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uniform manner and information about questionnaires is
lacking, results could not be compared and adequate
conclusions could not be made.
3.3.5. Postoperative pain
Brockschmidt et al reported similar analgesic usage for
postoperative pain between COKT and MAKT. Kishore et al
observed that morphine consumption did not differ
significantly between HSI and MFI. Malinka et al
observed no significant differences in pain or analgesic
usage after 30 mo. Mun et al found significantly lower
visual analogue scale scores at 8, 16, 24, and 48 h
postoperatively (all p < 0.05), in favor of MIVAKT.
Øyen et al found no significant difference in
analgesic usage in the first 3 postoperative days for MIKT
compared with COKT. Modi et al reported signifi-
cantly lower postoperative mean analgesic use (p = 0.005)
and visual analog scale scores (6, 12, and 24 h postopera-
tively, p = 0.002–0.001) in favor of LKT compared with GIBI.
Mean analgesic requirement in the first 24 h was higher in
LKT through transabdominal insertion compared with
transvaginal insertion (p = 0.046).
3.3.6. Recovery and return to work/normal activity
Mun et al found that time until return to work or
resumption of normal daily activity was significantly
shorter when MIVAKT was used (p 0.001). No differences
were observed for total hospital stay.
Øyen et al found significantly shorter hospitaliza-
tion for MIKT (8.2 vs 12.4 d, p = 0.02); on the contrary, Park
et al reported no difference in hospital stay. No
significant difference was observed for hospital stay
between GIBI and LKT . In RAKT techniques, hospital
stay varied between 8.2 and 13.6 d (mean). When
comparing GIBI and RAKT, duration of hospitalization
was not significantly different See also
Other reported outcomes included wound dehiscence,
lymphocele, hematoma, living versus cadaveric kidney
donor, and delayed graft function, none of which differed
significantly between groups.
3.4. Discussion
The primary treatment in end-stage renal disease is kidney
transplantation. Therefore, the most important postopera-
tive outcome factors are graft and patient survival. In
included studies, no significant differences were found in
graft or patient survival. With the average graft survival of
10.6 yr, most patients with end-stage renal disease will
need second, third, or even fourth transplantation proce-
dures during their lifetime . New techniques have not
yet been tested in patients with repeat kidney transplanta-
tion, andmay be more difficult due to adhesion formation or
disturbed anatomy, especially in a limited surgical field.
As extensively shown in previous research, the use of
living related kidney grafts results in better graft survival
and fewer postoperative complications . Improved gene
matching, earlier transplantation, and shorter CIT have been
named as factors responsible for these postoperative results
As shown in , five out of 18 studies did not
report on cadaveric or living-related grafts. In seven studies,
exclusively living related grafts were used, and in five
studies, both cadaveric and living related grafts were used.
Owing to the limited data available, it was not possible to
take this variable into account in our study. It is, however,
suspected that this variable might have influenced results.
These data should be reported in future studies.
Benefits of conventional open techniques include a
relatively short learning curve, inexpensive operating
equipment, and good exposure of the operating field
. Open techniques in donor nephrectomies have been
associated with an increased risk of wound complications
(SSI, abdominal wound dehiscence, and incisional hernia)
Cosmetic results of conventional kidney transplantation
techniques were reported as poor in most studies
In particular with the HSI, up
to 24% abdominal wall relaxation and up to 16% incisional
hernia have been reported, and results were significantly
worse compared with MLI and GIBI . Cosmetic
outcomes have not been reported in a uniform manner;
therefore, no overlapping conclusions could be drawn.
In mini-incision techniques, incision length was short-
ened. Uneven scarring, incisional hernia, and SSI were less
seen after a median follow-up of 105 mo (range 27–192 mo)
compared with conventional techniques . For MIOKT
and all minimally invasive techniques (see below), careful
back table preparation has been advised for this technique
because of the more narrow operating field and possibility
of graft placement issues. When deciding between minimal
invasive open techniques, patient characteristics such as
BMI, side of placement, and previous allograft placement
should be taken into account. Inmost techniques, a Gibson(-
like) incision was used, offering the possibility of lengthen-
ing the incision to a traditional open technique, if necessary
For laparoscopic techniques, longer learning curves and
higher direct costs have been reported . Direct costs
include expenses related to advanced laparoscopic equip-
ment including disposables. In addition, longer operating
times for the transperitoneal approach should be taken into
account, resulting in longer CIT, WIT and anastomosis time,
especially in the early learning curve . During the
first six cases, two grafts were lost due to allograft torsion.
This is an indication that transition to laparoscopic and/or
robotic-assisted techniques can be challenging in KTx
surgery.
WIT is known to be a negative predictor for postopera-
tive creatinine levels, delayed graft function, and graft
survival . More recently, Marzouk et al
reported that anastomosis time >29 min significantly
increases postoperative delayed graft function (3.5 ).
Weissenbacher et al showed significant negative effects
of prolonged anastomosis time >30 min for patient and graft
survival. WIT can shorten over time, as Modi et al
showed significant improvement comparing vascular anas-
tomosis time between their first group of 30 LKT and second
group of 42 LKT. A trend was seen toward longer operating
time for LKT and RAKT compared with conventional and
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