What is the optimal method for controlling bleeding during robotic nephrectomy?

From the Guidelines

The optimal method for controlling bleeding during robotic nephrectomy is a multi-faceted approach that includes meticulous surgical technique, early control of the renal hilum, and the use of advanced hemostatic technologies, as supported by the European Association of Urology guidelines on renal cell carcinoma 1. This approach is crucial in minimizing blood loss and ensuring a successful outcome. Key strategies include:

• Careful dissection and early control of the renal hilum, with the artery being ligated first, followed by the vein
• Utilization of bipolar electrocautery for smaller vessels and advanced energy devices like the Harmonic scalpel or LigaSure for medium-sized vessels
• Employment of vascular staplers or Hem-o-lok clips for larger vessels to achieve secure hemostasis
• Maintenance of intraoperative hypotensive anesthesia, with a mean arterial pressure between 60-70 mmHg, to reduce bleeding during critical dissection phases
• Application of topical hemostatic agents such as Floseal or Surgiflo to areas of persistent oozing
• Proper patient positioning with adequate pneumoperitoneum pressure, ranging from 12-15 mmHg, to create a relatively bloodless field
• A low threshold for conversion to open surgery if bleeding cannot be controlled robotically, as emphasized in the guidelines 1. The use of robotic or pure laparoscopic partial nephrectomy (PN) has been shown to have similar perioperative outcomes, with robotic PN resulting in significantly lower estimated blood loss and shorter warm ischemia time 1. By adopting this comprehensive approach, surgeons can effectively manage bleeding during robotic nephrectomy, ultimately reducing morbidity, mortality, and improving the quality of life for patients.

From the Research

Optimal Control of Bleeding during Robotic Nephrectomy

• The use of hemostatic agents during robotic partial nephrectomy has been shown to be effective in controlling bleeding, with a high success rate without vascular clamping 2.
• Robot-assisted laparoscopic live donor nephrectomies have been carried out with minimal blood loss, and the use of robotics has been shown to enhance the laparoscopist's skills and prevent problematic bleeding 3.
• Various modalities are available to reduce bleeding during laparoscopic partial nephrectomies, including hemostatic maneuvers and renorrhaphy techniques 4.
• The early unclamping technique in robot-assisted partial nephrectomy has been shown to be a safe and feasible option, allowing for a shorter warm ischemia time without increasing blood loss 5.
• Robotic-assisted partial nephrectomy has been shown to have good oncologic outcomes, with operative time, blood loss, postoperative renal function, and hospital stay being at least equivalent to laparoscopic partial nephrectomy 6.

Methods for Hemostasis

• Hemostatic agents can be used to control bleeding during robotic partial nephrectomy 2.
• Vascular clamping can be used to control bleeding, but it can be a challenging aspect of the procedure 6.
• The early unclamping technique can be used to reduce warm ischemia time and minimize blood loss 5.
• Renorrhaphy techniques can be used to repair the kidney and control bleeding 4.

Benefits of Robotic Nephrectomy

• Robotic nephrectomy can be carried out with minimal blood loss and minimal complications 3.
• The use of robotics can enhance the laparoscopist's skills and prevent problematic bleeding 3.
• Robotic-assisted partial nephrectomy has been shown to have good oncologic outcomes and can be a safe and effective alternative to traditional laparoscopic approaches 6.