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mini-incision open techniques . Only Modi
et al found significantly prolonged operating time,
CIT, and WIT (including anastomosis time). With pro-
longed WIT, significantly lower glomerular filtration rates
(eGFRs) were observed after 7 and 30 d postoperatively.
However, after 3 mo no difference was seen between
groups for eGFRs, and patient or graft survival. Develop-
ment of postoperative complications should also be taken
into account. Recently, Ooms et al reported total
operation time as an independent risk factor for develop-
ing incisional hernia.
For women, a transvaginal technique was described by
Modi et al in 2015, placing the kidney in the abdominal
cavity through colpotomy. From the point of view of
cosmetics and postoperative recovery, this approach
appears promising. The learning curve for this particular
approach remains unclear though.
These days, LKT has been replaced by RAKT. The latter
technique requires an up-to-date facility with sufficient
financial and technical support. However, major advantages
of using robotic-assisted devices are the use of articulated
instruments, a three-dimensional view, and good surgeon
ergonomy, making it an easier and more reproducible
procedure As for laparoscopic techniques,
careful back table preparation, and longer operating times
and learning curve should be taken into account. Menon
et al reported a new technique for intraperitoneal
cooling with ice slush of allograft during vascular anasto-
mosis in order to reduce WIT. This technique was later
confirmed to be safe and effective by Sood et al . Tugcu
et al reported paralytic ileus as a complication with the
use of extensive ice slush; on decreasing the amount of ice
slush, no ileus occurred. Tsai et al described a
retroperitoneal approach, averting possible negative effects
of pneumoperitoneum such as respiratory acidosis, hyper-
tension, and reduced renal blood flow . In laparos-
copy, to reduce the negative effect, suturing under 10–
12 mmHg pressure is recommended. Further elimination of
pneumoperitoneum helps improve urine output .
The safety of the procedure and graft outcome should be
guaranteed even during the learning phase. Therefore,
proctoring and patient selection (eg, BMI and no previous
abdominal surgery) are important. Recently, Sood et al
reported RAKT as a safe surgical alternative to COKT with
reduced postoperative pain and analgesic requirement, and
better cosmesis. It appears to be associated with lower
complication rates when compared with COKT. Graft and
patient survival were comparable. It needs to be empha-
sized that RAKT is not yet a commonly used technique and
requires a high level of expertise, especially in organ
transplantation, but can be proved to be profitable in the
long term according to Tzvetanov et al . Data
presented are subject to selection bias because of the use
of living kidney allografts. Cadaveric donor is still not
performed since iliac vessels are usually noticeably more
calcified with corresponding anastomosis problems .
SSI rates varied between 2% and 20% in this review
. Oberholzer et al found significantly less
SSI in RAKT versus GIBI (0% vs 29%, p = 0.004). Other
included studies did not find any significant differences.
Wszola et al reported CIT >30 h, total operating time
>200 min, diabetes mellitus, BMI >27 kg/m2, delayed graft
function, and expanded criteria donor grafts (donor age 60
yr, donor over 50 yr oldwith two risk factors) as independent
risk factors for the development of SSI. There was no
uniformity between studies with regard to immunosup-
pressive regiments. In most studies, induction therapy using
rabbit antithymocytic globulin was combined with mainte-
nance treatment of steroids, calcineurin inhibitor, and/or
mycophenolate mofetil (MMF). Maintenance immunosup-
pression with MMF has been associated with an increased
risk of wound complications, as observed by Humar et al
. Furthermore, two studies found an increased risk of
complications with high levels of sirolimus and
Ramos et al found it specifically for incisional SSIs.
Nashan and Citterio reported that cautious use of
mammalian target of rapamycin inhibitors can lower the
incidence of wound healing disorders, particularly in
overweight patients. Use of MMF was shown to be a risk
factor for incisional hernia by Filocamo et al , who also
reported an odds ratio of 5.5 (95% confidence interval 2.0–
15.1) for developing incisional hernia after reoperation
through a transplant incision.
Postoperative recovery was generally faster after mini-
mally invasive techniques. MIVAKT and LKT were associat-
ed with lower postoperative pain scores and analgesic use
. Analgesic usage and postoperative pain were not
reported in RAKT studies. Hospital stay and return to
normal daily activities were significantly shorter in patients
operated with MIKT and MIVAKT techniques . How-
ever, Oberholzer et al reported no significant difference
between RAKT and GIBI for duration of hospitalization.
3.4.1. Limitations of the study
Articles were reviewed by two independent reviewers (S.W.
and G.H.V.R.), and only published articles out of selected
databases including patient data were included. This could
be a reason for selection bias (eg, congress papers that were
not included).
Important limitation of our study is the lack of high-
quality evidence. Out of 18 reviewed articles, only one was
an RCT and of high quality. Most studies were retrospective,
and suffered from insufficient follow-up and/or chance of
bias. The major limitation was the lack or incomplete
reporting of baseline characteristics, peri- and postopera-
tive parameters (inotrope and fluid management), and
perioperative techniques (renal artery and ureteric anasto-
mosis). Moreover, in 18 studies, 16 different techniques
were used. Owing to insufficient data and severe heteroge-
neity, no meta-analysis could be performed. Therefore, only
direct conclusions from studies could be reported, and it
proved impossible to merge these conclusions into one
recommendation of surgical technique.
4. Conclusions
To our knowledge, this is the first systematic review on
operating techniques in kidney transplant recipients. The
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