Laparoscopic Partial Nephrectomy

During laparoscopic partial nephrectomy transection of intra-renal blood vessles and violation of urinary collecting system account for the two major complications, e.g., delayed hemorrhage and urinoma. Even with hilar control, laparoscopic suturing of the interlobar arteries and opened calyces can be challenging due to suboptimal visualization and/or difficult angles. All sorts of hemostatic agents have been experimented with and documented during laparoscopic partial nephrectomy.

Johnson & Johnson, New Brunswick, NJ. sEthicon, Somerville, NJ.

Oxidized cellulose, gelatin, collagen, and gelatin matrix/thrombin combination are not considered sealants or adhesives and should not be used to close any part of the collecting system. Therefore, only fibrin sealant should be employed for controlling urinary leakage after planned or traumatic disruption of the collecting system.

Wolf et al., using a porcine model to compare the efficacy of fibrin sealant for closure of five linear ureterotomies with laser-assisted anastomosis, mechanical suturing device, and conventional laparoscopic suturing, concluded that fibrin sealant yielded more favorable radiographic findings, flow characteristics, and histology.

Initially, oxidized cellulose, gelatin, and collagen were used either alone or in conjunction with a hemostatic energy source such as an argon beam coagulator. Kletscher et al. evaluated the efficacy of both Gelfoam and Avitene to control parenchymal hemorrhage during laparoscopic anatrophic nephrolithotomy in a porcine model (38). Gelfoam and Surgicel were welded to the cut and outer surface of the kidney using an. argon beam coagulator. Since this early report, cellulose, gelatin, and collagen have all been utilized for hemostasis in laparoscopic partial nephrectomy Stifelman et al. (37) performed 11 hand-assisted laparoscopic partial nephrectomies (mean tumor size 1.9 cm) and applied Surgical, Avitene, or fibrin-soaked Gelfoam activated by thrombin to the renal defects. Vascular hilar control was not obtained prior to excision of the renal lesion. The authors experienced no major complications and only two minor complications other than postoperative hemorrhage. Cellulose in conjunction with fibrin sealant for hemostasis has also been employed during laparoscopic partial nephrectomy Jeschke et al. (39) performed 51 laparoscopic partial nephrectomies for small (2.0 cm) exophytic renal tumors and covered the renal defect with oxidized cellulose and 2 mL fibrin sealant. Vascular hilar control was not performed and the integrity of the collecting system was not tested intraoperatively. One patient required reoperation for hemorrhage on postoperative day 1, and three developed urinary fistulas on postoperative days 3 to 4.

Floseal also has been used to enhance hemostasis during laparoscopic partial nephrectomy (34-36). Richter et al. (34) performed 10 laparoscopic partial nephrectomies for tumors (median tumor size 2.8 cm) and applied Floseal after tumor resection and before reperfusion of the kidney. Immediate hemostasis was obtained and maintained even after kidney reperfusion. No postoperative hemorrhage occurred and no significant perirenal hematoma was detected with follow-up ultrasonography at 24 hours and 10 days postoperatively. Bak et al. (35) reported similar results after six laparoscopic partial nephrectomies performed for 2 to 5 cm exophytic lesions (median size: 2.5 cm). Also in this study, hemostasis was achieved immediately upon application of Floseal on the moist surface of partial nephrectomy bed, and clinically evident postoperative hemorrhage did not occur.

During laparoscopic partial nephrectomy, we routinely obtain vascular control, and test the integrity of the collecting system with dilute methylene blue injected via a retrograde catheter. Any disruption of the collecting system is closed with intracorpo-real figure-of-eight suturing. Tisseel is dripped over the areas of the collecting system and Floseal is applied on the moist surface of the cut renal parenchyma. Gelfoam bolsters are placed under the slightly tightened capsular sutures. Lastly, the remainder of the Tisseel is applied over the entire repair prior to removing the vascular clamp. No postoperative hemorrhage or urinary leak occurred in our experience.

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