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

  • Douglas C. Cheung Division of Urology, Department of Surgery, University of Toronto, ON, Canada
  • Christopher J.D. Wallis Department of Urology, Vanderbilt University Medical Center, Nashville, TN, USA
  • Simon Possee Division of Medicine, The Rotherham Foundation Trust, South Yorkshire, UK
  • Camilla Tajzler Division of Urology, McMaster Institute of Urology, Hamilton, ON, Canada
  • Maurice Anidjar Division of Urology, McGill University, Montreal, QC, Canada
  • Keith Barrett Kitchener Urology Partners, Kitchener, ON, Canada
  • Tom Deklaj Department of Surgery (Urology), Western University (Windsor Regional Hospital), ON, Canada
  • Darrel E. Drachenberg Section of Urology, University of Manitoba, Winnipeg, MB Canada
  • Howard Evans Division of Urology, Department of Surgery, University of Alberta, AB, Canada
  • Christopher French Discipline of Surgery (Urology), Memorial University, NL, Canada
  • Geoffrey Gotto Division of Urology, Department of Surgery, University of Calgary, AB, Canada
  • Jason Izard Department of Urology, Queen’s University, Kingston, ON, Canada
  • Umesh Jain Division of Urology, Department of Surgery, University of Toronto, ON, Canada
  • Jun Kawakami Division of Urology, Department of Surgery, University of Calgary, AB, Canada
  • Girish S. Kulkarni Division of Urology, Department of Surgery, University of Toronto, ON, Canada
  • Jason Lee Division of Urology, Department of Surgery, University of Toronto, ON, Canada
  • Jeffrey McCracken Victoria Urology, Victoria, BC, Canada
  • Thomas McGregor Department of Urology, Queen’s University, Kingston, ON, Canada
  • Patrick O. Richard Division of Urology, Department of Surgery, Centre Hospitalier Universitaire de Sherbrooke and Centre de Recherche du CHUS, Université de Sherbrooke, QC, Canada
  • Neal E. Rowe Division of Urology, Department of Surgery, University of Ottawa, ON, Canada
  • Robert Sabbagh Division of Urology, Department of Surgery, Centre Hospitalier Universitaire de Sherbrooke and Centre de Recherche du CHUS, Université de Sherbrooke, QC, Canada
  • Blair St. Martin Division of Urology, Department of Surgery, University of Alberta, AB, Canada
  • Stephanie Tatzel Division of Urology, Department of Surgery, McMaster University (Niagara Health), ON, Canada
  • Naji Touma Department of Urology, Queen’s University, Kingston, ON, Canada
  • Hugues Widmer Section of Urology, Department of Surgery, University of Montreal Hospital Center (CHUM), QC, Canada
  • Joshua Wiesenthal Kelowna General Hospital, Kelowna, BC, Canada
  • Brian Yang Department of Urological Sciences, University of British Columbia, BC, Canada
  • Kevin C. Zorn Section of Urology, Department of Surgery, University of Montreal Hospital Center (CHUM), QC, Canada
  • Anil Kapoor Division of Urology, McMaster Institute of Urology, Hamilton, ON, Canada
  • Antonio Finelli Division of Urology, Department of Surgery, University of Toronto, ON, Canada
  • Raj Satkunasivam Center for Outcomes Research, Houston Methodist Hospital, Houston, TX, USA Medical Center, Houston, Texas
Keywords: Minimally invasive partial nephrectomy, partial nephrectomy, laparoscopic, robotic, hemostasis, surgical technique

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 fellowshipand 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.

Published
2020-06-09
How to Cite
Cheung, D. C., Wallis, C. J., Possee, S., Tajzler, C., Anidjar, M., Barrett, K., Deklaj, T., Drachenberg, D. E., Evans, H., French, C., Gotto, G., Izard, J., Jain, U., Kawakami, J., Kulkarni, G. S., Lee, J., McCracken, J., McGregor, T., Richard, P. O., Rowe, N. E., Sabbagh, R., St. Martin, B., Tatzel, S., Touma, N., Widmer, H., Wiesenthal, J., Yang, B., Zorn, K. C., Kapoor, A., Finelli, A., & Satkunasivam, R. (2020). Canadian Update on Surgical Procedures (CUSP) Urology Group consensus for intraoperative hemostasis during minimally invasive partial nephrectomy. Canadian Urological Association Journal, 14(9), E387-93. https://doi.org/10.5489/cuaj.6579
Section
Special Feature