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longitudinal direction below the umbilicus, in the trans-
verse direction above the inguinal ligament, or above the
pubic bone . The minimally invasive kidney
transplantation (MIKT) technique was used in two articles,
both describing different techniques . In all cases of
MIOKT techniques, the kidney was placed in the iliac fossa.
For LKT, two different techniques were described for
intraperitoneal graft placement: either through a transverse
suprapubic incision or through an incision in the posterior
fornix of the vagina . In both studies, grafts were
placed in the iliac fossa and covered by a retroperitoneal
flap, thereby creating retroperitoneal graft placement.
Finally, for RAKT four different techniques were de-
scribed in five studies, three techniques using a transper-
itoneal approach, with the graft being placed
retroperitoneally with the aid of a retroperitoneal flap in
three out of four studies, and the other one placing the graft
intraperitoneally in the right lower quadrant
The fourth RAKT technique was described using a
retroperitoneal approach with lifting of the abdominal wall
and placing the graft retroperitoneally in the iliac fossa
The main characteristics of the identified techniques
are summarized in .
Ameta-analysis of reported data was, after consideration
by two different epidemiologists, not possible because of
the heterogeneity of subgroups; techniques; pre-, peri-, and
postoperative care; and lack of data.
3.3. Outcomes
3.3.1. Baseline characteristics
Baseline population characteristics, and inclusion and
exclusion criteria differed widely ). For example,
with regard to body mass index (BMI), wide varieties were
observed (means between 17.5 and 43.6 kg/m2
[17_TD$DIFF]) .
The mean operating time for LKT and RAKT varied from
224 to 242 min and from 201 to 300 min, respectively
. For conventional and minimally invasive
open techniques, the mean operating time varied from
111 to 189 min and from 118 to 194 min
respectively . Owing to the hetero-
geneity of studies, statistical differences could not be
shown. CIT was reported differently between studies, with
means varying from 27.7 min (with simultaneous laparo-
scopic donor nephrectomy and RAKT) to 14.4 h with
cadaveric kidney donor transplantation .
There was heterogeneity within reporting of ischemic
time. Modi et al found significantly longer WIT for LKT
compared with open kidney transplantation. In the open
technique, the kidney was actively cooled until the
anastomosis was completed . Brockschmidt et al
cooled kidney graft extracorporally during creation
of the anastomosis. In LKT and RAKT, this is challenging
because of intraperitoneal graft placement CO2 insufflation.
Techniques have been described to overcome this problem,
using regional hypothermia with ice slush resulting in
shortened mean WIT of 1.9–2.3 min In these
latter studies reported rewarming times were 73.3, 46.6,
and 42.9 min, comparable with open and minimal invasive
open techniques (27–49.2 min). Tugcu et al reported
paralytic ileus as a complication of using ice slush in two
patients .
3.3.2. Graft and patient survival
Death-censored graft survival varied between 93% and 100%
(mean follow-up 3–105 mo). Modi et al described two
graft losses due to allograft torsion in the first six cases of
LKT. The graft was later fixated with a retroperitoneal flap,
after which no further graft loss was seen. Kidney function
was comparable and patient survival varied between 93%
and 100%. No significant differences were reported between
open, laparoscopic, and robotic-assisted kidney transplan-
tation techniques for the most important parameters:
patient and graft survival.
3.3.3. Wound complications
SSI rates varied between 0% and 19%, with the highest rate
found after GIBI . Incisional hernia was seen in 0–16% of
kidney recipients. The highest incisional hernia rate was
observed in the HSI group. Filocamo et al reported
significantly less incisional hernia in midline incision (MLI)
compared with HSI (2% vs 11%, p = 0.005). When comparing
HSI with GIBI, significantly lower hernia rates of 4% versus
16%, were reported In MIOKT, a maximum rate of 6%
was observed . For LKT, incisional hernia was not
reported. For RAKT, no incisional hernia was found in three
out of five studies
3.3.4. Cosmetic result
In the conventional group, the mean incision length varied
between 14.2 and 21.2 cm. The incision length was
significantly shorter in the MIOKT and LKT groups
compared with the COKT group (5.5–13 cm)
. In the RAKT group, the mean incision
length varied between 5.3 and 7.7 cm
Cosmesis was not reported in a standard manner. Nanni
et al described widening of the scar in 20% of the HSI
group and 10% of the GIBI group, with a significantly higher
rate of abdominal wall relaxation in HSI compared with GIBI
(24% vs 8%, p < 0.05). Filocamo et al defined cosmetic
result by irregular scar margins and/or if the vertical arm of
the scar was prolonged above the transverse umbilical line.
For the HSI group, this was the case in 20% and 25%,
respectively. This was significantly higher than MLI with 2%
irregular scar margins and a lack of vertical prolongment. In
the MIVAKT group, all scars were under the belt line, and in
the conventional group the mean was 5.4 cm above the belt
line . Park et al and Brockschmidt et al
reported only patient satisfaction. Kishore et al and Modi
et al used surgical satisfaction scores completed by
patients (scale 0–10; 0, ‘‘extremely displeased’’ to 10,
‘‘extremely pleased’’). They found significant differences in
favor of the modified Pfannenstiel incision (MFI) group
(p = 0.002) and the latter for LKT (p = 0.001) compared with,
respectively, HSI and GIBI. Malinka et al used a
dichotomous score (satisfied with scar yes/no) and found no
significant differences between the HSI and the STI group.
Since cosmetic outcomes have not been reported in a
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