Douglas C Cheung1, Christopher J D Wallis1,2, 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. 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, 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 Center (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.
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.
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.