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1. Introduction
In recent years, minimally invasive techniques have become
increasingly popular for kidney transplantation surgery
(KTx) and for living kidney donation in particular.
Minimally invasive living donor nephrectomy has been
shown to minimize adverse effects for living donors, by
decreasing incisional hernia rates and pain, while improv-
ing body image compared with lumbotomy . In
contrast, many kidney transplant recipients are still
operated through conventional incisions using Gibson
incision (GIBI) or hockey-stick incisions (HSI).
Traditionally, KTx was performed with an oblique
incision from the symphysis in the midline, curving in a
lateral and superior direction to the iliac crest (GIBI) . In
the recent past, a shift was observed toward a pararectal
curvilinear incision (also described as an HSI or an inverted
J-shaped incision), for enhanced exposure These inci-
sions cause morbidity, including abdominal wall relaxation
of up to 24%, abdominal wound dehiscence (4%), and
incisional hernia (up to 16%) In addition, larger
incisions have been associated with an increased risk of
surgical site infection (SSI), especially in light of delayed
wound healing due to the use of immunosuppressants, such
as sirolimus, in KTx recipients . Wound healing
complications are a major cause of morbidity in KTx
recipients, as both graft and patient survival are worse in
KTx recipients who develop SSI .
Recently, minimally invasive techniques including laparo-
scopic, robotic-assisted, minimally invasive video-assisted
(MIVAKT), minimal-access kidney transplantation (MAKT),
and minimal skin incision (MSI) techniques have been
described for kidney recipients In 2015, laparoscopic
kidney transplantation (LKT) following transvaginal insertion
of the kidney was described as a novel option In 2016,
transvaginal insertion was first performed in conjunction
with robotic-assisted kidney transplantation (RAKT)
These techniques proclaim to have the advantages of
smaller incisions, less complications, and faster recovery.
Despite potential advantages, adverse effects also need to
be considered. For instance, prolonged duration of cold
ischemic time (CIT) and warm ischemic time (WIT) and
operation time have been reported, with corresponding
lower graft and patient survival Our study
aim was to systematically evaluate literature on conven-
tional and minimally invasive techniques with regard to
graft survival, SSI, incisional hernia, and cosmesis.
2. Evidence acquisition
2.1. Search strategy
A systematic search of PubMed–Medline, Embase, and
Cochrane Library was performedwith expertise of a medical
librarian. Searches were limited to studies in adults and
published in English, German, French, Spanish, and Dutch
between 1966 and September 1, 2016. The main keywords
were ‘‘kidney,’’ ‘‘transplantation,’’ and ‘‘incision.’’ Appendix
A contains full search strategies.
2.2. Inclusion criteria
All articles were evaluated by two independent researchers
(S.W. and G.H.V.R.). Preferred Reporting Items for System-
atic Review and Meta-analysis guidelines were followed
After selection based on title and abstract, full-
text manuscripts were assessed and cross referencing was
applied. Types of research, which included patient data,
were considered eligible (randomized controlled trials
[RCTs], prospective and retrospective cohort studies,
case–control studies, and case series).
2.3. Study eligibility
Articles were graded and evaluated independently based on
quality using the Group Reading Assessment and Diagnostic
Evaluation (GRADE) scale Newcastle–Ottawa Quality
Assessment Scale (NOS), and level of evidence based on
Oxford Centre for Evidence Based Medicine (EBM, version
2011) .
Based on study type, studies were classified into four
GRADE categories: high, moderate, low, and very low
quality . Articles were downgraded for suspected bias,
inconsistency, indirectness, imprecision, or publication
bias. Articles were upgraded in case of a low risk of bias,
or all plausible confounding and bias would reduce
demonstrated effect. Articles showing a relatively large
effect were upgraded.
For the NOS, the applicable assessment score was used.
Cohort studies and case–control studies could be awarded
maximum scores of 10 and 9 points, respectively. Studies
were scored based on selection of cases and controls,
comparability of cases and controls, and exposure to bias
Level of evidence of included articles was assessed
following EBM guidelines . Both researchers indepen-
dently assessed the risk of bias and graded the articles.
Articles were categorized in three subcategories (low,
intermediate, and high). In case of disagreement, consensus
was reached after discussion. A reported p value 0.05 was
considered statistically significant.
3. Evidence synthesis
3.1. Included studies
Database searches yielded a total of 1954 records. After
removing duplicates and assessing all records for eligibility,
a total of 17 articles were selected for a systematic review.
One article was added upon reviewer suggestion, see
. Two articles describing other techniques
were excluded; one was a case report on RAKT using a
transperitoneal technique through a transverse suprapubic
incision, and the other lacked patient data .
3.2. Study characteristics
Using the GRADE methodology, most studies were rated 1–
2. One study was an RCT, which could not be assessed using
GRADE or NOS methodology , Most publications were
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