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

Douglas C Cheung¹, Christopher J D Wallis^{1

2}, Simon Possee³, Camilla Tajzler⁴, Maurice Anidjar⁵, Keith Barrett⁶, Tom Deklaj⁷, Darrel E Drachenberg⁸, Howard Evans⁹, Christopher French¹⁰, Geoffrey Gotto¹¹, Jason Izard¹², Umesh Jain¹, Jun Kawakami¹¹, Girish S Kulkarni¹, Jason Lee¹, Jeffrey McCracken¹³, Thomas McGregor¹², Patrick O Richard¹⁴, Neal E Rowe¹⁵, Robert Sabbagh¹⁴, Blair St Martin⁹, Stephanie Tatzel¹⁶, Naji Touma¹², Hugues Widmer¹⁷, Joshua Wiesenthal¹⁸, Brian Yang¹⁹, Kevin C Zorn¹⁷, Anil Kapoor⁴, Antonio Finelli¹, Raj Satkunasivam²⁰; Canadian Update on Surgical Procedures (CUSP) Urology Group

Affiliations

¹ Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada.
² Department of Urology, Vanderbilt University Medical Center, Nashville, TN, United States.
³ Division of Medicine, The Rotherham Foundation Trust, South Yorkshire, United Kingdom.
⁴ Division of Urology, McMaster Institute of Urology, Hamilton, ON, Canada.
⁵ Division of Urology, McGill University, Montreal, QC, Canada.
⁶ Kitchener Urology Partners, Kitchener, ON, Canada.
⁷ Department of Surgery (Urology), Western University (Windsor Regional Hospital), London, ON, Canada.
⁸ Section of Urology, University of Manitoba, Winnipeg, MB Canada.
⁹ Division of Urology, Department of Surgery, University of Alberta, AB, Canada.
¹⁰ Discipline of Surgery (Urology), Memorial University, St. John's, NL, Canada.
¹¹ Division of Urology, Department of Surgery, University of Calgary, Calgary, AB, Canada.
¹² Department of Urology, Queen's University, Kingston, ON, Canada.
¹³ Victoria Urology, Victoria, BC, Canada.
¹⁴ Division of Urology, Department of Surgery, Centre Hospitalier Universitaire de Sherbrooke and Centre de Recherche du CHUS, Université de Sherbrooke, Sherbrooke, QC, Canada.
¹⁵ Division of Urology, Department of Surgery, University of Ottawa, Ottawa, ON, Canada.
¹⁶ Division of Urology, Department of Surgery, McMaster University (Niagara Health), Hamilton, ON, Canada.
¹⁷ Section of Urology, Department of Surgery, University of Montreal Hospital Centre (CHUM), Montreal, QC, Canada.
¹⁸ Kelowna General Hospital, Kelowna, BC, Canada.
¹⁹ Department of Urological Sciences, University of British Columbia, Vancouver, BC, Canada.
²⁰ Center for Outcomes Research, Houston Methodist Hospital, Medical Center, Houston, TX, United States.

PMID: 32569571
PMCID: PMC7492033
DOI: 10.5489/cuaj.6579

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

Douglas C Cheung et al. Can Urol Assoc J. 2020 Sep.

. 2020 Sep;14(9):E387-E393.

doi: 10.5489/cuaj.6579.

Authors

Affiliations

¹ Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada.
² Department of Urology, Vanderbilt University Medical Center, Nashville, TN, United States.
³ Division of Medicine, The Rotherham Foundation Trust, South Yorkshire, United Kingdom.
⁴ Division of Urology, McMaster Institute of Urology, Hamilton, ON, Canada.
⁵ Division of Urology, McGill University, Montreal, QC, Canada.
⁶ Kitchener Urology Partners, Kitchener, ON, Canada.
⁷ Department of Surgery (Urology), Western University (Windsor Regional Hospital), London, ON, Canada.
⁸ Section of Urology, University of Manitoba, Winnipeg, MB Canada.
⁹ Division of Urology, Department of Surgery, University of Alberta, AB, Canada.
¹⁰ Discipline of Surgery (Urology), Memorial University, St. John's, NL, Canada.
¹¹ Division of Urology, Department of Surgery, University of Calgary, Calgary, AB, Canada.
¹² Department of Urology, Queen's University, Kingston, ON, Canada.
¹³ Victoria Urology, Victoria, BC, Canada.
¹⁴ Division of Urology, Department of Surgery, Centre Hospitalier Universitaire de Sherbrooke and Centre de Recherche du CHUS, Université de Sherbrooke, Sherbrooke, QC, Canada.
¹⁵ Division of Urology, Department of Surgery, University of Ottawa, Ottawa, ON, Canada.
¹⁶ Division of Urology, Department of Surgery, McMaster University (Niagara Health), Hamilton, ON, Canada.
¹⁷ Section of Urology, Department of Surgery, University of Montreal Hospital Centre (CHUM), Montreal, QC, Canada.
¹⁸ Kelowna General Hospital, Kelowna, BC, Canada.
¹⁹ Department of Urological Sciences, University of British Columbia, Vancouver, BC, Canada.
²⁰ Center for Outcomes Research, Houston Methodist Hospital, Medical Center, Houston, TX, United States.

PMID: 32569571
PMCID: PMC7492033
DOI: 10.5489/cuaj.6579

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.

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Conflict of interest statement

Competing interests: Dr. Deklaj has been a consultant for TerSera. Dr. Gotto has been an advisory board member for and received honoraria from Amgen, Astellas, Bayer, Janssen, Merck, Roche, and Sanofi; and has participated in clinical trials supported by Amgen, Astellas, Astra Zeneca, Bayer, Janssen, Myovant, and Pfizer. Dr. Izard has been an advisory board member for and received consulting fees from AbbVie, Astellas, Ferring, Janssen, and Sanofi; and has participated in clinical trials supported by Astellas, AstraZeneca, and Merck. Dr. Kawakami has been a procter for Minogue Medical and is a stockholder in and advisor for Vibe Bioscience. Dr. Lee received honoraria for a lecture from Baxter. Dr. Richard has been an advisory board member for BMS and Sanofi; a speakers’ bureau member for Abbvie, Amgen, Astellas, Ferring, and Janssen; and has participated in clinical trials supported by Calithera and Lidds Pharma. Dr. Rowe has participated in an advisory board meeting for Acerus and has received honoraria from Sanofi. Dr. St. Martin has received speaker honoraria from Pfizer. Dr. Zorn has received honoraria as a procter/Greenlight lecturer for Boston Scientific; and has participated in clinical trials supported by Procept Biorobotics. Dr. Kapoor has been an advisory board member for and participated in clinical trials supported by Amgen, Astellas, Janssen, GSK, Novartis, Pfizer, and Sanofi. Dr. Finelli has been an advisory board member for Abbvie, Astellas, Bayer, Ipsen, Janssen, Sanofi, and TerSera; and has participated in clinical trials supported by Astellas, Bayer, and Janssen. The remaining authors report no competing personal or financial interests related to this work.

Figures

**Fig. 1**
Modified Delphi technique process.

See this image and copyright information in PMC

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

Affiliations

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

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

LinkOut - more resources

Full Text Sources