The current study adds to a growing body of literature investigating the feasibility, safety, and outcomes of sutureless PN. Patients who receive HB rather than SR had lower overall operative time, warm ischemic time, estimated blood loss, and length of stay while residual renal function was comparable between the two groups. Previously, our group has published data showing that TE demonstrated improved long-term renal function when compared to standard PN.(7) Therefore, the data presented here can be seen as a continuation of the trend toward maximal preservation of renal parenchyma moving from a standard PN with SR, then TE with SR, and finally full transition to TE with a HB with a resultant improvement in perioperative outcomes with each iteration.
Indeed, these results verify and add to data by other groups around the world investigating novel approaches to maximal renal function preservation. A meta-analysis assessing the literature for surgical outcomes when attempting sutureless PN by Liu and colleagues showed that using this approach had a smaller decline in eGFR, no significant difference in post-operative complications, shorter operative time and warm ischemia time, and no significant blood loss difference or rates of urine leak when compared to SR.(15) The meta-analysis included both robotic and laparoscopic studies but was reassuring as the outcomes assessed are some of the first concerns that come to mind when considering the use of a sutureless approach.
Within the meta-analysis were three studies that reported the use of hemostatic agents along their resection bed. Tiscione and associates used a fibrin glue in their experimental arm with similar outcomes found between fibrin glue cohort and the suture control, but their study was much smaller than the present study with a total of 40 patients enrolled, 19 of whom received the fibrin gel.(12) Another study, which utilized a Fibrin gel (Tissucol®), demonstrated shorter warm ischemia time, a lower postoperative rate of acute kidney injury, and similar long-term oncologic outcomes when compared to the SR control. However, this study can be differentiated from our own by the limitation to tumors with a RENAL nephrometry score of ≤ 7 and by the fact that only 65 patients underwent sutureless PN.(16) The final study utilized a TachoSil® fibrin sealant patch along the surgical bed, and again patients who did not undergo a renorrhaphy had shorter operative time with otherwise similar surgical outcomes in terms of warm ischemia time, negative margins, and perioperative complications.(17) However, the study was also small with 29 patients receiving HB and 29 receiving SR.(17) Our study represents, to our knowledge, the largest experience in the literature to date of surgical and oncologic outcomes of sutureless PN aided by a hemostatic agent.
Among the patients for whom HB was the first attempted means of hemostasis, 11 ultimately required a SR prior to completion of the procedure for a rate of 7.2% overall although the rate was 0% during 2018–2022. Of these, three had a renorrhaphy given the depth of the defect despite perceived adequate hemostasis. The remainder were classified as “bandage failures” given varying degrees of intraoperative hemorrhage (three of these had only a single stitch placed while others required a standard suture renorrhaphy). Despite these intraoperative failures, none of these patients needed additional transfusions or procedures for post-operative bleeding.
Limitations of the present study include its retrospective nature and the fact that all PN cases were performed by a single surgeon. Patients in this cohort that underwent SR had tumors with a higher degree of complexity than those which underwent HB. This reflects selection towards utilizing SR for more complex tumors in the earlier years included. When the relative utilization of HB increased to 100% starting in 2018, there were no detrimental outcomes. Several significant differences in postoperative outcomes remained after stratifying by RENAL nephrometry score, though an element of residual confounding cannot be ruled out. Nonetheless, this analysis supports the utilization of a HB in appropriately selected cases without a significant impact towards adverse outcomes.