A combination of hemostatic agents may safely replace deep medullary suture during laparoscopic partial nephrectomy in a pig model

Evaluation of the hemostatic effect of a combination of hemostatic agents and fibrin glue in a rabbit venous hemorrhage model

BACKGROUND

In neurosurgery, it is important to use local hemostatic agents. We have explored a more powerful method of hemostasis by the combination of commercially available hemostatic agents with fibrin glue in the hopes of synergistic effects.

METHOD

A bleeding model was constructed by puncturing the rabbit posterior vena cava with a needle. After applying the sample to the bleeding point, compression was performed for 10 s. If temporary hemostasis was achieved after pressure release, a 30 s wash was performed to confirm that ultimate hemostasis was achieved. Up to three hemostasis attempts were performed on the same bleeding point until hemostasis was achieved, and the number of attempts required for hemostasis was counted. If hemostasis was not achieved after three attempts, it was counted as four times. Four groups were evaluated: (1) gelatin sponge alone, (2) gelatin sponge + fibrin glue, (3) oxidized cellulose alone, and (4) oxidized cellulose + fibrin glue; each group was tested 16 times.

RESULTS

The median value (range minimum value-maximum value) of the number of hemostatic attempts in Group 1 to Group 4 was 3 (1-4), 1 (1-1), 4 (4-4), and 4 (2-4). In Group 2, there were two test exclusions owing to deviations of the test procedure.

CONCLUSIONS

The compatibility of gelatin sponge and fibrin glue was very good, with a very strong and rapid hemostatic effect compared to other methods, showed its usefulness. This combination method may be effective for a variety of venous hemorrhages in neurosurgery.

Single-Site Sutureless Partial Nephrectomy for Small Exophytic Renal Tumors

Partial nephrectomy (PN) is the standard procedure for most patients with localized renal cancer. Laparoscopy has become the preferred surgical approach to target this cancer, but the steep learning curve with laparoscopic PN (LPN) remains a concern. In LPN intracorporeal suturing, the operation time is further extended even under robot assistance, a step which prolongs warm ischemic time. Herein, we shared our experience to reduce the warm ischemia time, which allows surgeons to perform LPN more easily by using a combination of hemostatic agents to safely control parenchymal bleeding. Between 2015 and 2018, we enrolled 52 patients who underwent LPN in our hospital. Single-site sutureless LPN and traditional suture methods were performed in 33 and 19 patients, respectively. Preoperative, intra-operative, and postoperative variables were recorded. Renal function was evaluated by estimated glomerular filtration rate (eGFR) pre- and postoperatively. The average warm ischemia time (sutureless vs. suture group; 11.8 ± 3.9 vs. 21.2 ± 7.2 min, p < 0.001) and the operation time (167.9 ± 37.5 vs. 193.7 ± 42.5 min, p = 0.035) were significantly shorter in the sutureless group. In the sutureless group, only 2 patients suffered from massive urinary leakage (>200 mL/day) from the Jackson Pratt drainage tube, but the leakage spontaneously decreased within 7 days after surgery. eGFR and serum hemoglobin were not found to be significantly different pre- and postoperatively. All tumors were removed without a positive surgical margin. All patients were alive without recurrent tumors at mean postoperative follow-ups of 29.3 ± 12.2 months. Single-site sutureless LPN is a feasible surgical method for most patients with small exophytic renal cancer with excellent cosmetic results without affecting oncological results.

An update on oxidized regenerated cellulose (fibrillar™) in reducing postoperative corporal bleeding following inflatable penile prosthesis surgery

Background

Scrotal hematoma formation is a dreaded complication of penile prosthesis surgery that increases patient pain and healthcare costs, as well the risk for eventual device infection and failure. The efficacy of hemostatic agents in reducing the incidence of scrotal hematoma development has not been extensively studied in urologic prosthetic surgery. In this paper we further evaluate our experience with oxidized regenerated cellulose (ORC; Surgicel Fibrillar™) as an adjunct to standard hemostatic practices in inflatable penile prosthesis (IPP) implantation.

Methods

From April 2016 onward, intracorporal ORC pledgets were placed during corporotomy closure in all patients undergoing IPP implantation or revision by a single surgeon using an identical surgical technique. Perioperative parameters and outcomes-primarily postoperative cumulative drain output, secondarily patient phone calls in the postoperative period-were compared among successive cases with ORC (April 2016 to February 2019) and without ORC (April 2013 to March 2016).

Results

A total of 274 men underwent IPP implantation during the study period; 175 (64%) had ORC included in their corporotomy closures. Median drain output was significantly reduced in the ORC patients relative to the non-ORC group (50 vs. 65 mL; P=0.0001). A significant reduction in patient-initiated phone calls regarding scrotal pain, swelling, or discomfort in the first 4 weeks following surgery was also observed in the ORC group (average 0.69 vs. 1.1 calls per patient; P=0.03). A total of 9 patients underwent IPP explantation during the study period, all due to device infection; 5 of these were in the ORC group, while 4 were in the non-ORC group (P=0.73). ORC use did not constitute any additional infection risk.

Conclusions

Bilateral incorporation of ORC pledgets during corporotomy closure in IPP surgery significantly decreases postoperative scrotal drain output, a well-documented risk factor for scrotal hematoma formation.

Establishment of Renal Failure Models by Laparoscopy in Bama Pigs Which Underwent Partial Nephrectomy and Radical Contralateral Nephrectomy

Introduction

The miniature pig possesses unmatched advantages as an animal model because of its high homology with humans. Our experiment aimed to build a chronic renal failure (CRF) model in pigs via laparoscopy.

Material and Methods

Laparoscopic surgery was performed twice to build a CRF model. The first surgery was a left partial nephrectomy and the second was a right radical nephrectomy. Pigs were grouped by the total renal tissue to be resected: ⅔, ¾ or ⅚. Physiological parameters (rectal temperature and heart rate), haematological parameters (WBC and RBC) and renal function (serum creatinine - CR and blood urea nitrogen - BUN) were measured preoperatively and every week postoperatively.

Results

After renal resection the pigs manifested chronic renal failure. Heart rate and body temperature declined to varying degrees over 12 postoperative weeks. No significant difference was observed between the different groups. The result of renal function tests found that postoperative serum CR and BUN in all groups were continuously elevated, and the level of serum CR at two weeks post procedure differed very significantly from its preoperative value (P < 0.05). BUN was significantly elevated at one week (P < 0.05). The renal function decreased significantly faster in the ⅚ group than in the other two groups. The trend of renal function change was similar among groups, but progress was slower in the ⅔ and ¾ groups.

Conclusion

⅚ kidney resection was the optimal miniature pig model of CRF.

Oxidized Regenerated Cellulose (Fibrillar) Reduces Risk of Postoperative Corporal Bleeding Following Inflatable Penile Prosthesis Surgery

OBJECTIVE

To report our initial experience with oxidized regenerated cellulose (ORC; Surgicel Fibrillar) as a hemostatic adjunct during inflatable penile prosthesis (IPP) surgery.

MATERIALS AND METHODS

Beginning in April 2016, ORC pledgets were placed within the corporotomy closures of all men undergoing IPP insertion. Perioperative characteristics and outcomes including cumulative postoperative drain output were evaluated among consecutive cases with (April 2016 to October 2016) and without ORC (December 2015 to March 2016) using an identical surgical technique by a single surgeon.

RESULTS

During the study period, 64 men underwent IPP implantation, of whom 32 (50%) received ORC. There was a significant reduction in median drain output relative to controls (33 mL vs 65 mL; P = .01). Postoperatively, ORC use was associated with a reduction in the number of patient phone calls for scrotal-related concerns in the immediate postoperative period (average 0.5 vs 1.1; P = .03). There were 3 IPP explantations in the non-ORC group (2/3 for infection)-one of which was directly related to an infected hematoma. After controlling for other clinical features, the use of ORC (β -32, 95% confidence interval: -61 to -5; P = .02) was independently associated with a reduction in drain output.

CONCLUSION

ORC use during IPP corporotomy closure reduces postoperative drain output, a known risk factor for hematoma-related complications.

Emergent Embolization of a Very Late Detected Pseudoaneurysm at a Lower Pole Subsegmental Artery of the Kidney after Clampless Laparoscopic Partial Nephrectomy

Renal artery pseudoaneurysm is a rare but life-threatening condition. Its incidence is higher after minimally invasive partial nephrectomy (PN) than after the open approach. We reported a case of a renal artery pseudoaneurysm occurred about four months after a clampless laparoscopic PN. A 49-year-old female underwent a clampless laparoscopic PN for a right renal tumor with high surgical complexity. The patient experienced an intraoperative blood loss from renal bed and the surgeons performed a deep medullary absorbable suture. Three months after surgery the patient underwent a renal ultrasonography with good results. The patient came to our emergency department 115 days after surgery with a hypovolemic shock stage 3. Her CT scan showed a pseudoaneurysm of a lower pole vessel of the right kidney. She underwent a superselective embolization of the segmental renal artery. The surgical complexity of the tumor, the anatomical relationships with the renal sinus and the deep medullary suture could be responsible for the development of the pseudoaneurysm. The authors presented an unusual case of a very late detected pseudoaneurysm of a renal vessel, suggesting that all very complex renal tumors removed with a minimally invasive technique should be followed up closely at least during the first six-months in order to early detect this major complication.

Laparoscopic partial nephrectomy without intracorporeal suturing

BACKGROUND

Partial nephrectomy has gained wider acceptance as a surgical technique in treating small renal tumors. Laparoscopic partial nephrectomy (LPN) still remains a technically demanding surgery to this day. We present our technique of laparoscopic partial nephrectomy, one that is performed without intracorporeal suturing.

METHODS

We performed LPN on 31 patients with localized renal parenchymal tumor (stage T1). The procedures were done from September 2009 to March 2015 at the Kaohsiung Medical University Hospital and the Kaohsiung Municipal Ta-Tung Hospital. Our technique involves the covering of renal defect layer by layer with FloSeal, Tisseel and a fat pad after monopolar coagulation.

RESULTS

Thirty-one patients were included in this study. Mean patient age was 53 years old (range 39-70). Mean tumor size was 2.9 cm (range 1.8-6.3). Mean RENAL nephrometry score was 5.3 (range 4-7). The average operation time was 188 min (range 120-290), and the average warm ischemic time was 19.0 min (range 9-26). Mean estimated blood loss was 171 ml (range 10-650), with no postoperative bleeding among the total 31 patients. No recurrent tumors were identified at a mean follow-up of 29 months postoperatively. The mean change in eGFR was 6.5 (ml/min/m2).

CONCLUSION

Laparoscopic partial nephrectomy is a feasible surgical method for most patients with stage 1 tumor. Our technique has shown to reduce warm ischemic time significantly and provide patients with excellent functional outcomes without affecting oncological results. With this technique, surgeons can perform LPN with more efficiency and with fewer complications.