Abstract
Introduction:
During retroperitoneal robot-assisted partial nephrectomy (RAPN), achieving hemostasis, while maintaining optimum renal function continues to be a key challenge. 1 The renorrhaphy in retroperitoneal RAPN often results in prolongation of the warm ischemia time (WIT) and pseudoaneurysm formation later. 2 A Sutureless approach can minimize the WIT and tissue damage due to ligation of segmental arteries and strangulation of the parenchyma during renorrhaphy. Therefore, various methods like segmental and selective arterial clamping, unclamped RAPN, and different hemostatic patches on the tumor bed are being explored. We routinely perform clamp-free RAPN, specially in the patients with a solitary functioning kidney and post-unilateral nephrectomy. We try not to perform the inner renorrhaphy unless necessary, and we have started using hemostatic patches to bring down the rate of pseudoaneurysm formation later.
Veriset™ is a hemostatic patch of oxidized cellulose infused with buffer salts, trilysine, and polyethylene glycol developed by Covidien Inc. (Mansfield, MA, USA). It’s being used successfully in cardiovascular and hepatobiliary surgeries to achieve hemostasis. 3 Erne et al. found that Veriset™ resulted in decreased operating time and WIT and achieved a satisfactory “Trifecta outcome” without increasing the complications in laparoscopic partial nephrectomy while compared with the conventional suture technique. 4 In our study, we found a similar outcome along with less blood loss and hemoglobin drop while applying Veriset in transperitoneal RAPN. 5
In this video, we explored the safety and feasibility of the sutureless approach in retroperitoneal RAPN to achieve hemostasis using Veriset™ hemostatic patch without any renorrhaphy.
Materials and Methods:
Our first patient, a 35-year-old male, had an incidentally detected right renal mass. The CT showed a well-defined enhancing partially exophytic solid-cystic lesion in the interpolar region of right kidney, 3 × 2.7 × 2.4 cm (R.E.N.A.L. score 4p). Our second patient, a 67-year-old male, had an incidentally detected left renal mass. The CT showed a well-defined heterogeneously enhancing endophytic mass in the upper pole of the left kidney 2.5 × 2.8 × 2 cm (R.E.N.A.L. score 8p). Both patients underwent retroperitoneal RAPN.
Intraoperatively, after hilar dissection, peri-tumor fat removal, and tumor resection after ultrasound localization, and arterial clamping a single 4 × 2 cm Veriset™ patch was applied over the tumor bed in the first case. Two such patches were used in the second patient after tumor enucleo-resection. The patches were kept for a few minutes with a moist gauze compression. Hemostasis was achieved after removal of compression. The console time and WIT were 40 minutes and 11 minutes, respectively, in the first case, and 68 minutes, and 13 minutes in the second case.
We presented the perioperative and outcome data of the 20 patients who underwent retroperitoneal RAPN with Veriset™.
Results:
Both patients had uneventful postoperative recoveries and were discharged on the third postoperative day. The histopathology showed clear cell renal cell carcinoma with a negative surgical margin. On follow-up, they are doing well without any disease.
Conclusion:
Sutureless retroperitoneal RAPN with a hemostatic patch like Veriset™ can reduce the WIT, the total operating time, and pseudoaneurysm formation. However, it’s application should be individualized based on anatomy, tumor location, and intraoperative findings.
Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.
No conflict of interest is involved.
Runtime of video: 8 mins.