Canadian Update on Surgical Procedures (CUSP) Urology Group consensus for intraoperative hemostasis during minimally invasive partial nephrectomy

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.

Experimental substantiation of kidney sutures

“…однако нужно отметить мануальные сложности в позиционировании этого материала при наложении шва на почку и риски нарушения целостности структуры плетения сетки при моделировании её к соответствующей клинической ситуации. Видимо поэтому в ряде сообщений предлагается изготовление специальных имплантов для ушивания почечной раны [17,19]. Мы полагаем, что наиболее удобным в мануальном позиционировании и моделировании, а также приоритетным со стороны механических характеристик является политетрафторэтилен, используемый для изготовления сосудистых протезов.…”

PEG-coated patch parenchymal closure technique and initial outcomes during minimally invasive partial nephrectomy

“…The Canadian update of surgical procedures (CUSP) urology group recently developed a consensus describing best practices for managing bleeding during renorrhaphy: using a barbed absorbable hemostatic running stich, considering the use of gelatin thrombin agents, placing clips as opposed to knot tying sutures, and early unclamping to identify and ligate bleeding vessels. 4 The use or consideration of PEG-coated patches was not endorsed by the consensus group, likely contributed by the minimal evidence for this technique.…”

“…While there is significant variability in the management of the renal parenchymal defect with respect to hemostasis, the main options include a combination of suture closure and hemostatic agents. 4 Topical hemostatic agents have become commonplace in minimally invasive partial nephrectomy (MIPN) to reduce bleeding associated with the defect. 4,5 There has been increasing interest in the use of a new synthetic hemostatic agent, the polyethylene glycol-coated (PEGcoated) collagen patch (Hemoaptch®, Baxter healthcare Corporation) to control intraoperative bleeding.…”

“…4 Topical hemostatic agents have become commonplace in minimally invasive partial nephrectomy (MIPN) to reduce bleeding associated with the defect. 4,5 There has been increasing interest in the use of a new synthetic hemostatic agent, the polyethylene glycol-coated (PEGcoated) collagen patch (Hemoaptch®, Baxter healthcare Corporation) to control intraoperative bleeding. 6 This solid patch can be precisely placed over the area of bleeding direct from the package without preparation unlike other topical agents.…”