Does the stapler for en bloc resection of renal pedicles during kidney removal surgery increase the risk of arteriovenous fistula?

Abstract

It was previously thought that renal hilum en bloc ligation during kidney removal may increase the risk of renal arteriovenous fistula (AVF) formation. We evaluated the safety and effectiveness of en bloc ligation of the renal pedicle using a stapler during laparoscopic nephrectomy and nephroureterectomy. Ninety patients underwent en bloc renal hilar ligation using 45-mm endo-gastrointestinal anastomosis stapler and 2.5-mm staples during laparoscopic nephrectomy and nephroureterectomy from 2002 to 2015. Perioperative outcomes including estimated blood loss, operative time, and perioperative complications were documented. Twenty-seven patients underwent nephrectomy and 63 patients underwent nephroureterectomy. Thirty patients (33.3%) had perioperative complications. The majority of complications were of Clavien grade II. Six patients had Clavien Dindo grade III and none of the patients had grade IV complications. There were no significant differences in complication rates between right- and left-sided procedures (p = 0.233). Median blood loss was 190.1 ml and mean operative time was 227.1 minutes in nephrectomy and 256.6 minutes in nephroureterectomy. None of the patients had evidence of AVF formation on postoperative computerized tomography scan. Only three patients had a new diagnosis of heart failure. One of them was eventually lost to follow up. The remaining two patients had no evidence of AVF formation in imaging studies and physical examination. En bloc ligation of the renal pedicle during laparoscopic nephrectomy and nephroureterectomy using a stapler is safe. None of our patients developed an AVF during follow up.