En bloc stapler ligation of the renal vascular pedicle during laparoscopic nephrectomy

Does the stapler for en bloc resection of renal pedicles during kidney removal surgery increase the risk of arteriovenous fistula?

BACKGROUND

It was previously thought that renal hilum en bloc ligation during kidney removal may increase the risk of renal arteriovenous fistula (AVF) formation. We evaluated the safety and effectiveness of en bloc ligation of the renal pedicle using a stapler during laparoscopic nephrectomy and nephroureterectomy.

METHODS

Ninety patients underwent en bloc renal hilar ligation using 45-mm endo-gastrointestinal anastomosis stapler and 2.5-mm staples during laparoscopic nephrectomy and nephroureterectomy from 2002 to 2015. Perioperative outcomes including estimated blood loss, operative time, and perioperative complications were documented.

RESULTS

Twenty-seven patients underwent nephrectomy and 63 patients underwent nephroureterectomy. Thirty patients (33.3%) had perioperative complications. The majority of complications were of Clavien grade II. Six patients had Clavien Dindo grade III and none of the patients had grade IV complications. There were no significant differences in complication rates between right- and left-sided procedures (p = 0.233). Median blood loss was 190.1 ml and mean operative time was 227.1 minutes in nephrectomy and 256.6 minutes in nephroureterectomy. None of the patients had evidence of AVF formation on postoperative computerized tomography scan. Only three patients had a new diagnosis of heart failure. One of them was eventually lost to follow up. The remaining two patients had no evidence of AVF formation in imaging studies and physical examination.

CONCLUSION

En bloc ligation of the renal pedicle during laparoscopic nephrectomy and nephroureterectomy using a stapler is safe. None of our patients developed an AVF during follow up.

Safety and Efficacy of En Bloc Renal Hilar Vascular Staple Ligation: A Meta-Analysis

PURPOSE

We reviewed the literature on the safety of en bloc ligation. We also performed a meta-analysis of the effect of using this technique with vascular staplers on perioperative factors compared to conventional renal pedicle dissection and isolated staple ligation of the renal artery and vein.

MATERIALS AND METHODS

A literature search was performed to include all primary studies related to the safety of en bloc ligation of the renal hilum. After exclusion criteria were applied 9 studies were identified for review, of which 4 included a control group and were used in the meta-analysis. The primary end point was the incidence of arteriovenous fistula. Secondary end points were procedure duration, blood loss and the number of perioperative complications.

RESULTS

None of the total population of 595 patients in whom en bloc ligation was performed for nephrectomy were diagnosed with arteriovenous fistula formation at an average postoperative followup of 26.5 months. When comparing en bloc and isolated ligation of the renal artery and vein, the meta-analysis showed a significant improvement in procedure duration for en bloc nephrectomy. There was no difference in estimated blood loss or the number of complications.

CONCLUSION

En bloc ligation appears to be as safe as and potentially more beneficial in terms of perioperative factors than conventional renal pedicle dissection and isolated vascular ligation.

Comparative analysis of pedicular vascular control techniques during laparoscopic nephrectomy: en bloc stapling or separate ligation?

OBJECTIVE

To compare the safety and efficacy of en bloc stapling and separate ligation techniques for renal vascular control during laparoscopic nephrectomy.

PATIENTS AND METHODS

Clinical data were collected from 60 patients who underwent laparoscopic nephrectomies using en bloc stapling (n = 27, group 1) or the separate ligation method (n = 33, group 2). Comparative analysis was carried out between the two groups, examining operative times, blood loss, intra- and postoperative complications and hospital stay.

RESULTS

Compared with the separate ligation method, the en bloc hilar control technique was associated with a shorter total operating time (98 vs. 121 min, p = 0.029). However, both groups were similar in terms of estimated blood loss, hemoglobin drop, changes in creatinine level and postoperative hospital stay. The total complication rates in group 1 and 2 were 3.7 and 15.1%, respectively, with a statistically significant difference. There were no complications related to the use of the endo-GIA stapler and no patients required conversion to open surgery in group 1. In group 2, 2 patients required conversion to open surgery, including 1 due to renal vein bleeding secondary to inaccurate vascular control and the other due to bleeding from the vena cava during dissection. In addition, 1 patient had a superficial bowel injury that was repaired laparoscopically and another had a superficial liver tear that was managed without conversion or transfusion.

CONCLUSION

En bloc ligation of the renal hilum is an easy and reliable technique that allows safe and fast control of the renal pedicle.

Safety of en bloc ligation of the renal hilum during laparoscopic radical nephrectomy for renal cell carcinoma: a randomized controlled trial

AIM

To evaluate the safety of en bloc stapler ligation of the renal vascular pedicle during laparoscopic radical nephrectomy for renal cell carcinoma.

SUBJECTS AND METHODS

Clinical data were collected prospectively from 70 patients who underwent either en bloc stapling of the renal hilum (n=35) (Group A) or the separate ligation method (n=35) (Group B) to treat renal cell carcinoma. To evaluate the incidence of arteriovenous fistula (AVF), blood pressure and heart rate were measured, and abdominal auscultation was performed at 1 month, 3 months, 6 months, and 12 months post-surgery. Abdominal computed tomography was also performed at 6 and 12 months post-surgery. In addition, preoperative characteristics and postoperative outcomes (such as operation time and estimated blood loss [EBL]) were examined.

RESULTS

Both operation time and EBL were lower for Group A: operative time, Group A versus Group B, 60.26±10.94 minutes versus 67.51±10.49 minutes (P=.007); EBL, Group A versus Group B, 33.53±13.46 mL versus 49.14±32.21 mL (P=.011). No statistically significant differences were noted in either of the postoperative variables (blood pressure and heart rate), and there was no clinical evidence of bruit or AVF at 12 months post-surgery.

CONCLUSIONS

No AVF was observed after en bloc ligation upon clinical follow-up or on radiological evaluation.

Current status of en bloc stapling of the renal hilum during laparoscopic nephrectomy

INTRODUCTION

Increasing literature has been published lately addressing the safety and efficacy of en bloc stapling of the renal hilum during laparoscopic nephrectomy and nephroureterectomy. The aim of this review was to analyze the available literature on en bloc stapling of the renal hilum and to complement it with technical issues that are required, according to our vast experience in en bloc and separate stapling, to safely control the hilum with this technique.

MATERIALS AND METHODS

A PubMed search using the terms "en bloc," "nephrectomy," and "laparoscopy" was conducted. We identified seven publications that have looked into hilar stapling technique.

RESULTS

Seven publications were found, which included a total of 434 patients who underwent en bloc stapling of the renal hilum. No complications specifically ascribable to this type of hilar control were encountered. No cases of postoperative arteriovenous fistula have been reported.

CONCLUSIONS

En bloc stapling has become an established method to secure the renal hilum during laparoscopic nephrectomy and laparoscopic nephroureterectomy. Although no cases of postoperative arteriovenous fistula formation have been reported with the use of modern titanium staplers, longer follow-up is necessary to ascertain that it does not occur in the late postoperative period. We believe that well-trained laparoscopic surgeons should master this technique in both emergency and elective situations.

Advantages of en bloc hilar ligation during laparoscopic extirpative renal surgery

PURPOSE

By evaluating the technical challenges encountered during 123 laparoscopic nephrectomies, we have been able to modify the surgical technique to allow general urologists to effectively perform the procedure with minimal complications.

DESIGN AND METHOD

A retrospective chart review was performed on 123 patients who consecutively underwent laparoscopic nephrectomy or nephroureterectomy. Using a modified dissection approach to the hilum and en bloc ligation of the renal pedicle with a vascular stapler, a new standard of laparoscopic nephrectomy was developed at our institution. In 30 cases, the conventional technique was used, whereas in 93 cases the en bloc technique was used. Operating time, blood loss, transfusion requirements, intra- and postoperative complications, and the incidence of arteriovenous fistula (AVF) were documented. Follow-up included serial clinical evaluation and computed tomography angiogram at 3 months and repeated at 3-monthly intervals where indicated.

RESULTS

Operative and postoperative parameters were improved in the en bloc group compared with the conventional group. In the en bloc group, the average operating time was 56 minutes and the average blood loss was 32 mL. No patients required a blood transfusion and only two cases required conversion to open nephrectomy. No late vascular complications related to this method were observed with a mean follow-up of 28 months. There were no perioperative deaths. Postoperative complications were self-limiting and no patients developed postnephrectomy AVF.

CONCLUSION

The results of using the en bloc ligation technique for laparoscopic nephrectomy have been favorable in terms of operating time, risk to the patient, and surgeon's surgical preference. The risk of AVF formation after en bloc ligation of the renal pedicle and ligation by the conventional method appears to be equal based on the clinical follow-up and radiological evaluation. Therefore, long-term radiological follow-up is not mandatory in most cases.

Complications of laparoscopic surgery for renal masses: prevention, management, and comparison with the open experience

CONTEXT

The initial excitement about the laparoscopic treatment of renal masses has been tempered by concerns related to increased operative time, technical complexity, and the suitability of laparoscopic approaches to oncologic surgery.

OBJECTIVE

To provide a comprehensive review of intraoperative and postoperative complications and their prevention and management during laparoscopic surgery of renal tumors.

EVIDENCE ACQUISITION

A literature review of the Medline and Google Scholar databases was performed, searching for renal cell carcinoma, renal mass, laparoscopy, laparoscopic radical nephrectomy, open radical nephrectomy, laparoscopic partial nephrectomy, open partial nephrectomy, laparoscopic cryoablation, laparoscopic radiofrequency ablation, complications, intra-operative, and post-operative. English-language articles published between 1990 and 2008 were reviewed.

EVIDENCE SYNTHESIS

Laparoscopic radical nephrectomy (LRN), whether transperitoneal or retroperitoneal, can be performed safely. The overall complication rate is low and does not significantly differ from that of the open experience. Laparoscopic partial nephrectomy (LPN), in contrast, is a technically challenging procedure. Although the intermediate oncologic outcomes are comparable to those of the open experience, there are concerns related to warm ischemia time, and there is a risk of major complications such as urinary leakage and hemorrhage requiring transfusion. Laparoscopic-assisted ablative therapies (cryotherapy and radiofrequency) are being performed more commonly for the treatment of small exophytic renal lesions with a low complication rate and intermediate oncologic outcomes similar to LRN and LPN.

CONCLUSIONS

Complications associated with the laparoscopic management of renal masses vary among the different procedures and with surgeon experience. The rate of complication appears to be similar to that of open surgery.