Role of hemostatic matrix in course of partial nefrectomy. We still need sutures?

Gian Maria Badano1, Emanuele Daglio1, Antonia Di Domenico1, Elvis Rikani1, Luca Timossi1, Corrado Pezzica1, Carlo Introini1
  • 1 Ospedale Evangelico Internazionale (Genova)

Objective

To evaluate the safety and efficacy due to use of only hemostatic matrix in course of laparoscopic partial nephrectomy.

Materials and Methods

From July 2013 to December 2014 36 patient underwent partial nephrectomy for small renal masses were recruited into the study. Exclusion criteria were lesion major than 4 cm, completely endophytic lesion or lesion that infiltrate the urinary tract. Median age of 58,5 years (37-71yr). 19 patient were male and 17 woman. The median size of the tumor were 2,8cm (1,9-3,5cm).Left kidney were interested in 24 patients while in 12 patients the right one were interested. The tumor were localized at the lower pole in 25 patients, 7 in the middle part and 4 in the upper pole,all the lesion were exophytic . All the patients undergone laparoscopic partial nephrectomy with the palcement of two 10mm trocars and three 5mm trocars . All the procedures were perferomed with anatomic zero ischemia and no preparation of renal vessels. The tumors were isolated and removed using monopolar scissor and advaced bipolar forceps.Surgiflo were put immediatly after the tumor excision on the resection bed.At the end of the procedures we perform a reconstruction of the posterior parietal peritoneum. Surgiflo is a topical thrombin indicated as an aid to hemostasis whenever oozing blood and minor bleeding from capillaries and small venules is accessible and control of bleeding by standard surgical techniques (such as suture, ligature or cautery) is ineffective or impractical.

Results

No patients required an intraoperatory open conversion. Intraoperatory blood loss were less then 100cc in 22 patients (61,1%) 100cc -200cc in 10 patients (31,2%) more than 200 cc in 4 cases (12,5%). All the surgical procedure were performed by the same surgeon. The median operative time were 79 minutes (67-107min).3 patients required blood trasfusion No major complication occurred. The median recovery was 3,2 days (2-5). 28 of the tumor were renal cell carcinoma (RCC) Grade 2 , 4 RCC Grade 3, 1 angiomyolipoma, 3 patients present a Bosniak type 3 lesion with cellular atypia.Surgical resection margins were negative in 34 patient in 2 patients surgical margins were focal involved by the tumor. After at least 12 month no patient present local recurrence or progression of the disease.

Discussions

Partial nefrectomy rappresent the gold standard therapy for kidney tumor with size lower than 4 cm . The use of suture the ensecure hemostasis on bed resection is the most frequent tecnique used . Hemostasis control and collecting system suturing are the most difficult parts during a laparoscopic procedure. For best outcomes with nephron sparing surgery, several tissue sealants were developed to be associated with, or even replace sutures of the renal parenchyma . In this study we demostred that the use of Surgiflo were safety and efficacy in all the patients undergone partial nefrectomy both intraoperatively that postoperatively . No surgical procedure required emostatic suture to stop resection bed bleeding.

Conclusion

Laparoscopic partial nephrectomy is an effective surgical alternative in NSS in which the ultimate goal is to achieve the “trifecta” of a negative cancer margin, minimal decrease in renal function and an absence of complication. The biological glue is an important tool in laparoscopic partial nephrectomies. This data shows that during laparoscopic partial neprectomy for small lesions in selected cases the use of Surgiflo is sufficient to ensure a good hemostasis and the non-use of sutures on the renal parenchyma could ensure less damage to the parenchyma with a consequent improvement on renal function. Human clinical trials with larger numbers are needed to confirm our results in patients with small renal tumors that could lead us to better outcomes, by decreasing bleeding, when performing minimally invasive partial nephrectomy.

References

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