Temporary targeted hemostasis to facilitate bloodless partial nephrectomy

The bovine kidney as an experimental model: Simulated partial nephrectomy of the cranial pole and proportional analysis of the arterial segments

Previous studies have shown that the pig kidney is not a good model for some procedures. This study aimed to describe the relationship between the collecting system and the intrarenal arteries, the arterial segments, and to evaluate the bovine kidney as an experimental model for partial nephrectomy of the cranial pole. Polyester resin endocasts of the kidney collecting system together with the intrarenal arteries were prepared. Thirty-two kidneys were used to evaluate the relationship between the collecting system and the intrarenal arteries, while 25 kidneys were transversally sectioned at different points to simulate partial nephrectomy of the cranial pole. Polyester resin of different colors was injected into each segmental artery of the 24 kidneys to evaluate the arterial segments proportionally. The renal artery was divided into cranial and caudal primary branches in 75% of the cases. The cranioventral branch curved on the cranial pole and ran toward the ventral mid-zone in 56.3% of the cases, resembling the retropelvic artery of the human kidney. The kidney was divided into two (25%) or three (75%) arterial segments. The caudal arterial segment had the highest proportional volume (62%). The cranioventral branch was damaged in 28.6% of the kidneys sectioned 1 cm inside the hilum. The arterial branching pattern, the arterial segmentation, and the impairment of the arterial supply after the simulated partial nephrectomy of the cranial pole are quite different from those found in humans. Thus, all differences should be taken into account when using the bovine kidney as a model.

Canadian Update on Surgical Procedures (CUSP) Urology Group consensus for intraoperative hemostasis during minimally invasive partial nephrectomy

INTRODUCTION

Partial nephrectomy remains the gold standard in the management of small renal masses. However, minimally invasive partial nephrectomy (MIPN) is associated with a steep learning curve, and optimal, standardized techniques for time-efficient hemostasis are poorly described. Given the relative lack of evidence, the goal was to describe a set of actionable guiding principles, through an expert working panel, for urologists to approach hemostasis without compromising warm ischemia or oncological outcomes.

METHODS

A three-step modified Delphi method was used to achieve expert agreement on the best practices for hemostasis in MIPN. Panelists were recruited from the Canadian Update on Surgical Procedures (CUSP) Urology Group, which represent all provinces, academic and community practices, and fellowship-and non-fellowship-trained surgeons. Thirty-two (round 1) and 46 (round 2) panellists participated in survey questionnaires, and 22 attended the in-person consensus meeting.

RESULTS

An initial literature search of 945 articles (230 abstracts) underwent screening and yielded 24 preliminary techniques. Through sequential survey assessment and in-person discussion, a total of 11 strategies were approved. These are temporally distributed prior to tumor resection (five principles), during tumor resection (two principles), and during renorrhaphy (four principles).

CONCLUSIONS

Given the variability in tumor size, depth, location, and vascularity, coupled with limitations of laparoscopic equipment, achieving consistent hemostasis in MIPN may be challenging. Despite over two decades of MIPN experience, limited evidence exists to guide clinicians. Through a three-step Delphi method and rigorous iterative review with a panel of experts, we ascertained a guiding checklist of principles for newly beginning and practicing urologists to reference.