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A simple and reliable hemostatic technique during partial nephrectomy
SURGICAL TECHNIQUES IN UROLOGY
A SIMPLE AND RELIABLE HEMOSTATIC TECHNIQUE DURING PARTIAL NEPHRECTOMY ALEXANDER TSIVIAN
AND
A. AMI SIDI
ABSTRACT Introduction. To report our experience with a refined technique for hemostasis that obviates the need for vascular control and closure of the collecting system in partial nephrectomy. Technical Considerations. Four to five sutures, 2 cm apart, are placed 0.5 cm from the anticipated parenchymal incision border, using a specially designed, blunt-tip, straight needle with folded 2-0 Vicryl thread. The needle is removed, leaving the Vicryl thread with the loop on one side of the kidney and two free ends on the other side. A 1.0-cm-wide Vicryl mesh strip is passed circumferentially through the loops and between the free ends on each side, tension is applied on the strip during knotting of the free ends of the thread, and the tissue is incised. No additional hemostatic sutures are necessary. No attempt is made to identify and close the open collecting system. Vascular clamping and surface cooling are avoided. Sixty-one patients have undergone this technique since 1987: initially, for complicated nephrolithiasis (n ⫽ 15), localized purulent kidney disease (n ⫽ 4), trauma (n ⫽ 3), congenital anomalies (n ⫽ 2), and resection of horseshoe kidney (n ⫽ 6) and, recently, for peripherally located renal tumor (n ⫽ 31). Upper pole resection was performed in 11 patients, lower pole resection in 45, and middle segment resection in 5. The blood loss was minimal, with only 1 patient developing gross hematuria that resolved after conservative treatment. No other complications occurred. Conclusions. A simple and easily performed hemostatic method suitable for peripherally located and, particularly, polar renal tumors is described. The Vicryl mesh strip prevents tears of the parenchymal sutures and ensures good hemostasis without closing the collecting system separately. UROLOGY 63: 976–978, 2004. © 2004 Elsevier Inc.
N
ephron-preserving surgery in renal cell carcinoma has vastly expanded the indications for partial nephrectomy.1 Partial nephrectomy may, however, be technically challenging because of difficulties in achieving hemostasis and a watertight closure of the collecting system, and the possibility of ischemic damage to the kidney.2 We describe a simple and reliable technique for attaining hemostasis during partial nephrectomy.
Presented at the Annual Meeting of the American Urological Association, Chicago, Illinois, April 26 to May 1, 2003. From the Department of Urologic Surgery, Edith Wolfson Medical Center, Holon; and Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel Reprint requests: Alexander Tsivian, M.D., Department of Urologic Surgery, E. Wolfson Medical Center, P.O. Box 5, Holon 58100, Israel Submitted: August 13, 2003, accepted (with revisions): January 16, 2004
976
© 2004 ELSEVIER INC. ALL RIGHTS RESERVED
SURGICAL TECHNIQUE After opening the retroperitoneal space, we ensure complete mobilization of the kidney and adequate exposure of the renal hilum. The perinephric fat overlying the tumor area remains intact. Four to five sutures, 2 cm apart, are placed 0.5 cm from the anticipated parenchymal incision border, using a specially designed, blunt-tip, straight needle with folded 2-0 Vicryl thread (Fig. 1A). The needle is removed, leaving the Vicryl thread with a loop on one side of the kidney and two free ends on the other side. A 1.0-cm-wide Vicryl mesh strip is passed circumferentially through the thread loops (Fig. 1B) and between the free ends on each side (Fig. 1C), moderate tension is applied on the strip during knotting of the free ends of thread, and the tissue is incised (Fig. 1D). No additional hemostatic sutures are necessary, and no attempt is made to identify and close an open collecting system. Vascular clamping and surface cooling are avoided. At end of surgery, a vacuum drain is 0090-4295/04/$30.00 doi:10.1016/j.urology.2004.01.028
FIGURE 1. (A) Blunt-tip straight needles with folded 2-0 Vicryl thread. (B) A 1.0-cm-wide Vicryl mesh strip passed circumferentially through loops of thread from one side of kidney. (C) A 1.0-cm-wide Vicryl mesh strip passed between free ends on another side of kidney. (D) Pole of kidney incised.
placed. The drain is removed on the second or third postoperative day (output is less than 30 mL). We have applied our modification of the partial nephrectomy procedure since 1987.3 Temporary clamping of the hilar vessels was performed only in the initial 6 cases. In the remaining 55 patients, the surgery was performed without vascular clamping. RESULTS The new hemostatic technique was used in 61 patients, initially for complicated nephrolithiasis (n ⫽ 15), localized purulent kidney disease (n ⫽ 4), trauma (n ⫽ 3), congenital anomalies (n ⫽ 2), and resection of horseshoe kidney (n ⫽ 6) and, recently, for peripherally located renal tumors (n ⫽ 31). All tumors in our series were Stage T1 and were 3 to 5 cm in size. Resection of the upper pole was performed in 11 patients, of the lower pole in 45, and of the middle segment in 5. Neither additional hemostatic sutures nor tamponade of the resected surface was necessary. The maximal blood loss was 200 mL. Only 1 case of gross hematuria (1.6%) occurred. It was detected on the ninth postoperative day and resolved after conservative treatment. UROLOGY 63 (5), 2004
COMMENT The need for partial nephrectomy has soared because of changing indications and increased detection of incidental small renal tumors.1 Hemostasis of the resected surface is one of the most important problems that can arise during partial nephrectomy. Intraoperative and delayed bleeding and secondary nephrectomy have been reported as complications of this procedure.2,4 The different hemostatic modalities used during partial nephrectomy have included coronal sutures,5 fibrin glue,6 microwave tissue coagulation,7 several kinds of lasers,8,9 harmonic scalpels,10 various kinds of electric currents,11 several types of devices (eg, kidney tourniquet),12 dissecting clamp,13 and a linear stapling device.14 Desai et al.15 used Satinsky clamping of the entire renal pedicle. After tissue excision, the pelvicaliceal entry was sutured using continuous 2-0 Vicryl suture, renal parenchymal suture repair was performed using 0 Vicryl suture, and surgical bolsters were applied to complete a hemostatic renorrhaphy.15 Itoh et al.16 excised tissue with tumor after microwave tissue coagulation. The cut surface was cauterized with the argon beam coagulator and sealed with fibrin glue. In the series of 977
Polascik et al.,17 an argon beam coagulator was frequently applied to the surface of the operative site to achieve hemostasis. A microfibrillar collagen hemostat was then placed on the cut surface, the remaining renal parenchyma was approximated by chromic catgut and, after vascular clamp removal, manual compression of kidney was performed for 5 minutes.17 No totally reliable hemostatic technique is yet available, however, and nephron-sparing surgery continues to be technically more demanding than nephrectomy. Urinary fistula is the most common renal-related complication after nephron-sparing surgery, with a reported mean incidence of 6.5% (range 1.4% to 17.4%).4 Novick18 suggested that watertight closure of the collecting system with fine absorbable suture is essential to prevent urinary fistula formation. In the series of Polascik et al.,17 6 cases of urinary fistula occurred in 67 partial nephrectomies. To prevent fistula formation, they recommended injection of the collecting system with dilute methylene blue and repairing any defects in the collecting system intraoperatively with absorbable suture.17 Our modification simplifies the procedure and saves operating time. Some urologists initially used intraoperative ultrasonography to confirm the locations of the lesion’s border,15,17 but we, like Zucchi et al.,19 did not routinely perform ultrasonography intraoperatively. Because 1 patient in our series had positive surgical margins, we now plan to use this modality and to pass the needles under ultrasound guidance, although intraoperative ultrasonography cannot guarantee negative margins.15 We propose a simple and reliable method of hemostasis in which hilar clamping is obviated and, consequently, no ischemic renal damage occurs. Moreover, it is not necessary to close the collecting system separately or to close or cover a renal defect with adjacent fat, peritoneum, or oxidase cellulose. We do not use renal surface cooling with ice slush, and anti-ischemic prophylactic treatment is not needed. The procedure is inexpensive, saves operating time, and can be easily practiced by all urologists. A possible disadvantage of the procedure is an increased ischemic parenchymal area of approximately 0.5 cm in width, distal to the suture tying line. CONCLUSIONS The proposed hemostatic technique is suitable for peripherally located and, particularly, polar renal tumors and is different from previously used
978
conventional techniques. It is simple and quick to perform. The sutures do not cut through the parenchyma and ensure good hemostasis. This approach prevents serious complications, such as bleeding and urinary fistula formation. ACKNOWLEDGMENT. To Esther Eshkol for her editorial assistance. REFERENCES 1. Smith SJ, Bosniak MA, Megibow AJ, et al: Renal cell carcinoma: earlier discovery and increased detection. Radiology 170: 699 –703, 1989. 2. Campbell SC, Novick AC, Streem SB, et al: Complications of nephron sparing surgery for renal tumors. J Urol 151: 1177–1180, 1994. 3. Tsivian AL: A hemostatic method in kidney resection (in Russian). Vestn Khir Im I I Grek 148: 92–93, 1992. 4. Uzzo RG, and Novick AC: Nephron sparing surgery for renal tumors: indications, techniques and outcomes. J Urol 166: 6 –18, 2001. 5. Haddad FS, and Flint PA: Coronal hemostatic suture for partial nephrectomy. Br J Urol 68: 327, 1991. 6. Levinson AK, Swanson DA, Jonson DE, et al: Fibrin glue for partial nephrectomy. Urology 38: 314 –316, 1991. 7. Muraki J, Cord J, Addonizio JC, et al: Application of microwave tissue coagulation in partial nephrectomy. Urology 37: 282–287, 1991. 8. Taari K, Salo JO, Pitkaranta P, et al: Efficacy and complications of the Nd: YAG laser in partial nephrectomy: experimental study in piglets. Scand J Urol Nephrol 25: 303–306, 1991. 9. Lotan Y, Gettman MT, Ogan K, et al: Clinical use of the holmium: YAG laser in laparoscopic partial nephrectomy. J Endourol 16: 289 –292, 2002. 10. Jackman SV, Cadeddu JA, Chen RN, et al: Utility of the harmonic scalpel for laparoscopic partial nephrectomy. J Endourol 12: 441–444, 1998. 11. Barret E, Guillonneau B, Cathelineau X, et al: Laparoscopic partial nephrectomy in the pig: comparison of three hemostasis techniques. J Endourol 15: 307–312, 2001. 12. Goldwasser BZ, Carson CC III, Shalaby NF, et al: Kidney tourniquet: a new instrument for regional blood control in partial nephrectomy. Urology 30: 162–163, 1987. 13. Goldwasser B, Carson CC III, Shalaby NF, et al: Partial nephrectomy using a new dissecting instrument. J Urol 136: 54 –57, 1986. 14. Baniel J, and Schein M: Partial nephrectomy using a linear stapling device. Br J Urol 69: 218, 1992. 15. Desai MM, Gill IS, Kaouk JH, et al: Laparoscopic partial nephrectomy with suture repair of the pelvicaliceal system. Urology 61: 99 –104, 2003. 16. Itoh K, Suzuki Y, Miuru M, et al: Posterior retroperitoneoscopic partial nephrectomy using microwave tissue coagulator for small renal tumors. J Endourol 16: 367–371, 2002. 17. Polascik TJ, Pound CR, Meng MV, et al: Partial nephrectomy: technique, complications and pathological findings. J Urol 154: 1312–1318, 1995. 18. Novick AC: Partial nephrectomy for renal cell carcinoma. Urol Clin North Am 14: 419 –433, 1987. 19. Zucchi A, Mearini L, Mearini E, et al: Renal cell carcinoma: histological findings on surgical margins after nephron sparing surgery. J Urol 169: 905–908, 2003.
UROLOGY 63 (5), 2004
A SIMPLE AND RELIABLE HEMOSTATIC TECHNIQUE DURING PARTIAL NEPHRECTOMY ALEXANDER TSIVIAN
AND
A. AMI SIDI
ABSTRACT Introduction. To report our experience with a refined technique for hemostasis that obviates the need for vascular control and closure of the collecting system in partial nephrectomy. Technical Considerations. Four to five sutures, 2 cm apart, are placed 0.5 cm from the anticipated parenchymal incision border, using a specially designed, blunt-tip, straight needle with folded 2-0 Vicryl thread. The needle is removed, leaving the Vicryl thread with the loop on one side of the kidney and two free ends on the other side. A 1.0-cm-wide Vicryl mesh strip is passed circumferentially through the loops and between the free ends on each side, tension is applied on the strip during knotting of the free ends of the thread, and the tissue is incised. No additional hemostatic sutures are necessary. No attempt is made to identify and close the open collecting system. Vascular clamping and surface cooling are avoided. Sixty-one patients have undergone this technique since 1987: initially, for complicated nephrolithiasis (n ⫽ 15), localized purulent kidney disease (n ⫽ 4), trauma (n ⫽ 3), congenital anomalies (n ⫽ 2), and resection of horseshoe kidney (n ⫽ 6) and, recently, for peripherally located renal tumor (n ⫽ 31). Upper pole resection was performed in 11 patients, lower pole resection in 45, and middle segment resection in 5. The blood loss was minimal, with only 1 patient developing gross hematuria that resolved after conservative treatment. No other complications occurred. Conclusions. A simple and easily performed hemostatic method suitable for peripherally located and, particularly, polar renal tumors is described. The Vicryl mesh strip prevents tears of the parenchymal sutures and ensures good hemostasis without closing the collecting system separately. UROLOGY 63: 976–978, 2004. © 2004 Elsevier Inc.
N
ephron-preserving surgery in renal cell carcinoma has vastly expanded the indications for partial nephrectomy.1 Partial nephrectomy may, however, be technically challenging because of difficulties in achieving hemostasis and a watertight closure of the collecting system, and the possibility of ischemic damage to the kidney.2 We describe a simple and reliable technique for attaining hemostasis during partial nephrectomy.
Presented at the Annual Meeting of the American Urological Association, Chicago, Illinois, April 26 to May 1, 2003. From the Department of Urologic Surgery, Edith Wolfson Medical Center, Holon; and Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel Reprint requests: Alexander Tsivian, M.D., Department of Urologic Surgery, E. Wolfson Medical Center, P.O. Box 5, Holon 58100, Israel Submitted: August 13, 2003, accepted (with revisions): January 16, 2004
976
© 2004 ELSEVIER INC. ALL RIGHTS RESERVED
SURGICAL TECHNIQUE After opening the retroperitoneal space, we ensure complete mobilization of the kidney and adequate exposure of the renal hilum. The perinephric fat overlying the tumor area remains intact. Four to five sutures, 2 cm apart, are placed 0.5 cm from the anticipated parenchymal incision border, using a specially designed, blunt-tip, straight needle with folded 2-0 Vicryl thread (Fig. 1A). The needle is removed, leaving the Vicryl thread with a loop on one side of the kidney and two free ends on the other side. A 1.0-cm-wide Vicryl mesh strip is passed circumferentially through the thread loops (Fig. 1B) and between the free ends on each side (Fig. 1C), moderate tension is applied on the strip during knotting of the free ends of thread, and the tissue is incised (Fig. 1D). No additional hemostatic sutures are necessary, and no attempt is made to identify and close an open collecting system. Vascular clamping and surface cooling are avoided. At end of surgery, a vacuum drain is 0090-4295/04/$30.00 doi:10.1016/j.urology.2004.01.028
FIGURE 1. (A) Blunt-tip straight needles with folded 2-0 Vicryl thread. (B) A 1.0-cm-wide Vicryl mesh strip passed circumferentially through loops of thread from one side of kidney. (C) A 1.0-cm-wide Vicryl mesh strip passed between free ends on another side of kidney. (D) Pole of kidney incised.
placed. The drain is removed on the second or third postoperative day (output is less than 30 mL). We have applied our modification of the partial nephrectomy procedure since 1987.3 Temporary clamping of the hilar vessels was performed only in the initial 6 cases. In the remaining 55 patients, the surgery was performed without vascular clamping. RESULTS The new hemostatic technique was used in 61 patients, initially for complicated nephrolithiasis (n ⫽ 15), localized purulent kidney disease (n ⫽ 4), trauma (n ⫽ 3), congenital anomalies (n ⫽ 2), and resection of horseshoe kidney (n ⫽ 6) and, recently, for peripherally located renal tumors (n ⫽ 31). All tumors in our series were Stage T1 and were 3 to 5 cm in size. Resection of the upper pole was performed in 11 patients, of the lower pole in 45, and of the middle segment in 5. Neither additional hemostatic sutures nor tamponade of the resected surface was necessary. The maximal blood loss was 200 mL. Only 1 case of gross hematuria (1.6%) occurred. It was detected on the ninth postoperative day and resolved after conservative treatment. UROLOGY 63 (5), 2004
COMMENT The need for partial nephrectomy has soared because of changing indications and increased detection of incidental small renal tumors.1 Hemostasis of the resected surface is one of the most important problems that can arise during partial nephrectomy. Intraoperative and delayed bleeding and secondary nephrectomy have been reported as complications of this procedure.2,4 The different hemostatic modalities used during partial nephrectomy have included coronal sutures,5 fibrin glue,6 microwave tissue coagulation,7 several kinds of lasers,8,9 harmonic scalpels,10 various kinds of electric currents,11 several types of devices (eg, kidney tourniquet),12 dissecting clamp,13 and a linear stapling device.14 Desai et al.15 used Satinsky clamping of the entire renal pedicle. After tissue excision, the pelvicaliceal entry was sutured using continuous 2-0 Vicryl suture, renal parenchymal suture repair was performed using 0 Vicryl suture, and surgical bolsters were applied to complete a hemostatic renorrhaphy.15 Itoh et al.16 excised tissue with tumor after microwave tissue coagulation. The cut surface was cauterized with the argon beam coagulator and sealed with fibrin glue. In the series of 977
Polascik et al.,17 an argon beam coagulator was frequently applied to the surface of the operative site to achieve hemostasis. A microfibrillar collagen hemostat was then placed on the cut surface, the remaining renal parenchyma was approximated by chromic catgut and, after vascular clamp removal, manual compression of kidney was performed for 5 minutes.17 No totally reliable hemostatic technique is yet available, however, and nephron-sparing surgery continues to be technically more demanding than nephrectomy. Urinary fistula is the most common renal-related complication after nephron-sparing surgery, with a reported mean incidence of 6.5% (range 1.4% to 17.4%).4 Novick18 suggested that watertight closure of the collecting system with fine absorbable suture is essential to prevent urinary fistula formation. In the series of Polascik et al.,17 6 cases of urinary fistula occurred in 67 partial nephrectomies. To prevent fistula formation, they recommended injection of the collecting system with dilute methylene blue and repairing any defects in the collecting system intraoperatively with absorbable suture.17 Our modification simplifies the procedure and saves operating time. Some urologists initially used intraoperative ultrasonography to confirm the locations of the lesion’s border,15,17 but we, like Zucchi et al.,19 did not routinely perform ultrasonography intraoperatively. Because 1 patient in our series had positive surgical margins, we now plan to use this modality and to pass the needles under ultrasound guidance, although intraoperative ultrasonography cannot guarantee negative margins.15 We propose a simple and reliable method of hemostasis in which hilar clamping is obviated and, consequently, no ischemic renal damage occurs. Moreover, it is not necessary to close the collecting system separately or to close or cover a renal defect with adjacent fat, peritoneum, or oxidase cellulose. We do not use renal surface cooling with ice slush, and anti-ischemic prophylactic treatment is not needed. The procedure is inexpensive, saves operating time, and can be easily practiced by all urologists. A possible disadvantage of the procedure is an increased ischemic parenchymal area of approximately 0.5 cm in width, distal to the suture tying line. CONCLUSIONS The proposed hemostatic technique is suitable for peripherally located and, particularly, polar renal tumors and is different from previously used
978
conventional techniques. It is simple and quick to perform. The sutures do not cut through the parenchyma and ensure good hemostasis. This approach prevents serious complications, such as bleeding and urinary fistula formation. ACKNOWLEDGMENT. To Esther Eshkol for her editorial assistance. REFERENCES 1. Smith SJ, Bosniak MA, Megibow AJ, et al: Renal cell carcinoma: earlier discovery and increased detection. Radiology 170: 699 –703, 1989. 2. Campbell SC, Novick AC, Streem SB, et al: Complications of nephron sparing surgery for renal tumors. J Urol 151: 1177–1180, 1994. 3. Tsivian AL: A hemostatic method in kidney resection (in Russian). Vestn Khir Im I I Grek 148: 92–93, 1992. 4. Uzzo RG, and Novick AC: Nephron sparing surgery for renal tumors: indications, techniques and outcomes. J Urol 166: 6 –18, 2001. 5. Haddad FS, and Flint PA: Coronal hemostatic suture for partial nephrectomy. Br J Urol 68: 327, 1991. 6. Levinson AK, Swanson DA, Jonson DE, et al: Fibrin glue for partial nephrectomy. Urology 38: 314 –316, 1991. 7. Muraki J, Cord J, Addonizio JC, et al: Application of microwave tissue coagulation in partial nephrectomy. Urology 37: 282–287, 1991. 8. Taari K, Salo JO, Pitkaranta P, et al: Efficacy and complications of the Nd: YAG laser in partial nephrectomy: experimental study in piglets. Scand J Urol Nephrol 25: 303–306, 1991. 9. Lotan Y, Gettman MT, Ogan K, et al: Clinical use of the holmium: YAG laser in laparoscopic partial nephrectomy. J Endourol 16: 289 –292, 2002. 10. Jackman SV, Cadeddu JA, Chen RN, et al: Utility of the harmonic scalpel for laparoscopic partial nephrectomy. J Endourol 12: 441–444, 1998. 11. Barret E, Guillonneau B, Cathelineau X, et al: Laparoscopic partial nephrectomy in the pig: comparison of three hemostasis techniques. J Endourol 15: 307–312, 2001. 12. Goldwasser BZ, Carson CC III, Shalaby NF, et al: Kidney tourniquet: a new instrument for regional blood control in partial nephrectomy. Urology 30: 162–163, 1987. 13. Goldwasser B, Carson CC III, Shalaby NF, et al: Partial nephrectomy using a new dissecting instrument. J Urol 136: 54 –57, 1986. 14. Baniel J, and Schein M: Partial nephrectomy using a linear stapling device. Br J Urol 69: 218, 1992. 15. Desai MM, Gill IS, Kaouk JH, et al: Laparoscopic partial nephrectomy with suture repair of the pelvicaliceal system. Urology 61: 99 –104, 2003. 16. Itoh K, Suzuki Y, Miuru M, et al: Posterior retroperitoneoscopic partial nephrectomy using microwave tissue coagulator for small renal tumors. J Endourol 16: 367–371, 2002. 17. Polascik TJ, Pound CR, Meng MV, et al: Partial nephrectomy: technique, complications and pathological findings. J Urol 154: 1312–1318, 1995. 18. Novick AC: Partial nephrectomy for renal cell carcinoma. Urol Clin North Am 14: 419 –433, 1987. 19. Zucchi A, Mearini L, Mearini E, et al: Renal cell carcinoma: histological findings on surgical margins after nephron sparing surgery. J Urol 169: 905–908, 2003.
UROLOGY 63 (5), 2004