal LLDN is important to ensure the best outcome for the patients. I wonder if there is a transition process in real. According to their experience and educational program, surgeons use their individual techniques. Therefore they only can state that they decided to convert their technique to Retro. Otherwise, it could be misunderstood that nephrectomy should primarily be managed by transperitoneal and it might be converted to retro. Response : It is true that usually the surgeons will initially use transperitoneal approach for laparoscopic procedure due to its familiarity and natural orientation, then use retroperitoneal approach afterward. The statement will be added for clarity Methods How did the authors identify Phase 1, 2 and 3? Response: The three phases of the study are explained in the methodology section using the CUSUM analysis, as stated “The three phases of the learning curve were identified by the inflection point of the CUSUM curve. Phase 1 (learning period) showed an expected incline in CUSUM curve which was the initial learning curve, phase 2 (proficiency) showed a decline in CUSUM curve, with a plateau which was the proficient phase with additional experience obtained leading to the achievement of expert competence. Phase 3 was defined as the post-learning (mastery) period, as seen in typical learning curve studies in which there was steeper decline of the CUSUM curve.” Introduction Second paragraph: Preferentially, l advise the authors to cite paper 1 . This citation is about to gain experience of laparoscopy. Thus it may improve quality of the manuscript. If authors read it, they will find data supporting their hypothesis. Response: Added to the manuscript Sixth Paragraph: What were the time period for three centers? Were the authors observer or fellow? Response: The authors were fellow for 1-2 years on the centers. Added to the manuscript Discussion In second paragraph, CUSUM analysis should be given in detail. The authors should remember that many readers might not know about CUSUM analysis. Response: The analysis is already explained in the methods section (paragraph 2) Fifth paragraph - What is the reason for higher procedure experience need for team-based surgery compared to individual one? Please support it in the light of literature. Response: It is due to the alternating operators on the surgery, thus reducing the exposure of the case compared to surgery performed by a single operator Last paragraph - I supposed this paper should be a prospective one? Response: We concur with the comment. Revised accordingly View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Bolat MS. Peer Review Report For: Transition from transperitoneal to retroperitoneal approach in laparoscopic living donor nephrectomy: team-based and individual learning curve: a cross-sectional study [version 2; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 12 :464 ( https://doi.org/10.5256/f1000research.142165.r178114) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/12-464/v1#referee-response-178114 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Adjust parameters to alter display View on desktop for interactive features Includes Interactive Elements View on desktop for interactive features Competing Interests Policy Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. Consider the following examples, but note that this is not an exhaustive list: Examples of 'Non-Financial Competing Interests' Within the past 4 years, you have held joint grants, published or collaborated with any of the authors of the selected paper. You have a close personal relationship (e.g. parent, spouse, sibling, or domestic partner) with any of the authors. You are a close professional associate of any of the authors (e.g. scientific mentor, recent student). You work at the same institute as any of the authors. 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