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Cheung DC, Wallis CJD, Possee S, Tajzler C, Anidjar M, Barrett K, Deklaj T, Drachenberg DE, Evans H, French C, Gotto G, Izard J, Jain U, Kawakami J, Kulkarni GS, Lee J, McCracken J, McGregor T, Richard PO, Rowe NE, Sabbagh R, St Martin B, Tatzel S, Touma N, Widmer H, Wiesenthal J, Yang B, Zorn KC, Kapoor A, Finelli A, Satkunasivam R. Canadian Update on Surgical Procedures (CUSP) Urology Group consensus for intraoperative hemostasis during minimally invasive partial nephrectomy. Can Urol Assoc J 2020; 14:E387-E393. [PMID: 32569571 DOI: 10.5489/cuaj.6579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
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.
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Affiliation(s)
- Douglas C Cheung
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Christopher J D Wallis
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Department of Urology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Simon Possee
- Division of Medicine, The Rotherham Foundation Trust, South Yorkshire, United Kingdom
| | - Camilla Tajzler
- Division of Urology, McMaster Institute of Urology, Hamilton, ON, Canada
| | - Maurice Anidjar
- Division of Urology, McGill University, Montreal, QC, Canada
| | | | - Tom Deklaj
- Department of Surgery (Urology), Western University (Windsor Regional Hospital), London, ON, Canada
| | | | - Howard Evans
- Division of Urology, Department of Surgery, University of Alberta, AB, Canada
| | - Christopher French
- Discipline of Surgery (Urology), Memorial University, St. John's, NL, Canada
| | - Geoffrey Gotto
- Division of Urology, Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Jason Izard
- Department of Urology, Queen's University, Kingston, ON, Canada
| | - Umesh Jain
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Jun Kawakami
- Division of Urology, Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Girish S Kulkarni
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Jason Lee
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | | | - Thomas McGregor
- Department of Urology, Queen's University, Kingston, ON, Canada
| | - Patrick O Richard
- Division of Urology, Department of Surgery, Centre Hospitalier Universitaire de Sherbrooke and Centre de Recherche du CHUS, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Neal E Rowe
- Division of Urology, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Robert Sabbagh
- Division of Urology, Department of Surgery, Centre Hospitalier Universitaire de Sherbrooke and Centre de Recherche du CHUS, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Blair St Martin
- Division of Urology, Department of Surgery, University of Alberta, AB, Canada
| | - Stephanie Tatzel
- Division of Urology, Department of Surgery, McMaster University (Niagara Health), Hamilton, ON, Canada
| | - Naji Touma
- Department of Urology, Queen's University, Kingston, ON, Canada
| | - Hugues Widmer
- Section of Urology, Department of Surgery, University of Montreal Hospital Centre (CHUM), Montreal, QC, Canada
| | | | - Brian Yang
- Department of Urological Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Kevin C Zorn
- Section of Urology, Department of Surgery, University of Montreal Hospital Centre (CHUM), Montreal, QC, Canada
| | - Anil Kapoor
- Division of Urology, McMaster Institute of Urology, Hamilton, ON, Canada
| | - Antonio Finelli
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Raj Satkunasivam
- Center for Outcomes Research, Houston Methodist Hospital, Medical Center, Houston, TX, United States
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Pacheco M, Barros AA, Aroso IM, Autorino R, Lima E, Silva JM, Reis RL. Use of hemostatic agents for surgical bleeding in laparoscopic partial nephrectomy: Biomaterials perspective. J Biomed Mater Res B Appl Biomater 2020; 108:3099-3123. [PMID: 32458570 DOI: 10.1002/jbm.b.34637] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 04/29/2020] [Indexed: 12/20/2022]
Abstract
In recent years, there was an abrupt increase in the incidence of renal tumors, which prompt up the appearance of cutting-edge technology, including minimally invasive and organ-preserving approaches, such as laparoscopic partial nephrectomy (LPN). LPN is an innovative technique used to treat small renal masses that have been gaining popularity in the last few decades due to its promissory results. However, the bleeding control remains the main challenge since the majority of currently available hemostatic agents (HAs) used in other surgical specialities are inefficient in LPN. This hurried the search for effective HAs adapted for LPN surgical peculiarities, which resulted on the emergence of different types of topical HAs. The most promising are the natural origin HAs because of their inherent biodegradability, biocompatibility, and lowest toxicity. These properties turn them top interests' candidates as HAs in LPN. In this review, we present a deep overview on the progress achieved in the design of HAs based on natural origin polymers, highlighting their distinguishable characteristics and providing a clear understanding of their hemostat's role in LPN. This way it may be possible to establish a structure-composition properties relation, so that novel HAs for LPN can be designed to explore current unmet medical needs.
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Affiliation(s)
- Margarida Pacheco
- 3B's Research Group-Research Institute on Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, Avepark-Parque de Ciência e Tecnologia, Barco Guimarães, Portugal.,ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Alexandre A Barros
- 3B's Research Group-Research Institute on Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, Avepark-Parque de Ciência e Tecnologia, Barco Guimarães, Portugal.,ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Ivo M Aroso
- 3B's Research Group-Research Institute on Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, Avepark-Parque de Ciência e Tecnologia, Barco Guimarães, Portugal.,ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | | | - Estêvão Lima
- School of Health Sciences, Life and Health Sciences Research Institute (ICVS), University of Minho, Braga, Portugal.,Surgical Sciences Research Domain, Life and Health Sciences Research Institute, University of Minho, Braga, Portugal
| | - Joana M Silva
- 3B's Research Group-Research Institute on Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, Avepark-Parque de Ciência e Tecnologia, Barco Guimarães, Portugal.,ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Rui L Reis
- 3B's Research Group-Research Institute on Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, Avepark-Parque de Ciência e Tecnologia, Barco Guimarães, Portugal.,ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
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Xiong W, Ran Q, Du Y, Lv J, Chen F, Zhong S, Guo P, Dou K, Sun M. Laparoscopic Radiofrequency Ablation Combined with Surgical Excision for Exophytic Renal Angiomyolipoma: A Novel Technique Based on Tumor Vasculature Features of Enhancing Renal Masses Toward Hilar Off-Clamping Nephron-Sparing Surgery. J Laparoendosc Adv Surg Tech A 2016; 27:823-828. [PMID: 27805457 DOI: 10.1089/lap.2016.0348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Symptomatic angiomyolipoma (AML) and asymptomatic AML larger than 4 cm in size are usually treated with nephron-sparing surgery or transarterial embolization. We used radiofrequency ablation to treat the vascular pedicle of exophytic AML with low R.E.N.A.L. nephrometry score and investigated its feasibility for hilar off-clamping nephron-sparing surgery. METHODS Contrast-enhanced computed tomography (CT) showed enhanced, well-defined lipomatous tumors with a maximum diameter of 4-8 cm in the kidney of 15 patients. Results indicated that the exophytic tumors featured in the enlarged tumor vasculatures extended into the parenchyma of the involved kidney. The patients underwent radiofrequency ablation by using a Cool-tip™ probe placed into the root of the AML mass from different directions under laparoscopic ultrasonography guidance. After sealing the vascular pedicle of the tumor, the bloodless tumors were resected en bloc without renal hilar clamping or suturing the resection defect of the kidney. RESULTS All patients underwent the procedure smoothly, and no perioperative complications occurred. The contrast-enhanced CT scan showed small defects in the contrast-enhanced renal parenchyma at third month after the procedure, and the decrease in function of the treated kidneys was <10% during the 12-month follow-up. CONCLUSIONS Our initial experience suggests that sealing the tumor vessels by radiofrequency ablation based on the tumor vasculature features of a renal mass is an alternative to hilar clamping in laparoscopic nephron-sparing surgery. Laparoscopic radiofrequency ablation and tumor excision are a definitive and safe minimally invasive procedure that allows the successful removal of exophytic sporadic AML mass with low R.E.N.A.L. nephrometry score.
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Affiliation(s)
- Wei Xiong
- 1 Division of Urology and Transplantation, Department of Surgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital , Chengdu, China
| | - Qing Ran
- 1 Division of Urology and Transplantation, Department of Surgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital , Chengdu, China
| | - Yangchun Du
- 1 Division of Urology and Transplantation, Department of Surgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital , Chengdu, China
| | - Ji Lv
- 1 Division of Urology and Transplantation, Department of Surgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital , Chengdu, China
| | - Fang Chen
- 1 Division of Urology and Transplantation, Department of Surgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital , Chengdu, China
| | - Shan Zhong
- 1 Division of Urology and Transplantation, Department of Surgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital , Chengdu, China
| | - Pu Guo
- 1 Division of Urology and Transplantation, Department of Surgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital , Chengdu, China
| | - Ke Dou
- 1 Division of Urology and Transplantation, Department of Surgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital , Chengdu, China
| | - Minghan Sun
- 2 Department of Obstetrics and Gynecology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital , Chengdu, China
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