Introduction: The first hand assisted retroperitoneoscopic (HARP) living donor nephrectomy was performed in Sweden in 2002 and showed better outcomes compared to the trans-peritoneal approach. The first HARP nephrectomy was performed in the UK in 2005, and the initial UK experience of this technique was published by our unit in 2006, showing that HARP nephrectomies were safe and resulted in shorter post-operative hospital stays, even in a cohort of patients with a range of vascular anomalies. This resulted in an increase in our living donor pool. This report summarises our experience to date. Methods: Data were compiled prospectively for 295 consecutive HARP nephrectomies performed from May 2005 to January 2012. This included information on donor demographics, intra-operative parameters, and post-operative outcomes including length of stay, death, and major complications. All procedures were performed according to Wadström et al (2002). Results: There were 148 male donors and 147 female donors. Mean age was 48.25 years (range 18 - 77). Mean BMI was 26.17 ± 3.58 kg/m2 (range 17.7 - 38). 257 (87%) cases were left sided nephrectomies, and 38 (13%) were right nephrectomies. Mean operating time was 144.06 ± 53.7 minutes (range 60-361). Mean warm ischaemia time was 102.7 ± 50.7 seconds (range 1 - 422). One case had a recorded WIT of 30 minutes and was excluded because the patient involved had sickle cell disease and therefore the kidney was not cooled. Median blood loss was 20 mL (IQR = 100). 171 (58%) donors had simple renal anatomy with 1 artery, 1 vein, and 1 ureter while 117 (40%) had complex anatomy involving multiple vessels and/or ureters. Other anatomical difficulties encountered included dense peri-renal adhesions, retro-aortic renal veins, large renal cysts, early arterial bifurcation, horseshoe kidney, double IVC, renal stone, a 6 cm angiomyolipoma, and urethral stricture. Post-operatively, median length of stay was 2 days (IQR = 1). 11 patients (3.7%) had minor complications (including urinary tract infection, urinary retention, wound infection, neuropraxia, and excess serous wound discharge), and 10 patients (3.4%) had major complications (including chest infection, incisional hernia, one conversion to open, and 3 cases of bleeding: 2 from small branches of the iliac artery requiring re-operation and radiological embolisation respectively, and 1 from subcutaneous fat necessitating re-operation). There were no deaths. There was no significant difference in mean operating time, warm ischaemia time, blood loss, and length of hospital stay, between right and left sided nephrectomies, between cases with simple and complex anatomy, and between patients with BMI ≥ 30 kg/m2 or ≤ 30 kg/m2. Conclusion: Small scale studies have shown that HARP nephrectomy is superior to transperitoneal laparoscopic donor nephrectomy in terms of operation time, warm ischaemia time, blood loss, and complications. Our report reinforces that the hand-assisted retroperitoneoscopic approach continues to be a safe and effective way of performing live donor nephrectomies, even in obese donors, and despite a range of anatomical variations.