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A Review of Methods for Hemostasis and Renorrhaphy After Laparoscopic and Robot-assisted Laparoscopic Partial Nephrectomy

Current Urology Reports volume 11, pages 208–220 (2010)Cite this article

Abstract

The techniques for management of small renal masses (SRMs) have evolved over the past several years. Radical nephrectomy can lead to an increased risk of chronic kidney disease, and the emphasis is now shifting to nephron-conserving techniques. Partial nephrectomy is now considered a standard of care for the management of SRMs, and laparoscopic techniques are becoming popular because they are minimally invasive. The kidneys are extremely vascular organs, and renal hemorrhage is a major cause of morbidity after laparoscopic partial nephrectomies. Control of bleeding and management of calyceal injuries can be difficult and make the procedure technically challenging. This review looks at the various modalities that are available to reduce bleeding and reviews some advances in the area of hemostatic maneuvers during laparoscopic partial nephrectomies.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Barlow LJ, Korets R, Laudano M, et al.: Predicting renal functional outcomes after surgery for renal cortical tumours: a multifactorial analysis. BJU Int 2009 (Epub ahead of print).

  2. •• Campbell SC, Novick AC, Belldegrun A, et al.: Guideline for management of the clinical T1 renal mass. J Urol 2009, 182:1271–1279. This landmark paper based on the findings of the Practice Guidelines Committee of the American Urological Association emphasizes the role of PN (open and laparoscopic) as a standard of care in the management of SRMs.

    Article  PubMed  Google Scholar 

  3. Orvieto MA, Chien GW, Laven B, et al.: Eliminating knot tying during warm ischemia time for laparoscopic partial nephrectomy. J Urol 2004, 172:2292–2295.

    Article  PubMed  Google Scholar 

  4. Rosales A, Salvador J, De Graeve N, et al.: Clamping of the renal artery in laparoscopic partial nephrectomy: an old device for a new technique. Eur Urol 2005, 47:98–101.

    Article  CAS  PubMed  Google Scholar 

  5. Desai MM, Gill IS, Ramani AP, et al.: The impact of warm ischaemia on renal function after laparoscopic partial nephrectomy. BJU Int 2005, 95:377–383.

    Article  PubMed  Google Scholar 

  6. • Lifshitz DA, Shikanov S, Jeldres C, et al.: Laparoscopic partial nephrectomy: predictors of prolonged warm ischemia. J Urol 2009, 182:860–865. The authors performed a prospective institutional database search for predictors of WIT longer than 30 minutes. They re-emphasized that patients with certain risk factors such as higher body mass index and larger or more centrally located tumors were more prone to have longer WIT and higher complications. Their findings indicated that patients with two or more of certain risk factors, including body mass index greater than 30 kg/m 2 , tumor greater than 4 cm, and a centrally located tumor, were five times more likely to have warm ischemia time greater than 30 minutes than patients without the risk factors.

    Article  PubMed  Google Scholar 

  7. Gill IS, Abreu SC, Desai MM, et al.: Laparoscopic ice slush renal hypothermia for partial nephrectomy: the initial experience. J Urol 2003, 170:52–56.

    Article  PubMed  Google Scholar 

  8. Janetschek G, Abdelmaksoud A, Bagheri F, et al.: Laparoscopic partial nephrectomy in cold ischemia: renal artery perfusion. J Urol 2004, 171:68–71.

    Article  PubMed  Google Scholar 

  9. Abukora F, Albqami N, Nambirajan T, et al.: Long-term functional outcome of renal units after laparoscopic nephron-sparing surgery under cold ischemia. J Endourol 2006, 20:790–793.

    Article  PubMed  Google Scholar 

  10. Bermudez H, Guillonneau B, Gupta R, et al.: Initial experience in laparoscopic partial nephrectomy for renal tumor with clamping of renal vessels. J Endourol 2003, 17:373–378.

    Article  PubMed  Google Scholar 

  11. Beck SD, Lifshitz DA, Cheng L, et al.: Endoloop-assisted laparoscopic partial nephrectomy. J Endourol 2002, 16:175–177.

    Article  PubMed  Google Scholar 

  12. Wilhelm DM, Ogan K, Saboorian MH, et al.: Feasibility of laparoscopic partial nephrectomy using pledgeted compression sutures for hemostasis. J Endourol 2003, 17:223–227.

    Article  PubMed  Google Scholar 

  13. Verhoest G, Manunta A, Bensalah K, et al.: Laparoscopic partial nephrectomy with clamping of the renal parenchyma: initial experience. Eur Urol 2007, 52:1340–1346.

    Article  PubMed  Google Scholar 

  14. Moinzadeh A, Flacke S, Libertino JA, et al.: Temporary segmental renal artery occlusion using reverse phase polymer for bloodless robotic partial nephrectomy. J Urol 2009, 182:1582–1587.

    Article  PubMed  Google Scholar 

  15. Moinzadeh A, Hasan W, Spaliviero M, et al.: Water jet assisted laparoscopic partial nephrectomy without hilar clamping in the calf model. J Urol 2005, 174:317–321.

    Article  PubMed  Google Scholar 

  16. Shekarriz H, Shekarriz B, Upadhyay J, et al.: Hydro-jet assisted laparoscopic partial nephrectomy: initial experience in a porcine model. J Urol 2000, 163:1005–1008.

    Article  CAS  PubMed  Google Scholar 

  17. Corvin S, Oberneder R, Adam C, et al.: Use of hydro-jet cutting for laparoscopic partial nephrectomy in a porcine model. Urology 2001, 58:1070–1073.

    Article  CAS  PubMed  Google Scholar 

  18. Wille AH, Tullmann M, Roigas J, et al.: Laparoscopic partial nephrectomy in renal cell cancer—results and reproducibility by different surgeons in a high volume laparoscopic center. Eur Urol 2006, 49:337–342.

    Article  PubMed  Google Scholar 

  19. Tomita Y, Koike H, Takahashi K, et al.: Use of the harmonic scalpel for nephron sparing surgery in renal cell carcinoma. J Urol 1998, 159:2063–2064.

    Article  CAS  PubMed  Google Scholar 

  20. Hernandez AD, Smith JA Jr, Jeppson KG, Terreros DA: A controlled study of the argon beam coagulator for partial nephrectomy. J Urol 1990, 143:1062–1065.

    CAS  PubMed  Google Scholar 

  21. Quinlan DM, Naslund MJ, Brendler CB: Application of argon beam coagulation in urological surgery. J Urol 1992, 1472:410–412.

    Google Scholar 

  22. Shanberg AM, Zagnoev M, Clougherty TP: Tension pneumothorax caused by the argon beam coagulator during laparoscopic partial nephrectomy. J Urol 2002, 168:2162.

    Article  PubMed  Google Scholar 

  23. Mastragelopulos N, Sarkar M, Kaissling G, et al.: Argon gas embolism in laparoscopic cholecystectomy with the Argon Beam One coagulator [in German]. Chirurg 1992, 63:1053–1054.

    CAS  PubMed  Google Scholar 

  24. Urena R, Mendez F, Woods M, et al.: Laparoscopic partial nephrectomy of solid renal masses without hilar clamping using a monopolar radio frequency device. J Urol 2004, 171:1054–1056.

    Article  PubMed  Google Scholar 

  25. Stern JA, Simon SD, Ferrigni RG, Andrews PE: TissueLink device for laparoscopic nephron-sparing surgery. J Endourol 2004, 18:455–456.

    Article  PubMed  Google Scholar 

  26. Herrell SD, Levin BM: Laparoscopic partial nephrectomy: use of the TissueLink hemostatic dissection device. J Endourol 2005, 19:446–449.

    Article  PubMed  Google Scholar 

  27. Weld KJ, Venkatesh R, Huang J, Landman J: Evolution of surgical technique and patient outcomes for laparoscopic partial nephrectomy. Urology 2006, 67:502–506.

    Article  PubMed  Google Scholar 

  28. Klingler CH, Remzi M, Marberger M, Janetschek G: Haemostasis in laparoscopy. Eur Urol 2006, 50:948–956.

    Article  PubMed  Google Scholar 

  29. Oefelein MG: Delayed presentation of urinoma after radiofrequency ablation-assisted laparoscopic partial nephrectomy. J Endourol 2006, 20:27–30.

    Article  PubMed  Google Scholar 

  30. Nadler RB, Perry KT, Smith ND: Hybrid laparoscopic and robotic ultrasound-guided radiofrequency ablation-assisted clampless partial nephrectomy. Urology 2009, 74:202–205.

    Article  PubMed  Google Scholar 

  31. Moinzadeh A, Gill IS, Rubenstein M, et al.: Potassium-titanyl-phosphate laser laparoscopic partial nephrectomy without hilar clamping in the survival calf model. J Urol 2005, 174:1110–1114.

    Article  PubMed  Google Scholar 

  32. Anderson JK, Baker MR, Lindberg G, Cadeddu JA: Large-volume laparoscopic partial nephrectomy using the potassium-titanyl-phosphate (KTP) laser in a survival porcine model. Eur Urol, 2007, 51:749–754.

    Article  PubMed  Google Scholar 

  33. Lotan Y, Gettman MT, Lindberg G, et al.: Laparoscopic partial nephrectomy using holmium laser in a porcine model. JSLS 2004, 8:51–55.

    PubMed  Google Scholar 

  34. Lotan Y, Gettman MT, Ogan K, et al.: Clinical use of the holmium: YAG laser in laparoscopic partial nephrectomy. J Endourol 2002, 16:289–292.

    Article  PubMed  Google Scholar 

  35. Terai A, Ito N, Yoshimura K, et al.: Laparoscopic partial nephrectomy using microwave tissue coagulator for small renal tumors: usefulness and complications. Eur Urol 2004, 45:744–748.

    Article  PubMed  Google Scholar 

  36. Satoh Y, Uozumi J, Nanri M, et al.: Renal-tissue damage induced by laparoscopic partial nephrectomy using microwave tissue coagulator. J Endourol 2005, 19:818–822.

    Article  PubMed  Google Scholar 

  37. Itoh K, Suzuki Y, Miuru M, et al.: Posterior retroperitoneoscopic partial nephrectomy using microwave tissue coagulator for small renal tumors. J Endourol 2002, 16:367–371.

    Article  PubMed  Google Scholar 

  38. Harabayashi T Ureteral stricture developing after partial nephrectomy with a microwave tissue coagulator: case report. J Endourol 2003, 17:919–921.

    Article  PubMed  Google Scholar 

  39. Desai MM, Gill IS: Laparoscopic partial nephrectomy for tumour: current status at the Cleveland Clinic. BJU Int 2005, 95(Suppl 2):41–45.

    Article  PubMed  Google Scholar 

  40. Singh D, Rubenstein M, Gill IS: Laparoscopic partial nephrectomy. J Endourol 2005, 19:451–455.

    Article  PubMed  Google Scholar 

  41. Orvieto MA, Chien GW, Tolhurst SR, et al.: Simplifying laparoscopic partial nephrectomy: technical considerations for reproducible outcomes. Urology 2005, 66:976–980.

    Article  PubMed  Google Scholar 

  42. Orvieto MA, Lotan T, Lyon MB, et al.: Assessment of the LapraTy clip for facilitating reconstructive laparoscopic surgery in a porcine model. Urology 2007, 69:582–585.

    Article  PubMed  Google Scholar 

  43. L’Esperance JO, Marguet CG, Walters RC, et al.: Do nonspecific deep corticomedullary sutures performed during partial nephrectomy adequately control major vascular and collecting system injury? BJU Int 2010, 105:411–415

    Article  PubMed  Google Scholar 

  44. Ames CD, Perrone JM, Frisella AJ, et al.: Comparison of holding strength of suture anchors for hepatic and renal parenchyma. J Endourol 2005, 19:1221–1225.

    Article  PubMed  Google Scholar 

  45. Kimm S, Tarin T, Chung B, et al.: Comparison of holding strength of suture anchors on human renal Capsule. J Endourol 2010, 24:293–297.

    Article  PubMed  Google Scholar 

  46. Johnston WK III, Montgomery JS, Seifman BD, et al.: Fibrin glue v sutured bolster: lessons learned during 100 laparoscopic partial nephrectomies. J Urol 2005, 174:47–52.

    Article  PubMed  Google Scholar 

  47. Miller M, Anderson JK, Pearle MS, Cadeddu JA: Resorbable clip migration in the collecting system after laparoscopic partial nephrectomy. Urology 2006, 67:845 e7–8.

    PubMed  Google Scholar 

  48. Shikanov S, Wille M, Large M, et al.: Knotless closure of the collecting system and renal parenchyma with a novel barbed suture during laparoscopic porcine partial nephrectomy. J Endourol 2009, 23:157–160.

    Google Scholar 

  49. Abou-Elela A, Morsy A, Badawy H, Fathy M: Use of oxidized cellulose hemostats (surgicel) to support parenchymal closure and achieve hemostasis following partial nephrectomy. Surg Technol Int 2009, 18:75–79.

    PubMed  Google Scholar 

  50. Sabino L, Andreoni C, Faria EF, et al.: Evaluation of renal defect healing, hemostasis, and urinary fistula after laparoscopic partial nephrectomy with oxidized cellulose. J Endourol 2007, 21:551–556.

    Article  PubMed  Google Scholar 

  51. Thompson T, Ng CG, Tolley D: Renal parenchymal hemostatic aids: glues and things. Curr Opin Urol 2003, 13:209–214.

    Article  PubMed  Google Scholar 

  52. van Dijk JH, Pes PL: Haemostasis in laparoscopic partial nephrectomy: current status. Minim Invasive Ther Allied Technol 2007, 16:31–44.

    Article  PubMed  Google Scholar 

  53. Msezane LP, Katz MH, Gofrit ON, et al.: Hemostatic agents and instruments in laparoscopic renal surgery. J Endourol 2008, 22:403–408.

    Article  PubMed  Google Scholar 

  54. Kram HB, Ocampo HP, Yamaguchi MP, et al.: Fibrin glue in renal and ureteral trauma. Urology 1989, 33:215–218.

    Article  CAS  PubMed  Google Scholar 

  55. Levinson AK, Swanson DA, Johnson DE, et al.: Fibrin glue for partial nephrectomy. Urology 1991, 38:314–316.

    Article  CAS  PubMed  Google Scholar 

  56. Kouba E, Tornehl C, Lavelle J, et al.: Partial nephrectomy with fibrin glue repair: measurement of vascular and pelvicaliceal hydrodynamic bond integrity in a live and abbatoir porcine model. J Urol 2004, 172:326–330.

    Article  PubMed  Google Scholar 

  57. Pruthi RS, Chun J, Richman M: The use of a fibrin tissue sealant during laparoscopic partial nephrectomy. BJU Int 2004, 93:813–817.

    Article  CAS  PubMed  Google Scholar 

  58. Oz MC, Rondinone JF, Shargill NS: FloSeal Matrix: new generation topical hemostatic sealant. J Card Surg 2003, 18:486–493.

    Article  PubMed  Google Scholar 

  59. Gill IS, Ramani AP, Spaliviero M, et al.: Improved hemostasis during laparoscopic partial nephrectomy using gelatin matrix thrombin sealant. Urology 2005, 65:463–466.

    Article  PubMed  Google Scholar 

  60. Hick EJ, Morey AF, Harris RA, Morris MS: Gelatin matrix treatment of complex renal injuries in a porcine model. J Urol 2005, 173:1801–1804.

    Article  CAS  PubMed  Google Scholar 

  61. Desai PJ, Maynes LJ, Zuppan C, et al.: Hand-assisted laparoscopic partial nephrectomy in the porcine model using gelatin matrix hemostatic sealant without hilar occlusion. J Endourol 2005, 19:566–569.

    Article  PubMed  Google Scholar 

  62. Ramakumar S, Roberts WW, Fugita OE, et al.: Local hemostasis during laparoscopic partial nephrectomy using biodegradable hydrogels: initial porcine results. J Endourol 2002, 16:489–494.

    Article  PubMed  Google Scholar 

  63. Glickman M, Gheissari A, Money S, et al.: A polymeric sealant inhibits anastomotic suture hole bleeding more rapidly than gelfoam/thrombin: results of a randomized controlled trial. Arch Surg 2002, 137:326–331.

    Article  CAS  PubMed  Google Scholar 

  64. Hill A, Estridge TD, Maroney M, et al.: Treatment of suture line bleeding with a novel synthetic surgical sealant in a canine iliac PTFE graft model. J Biomed Mater Res 2001, 58:308–312.

    Article  CAS  PubMed  Google Scholar 

  65. Park EL, Ulreich JB, Scott KM, et al.: Evaluation of polyethylene glycol based hydrogel for tissue sealing after laparoscopic partial nephrectomy in a porcine model. J Urol 2004, 172(6 Pt 1):2446–2550.

    Article  CAS  PubMed  Google Scholar 

  66. Bernie JE, Ng J, Barman V, et al.: Evaluation of hydrogel tissue sealant in porcine laparoscopic partial-nephrectomy model. J Endourol 2005, 19:1122–1126.

    Article  PubMed  Google Scholar 

  67. Nadler RB, Loeb S, Rubenstein RA, Vardi IY: Use of BioGlue in laparoscopic partial nephrectomy. Urology 2006, 68:416–418.

    Article  PubMed  Google Scholar 

  68. Hidas G, Kastin A, Mullerad M, et al.: Sutureless nephron-sparing surgery: use of albumin glutaraldehyde tissue adhesive (BioGlue). Urology 2006, 67:697–700.

    Article  CAS  PubMed  Google Scholar 

  69. Hidas G, Lupinsky L, Kastin A, et al.: Functional significance of using tissue adhesive substance in nephron-sparing surgery: assessment by quantitative SPECT of 99 m Tc-Dimercaptosuccinic acid scintigraphy. Eur Urol 2007, 52:785–789.

    Article  PubMed  Google Scholar 

  70. Johnston WK III, Kelel KM, Hollenbeck BK, et al.: Acute integrity of closure for partial nephrectomy: comparison of 7 agents in a hypertensive porcine model. J Urol 2006, 175:2307–2311.

    Article  PubMed  Google Scholar 

  71. L’Esperance JO, Sung JC, Marguet CG, et al.: Controlled survival study of the effects of Tisseel or a combination of FloSeal and Tisseel on major vascular injury and major collecting-system injury during partial nephrectomy in a porcine model. J Endourol 2005, 19:1114–1121.

    Article  PubMed  Google Scholar 

  72. Uribe CA, Eichel L, Khonsari S, et al.: What happens to hemostatic agents in contact with urine? An in vitro study. J Endourol 2005, 19:312–317.

    Article  PubMed  Google Scholar 

  73. Antisdel JL, West-Denning JL, Sindwani R: Effect of microporous polysaccharide hemospheres (MPH) on bleeding after endoscopic sinus surgery: randomized controlled study. Otolaryngol Head Neck Surg 2009, 141:353–357.

    Article  PubMed  Google Scholar 

  74. Ramani AP, Desai MM, Steinberg AP, et al.: Complications of laparoscopic partial nephrectomy in 200 cases. J Urol 2005, 173:42–47.

    Article  PubMed  Google Scholar 

  75. Singh D, Gill IS: Renal artery pseudoaneurysm following laparoscopic partial nephrectomy. J Urol 2005, 174:2256–2259.

    Article  PubMed  Google Scholar 

  76. Shapiro EY, Ari Hakimi A, Hyams ES, et al.: Renal artery pseudoaneurysm following laparoscopic partial nephrectomy. Urology 2009, 74:819–823.

    Article  PubMed  Google Scholar 

  77. • Gill IS, Kamoi K, Aron M, Desai MM: 800 Laparoscopic partial nephrectomies: a single surgeon series. J Urol 2010, 183:34–41. This is one of the largest single surgeon series from 1999 to 2008 of around 800 LPNs, which, for analysis, is divided into three chronologic eras. With increasing surgeon comfort levels, increasing tumor complexity followed, but WIT became shorter and the overall rates of complications were significantly lower. Bleeding is one of the major causes of morbidity, and they describe an overall complication rate of 23.9% and blood transfusion rate of 14.1% in Era 1, which improved dramatically over time (See Table 1 for details).

    Article  PubMed  Google Scholar 

  78. • Benway BM, Bhayani SB, Rogers CG, et al.: Robot assisted partial nephrectomy versus laparoscopic partial nephrectomy for renal tumors: a multi-institutional analysis of perioperative outcomes. J Urol 2009, 182:866–872. This is a retrospective study involving chart review, evaluating 118 consecutive LPNs and 129 consecutive robot-assisted PNs performed between 2004 and 2008 by three experienced minimally invasive surgeons at three academic centers (See Table 1 for details).

    Article  PubMed  Google Scholar 

  79. • Shah SK, Matin SF, Singer EA, et al.: Outcomes of laparoscopic partial nephrectomy after fellowship training. JSLS 2009, 13:154–159. The authors looked at results of LPN of three urologists in their initial years of independent practice following laparoscopic fellowship training. Their conclusions noted that newly fellowship-trained surgeons performing LPN achieve initial outcomes comparable to those reported by highly experienced surgeons. Further experience reduced total operative and warm ischemia times.

    PubMed  Google Scholar 

  80. Scoll BJ, Uzzo RG, Chen DY, et al.: Robot-assisted partial nephrectomy: a large single-institutional experience. Urology 2010 (Epub ahead of print).

  81. Jeong W, Park SY, Lorenzo EI, et al.: Laparoscopic partial nephrectomy versus robot-assisted laparoscopic partial nephrectomy. J Endourol 2009, 23:1457–1460.

    Article  PubMed  Google Scholar 

  82. Simone G, Papalia R, Guaglianone S, et al.: Preoperative superselective transarterial embolization in laparoscopic partial nephrectomy: technique, oncologic, and functional outcomes. J Endourol 2009, 23:1473–1478.

    Article  PubMed  Google Scholar 

  83. Lifshitz DA, Shikanov SA, Deklaj T, et al.: Laparoscopic partial nephrectomy: a single-center evolving experience. Urology 2010, 75:282–287.

    Article  PubMed  Google Scholar 

  84. Wang AJ, Bhayani SB: Robotic partial nephrectomy versus laparoscopic partial nephrectomy for renal cell carcinoma: single-surgeon analysis of > 100 consecutive procedures. Urology 2009, 73:306–310.

    Article  PubMed  Google Scholar 

  85. Nadu A, Kleinmann N, Laufer M, et al.: Laparoscopic partial nephrectomy for central tumors: analysis of perioperative outcomes and complications. J Urol 2009, 181:42–47

    Article  PubMed  Google Scholar 

  86. DeVoe WB, Kercher KW, Hope WW, et al.: Hand-assisted laparoscopic partial nephrectomy after 60 cases: comparison with open partial nephrectomy. Surg Endosc 2009, 23:1075–1080.

    Article  PubMed  Google Scholar 

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Disclosure

Dr. Raymond J. Leveillee has received research support from AngioDynamics; has served as an unpaid consultant and received research lab support from Covidien; has served as a lecturer/proctor for Intuitive; and has served as a lecturer for Applied Medical. No other potential conflicts of interest relevant to this article were reported.

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  1. Division of Endourology, Laparoscopy and Minimally Invasive Surgery, Department of Urology, Miller School of Medicine, University of Miami, 1400 NW 10th Avenue, Dominion Tower Suite 507, Miami, FL, 33136, USA

    Rajan Ramanathan & Raymond J. Leveillee

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  1. Rajan Ramanathan
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Ramanathan, R., Leveillee, R.J. A Review of Methods for Hemostasis and Renorrhaphy After Laparoscopic and Robot-assisted Laparoscopic Partial Nephrectomy. Curr Urol Rep 11, 208–220 (2010). https://doi.org/10.1007/s11934-010-0107-7

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Keywords

  • Partial nephrectomy
  • Laparoscopic partial nephrectomy
  • Small renal masses
  • Hemostasis after partial nephrectomy
  • Renorrhaphy
  • Tissue sealants
  • Hemostatic agents