Sutureless Technique in Robot-Assisted Partial Nephrectomy

Abstract

Introduction and Objectives: Bleeding is one of the most unfavorable postoperative complications of partial nephrectomy. It is generally accepted that renorrhaphy is necessary for hemostasis because conventional coagulation is uncertain for hemostasis of renal tumor bed. In soft coagulation mode, the output voltage is regulated <190 V and generates Joule heat without producing sparks that cause tissue carbonization. Carbonized tissue sometimes drops off and it leads to bleeding; however, protein degeneration caused by Joule heat is durable. We introduce our minimally invasive sutureless technique using soft coagulation in robot-assisted partial nephrectomy (RAPN). Materials and Methods: We performed RAPN for 76 consecutive patients with cT1 renal tumor from December 2014 to March 2019. We utilize VIO 300D (ERBE, Germany) for hemostasis of renal tumor bed. The device was set in a “soft coagulation” mode with a power setting of effect 7 and 80 W. In each case, the renal artery was clamped without cooling. During tumor excision, the assistant used a suction/irrigator and a monopolar electrocautery coagulating renal tissue concurrently with the resection of tumor. The renal artery was unclamped after the bleeding was controlled using soft coagulation (early unclamping). After unclamping, additional coagulation was done until complete hemostasis was gained. We did not suture the renal parenchyma when sufficient hemostasis was achieved. The renal artery was reclamped if there was an arterial bleeding and additional coagulation was done. Results: Twenty-four out of 76 cases underwent RAPN by complete sutureless technique that was carried out with neither suture nor renorrhaphy. There was no case with >10 points of R.E.N.A.L nephrometry score, 6 cases were with scores between 7 and 9 points, and 18 cases were with score <6 points. The median age was 65 (39–85) years and the median body mass index was 24.6 kg/m2 (19.3–31.8). The median console time was 106 minutes (71–169) and the median estimated blood loss was 21 mL (0–250 mL). The median tumor size was 2.3 cm (1.1–4.0 cm) and the median warm ischemic time was 9.0 minutes (6.0–29.1 minutes). All cases had negative surgical margins. The median rate of change in estimated glomerular filtration rate was −3.9% (−22.7% to 24.4%) 1 month postoperatively. Clavien–Dindo Grade IIIa urinoma occurred in two patients and postoperative bleeding was not observed in all cases. In the first case of urinoma, no obvious opening of collecting system was observed during the surgery for deep endophytic 31 mm tumor. To assure whether there is leakage, retrograde pyelography was performed after wound closure. Minor leakage from renal calix was found and ureteral stent was positioned. Urinoma of the second patient was found with the stricture of ureteropelvic junction in 6 months after partial nephrectomy. The effect of soft coagulation might have been conducted because there was only a couple of millimeters between the ureteropelvic junction and the tumor bed. Ureteral stent was also positioned for the patient. Conclusion: Soft coagulation is an effective technology for tissue hemostasis. Sutureless hemostasis together with early unclamping is a safe and feasible minimally invasive technique for RAPN. No competing financial interests exist. Runtime of video: 4 mins 5 secs