Omission of Hemostatic Agents During Robotic Partial Nephrectomy Does Not Increase Postoperative Bleeding Risk.
The use of hemostatic agents (HA) during robotic partial nephrectomy (RPN) is largely empiric. We sought to assess the impact of HA on postoperative bleeding after RPN in a contemporary cohort.



Using our institutional RPN database, we identified consecutive patients treated between 2010 and 2015. HA were routinely placed in the nephrectomy bed at the time of renorrhaphy until 2014 when their use was phased out to reduce cost. We compared postoperative bleeding outcomes (blood transfusion and hemoglobin decline) between patients who did and did not receive HA, after excluding patients with preoperative anemia (hemoglobin <11 g/dL) or high estimated blood loss (≥175 mL). The total inflation-adjusted costs (for 2015) of HA were calculated.



Of 544 cases, HA were used in 240 (44.1%). The mean number of agents per case was 1.4 ± 0.73, including 77 (14.2%), 52 (9.6%), and 39 (7.2%) cases in which cellulose, fibrin, or gelatin-based agents were used alone, respectively, and 72 (13.2%) cases in which multiple agents were used. The mean cost of HA per case was $488 ± 421. Nearly 90% of cases were performed by surgeons who were beyond their learning curves. Overall, 13 (2.4%) patients were transfused, and the median hemoglobin decline was 2.2 g/dL (IQR, 1.4-3.0 g/dL). On univariate analysis, HA use and type of HA were not significantly associated with blood transfusion (p = 0.20 and p = 0.29, respectively), but were associated with hemoglobin decline (p = 0.01 and p = 0.02, respectively). After adjusting for covariates, HA use was no longer significantly associated with postoperative hemoglobin decline.



In nonanemic patients with minimal intraoperative bleeding, HA use does not alter postoperative bleeding outcomes after RPN, suggesting that their routine use in this setting merits reconsideration. Further research is needed to determine if HA may be useful in certain high-risk situations.
Department of Urology, Glickman Urological and Kidney Institute , Cleveland Clinic, Cleveland, Ohio.
Matthew J
MJ
Maurice
Department of Urology, Glickman Urological and Kidney Institute , Cleveland Clinic, Cleveland, Ohio.
Daniel
D
Ramirez
Department of Urology, Glickman Urological and Kidney Institute , Cleveland Clinic, Cleveland, Ohio.
Önder
Ö
Kara
Department of Urology, Glickman Urological and Kidney Institute , Cleveland Clinic, Cleveland, Ohio.
Ercan
E
Malkoç
Department of Urology, Glickman Urological and Kidney Institute , Cleveland Clinic, Cleveland, Ohio.
Ryan J
RJ
Nelson
Department of Urology, Glickman Urological and Kidney Institute , Cleveland Clinic, Cleveland, Ohio.
Peter A
PA
Caputo
Department of Urology, Glickman Urological and Kidney Institute , Cleveland Clinic, Cleveland, Ohio.
Jihad H
JH
Kaouk
D000368:Aged; D016022:Case-Control Studies; D002483:Cellulose, Oxidized / Q000627:therapeutic use; D005260:Female; D015718:Fibrin Tissue Adhesive / Q000627:therapeutic use; D006490:Hemostatics / Q000627:therapeutic use*; D006801:Humans; D007680:Kidney Neoplasms / Q000601:surgery*; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009392:Nephrectomy / Q000379:methods*; D019106:Postoperative Hemorrhage / Q000453:epidemiology*; D012189:Retrospective Studies; D012306:Risk; D065287:Robotic Surgical Procedures / Q000379:methods*; D016896:Treatment Outcome
D002483:Cellulose, Oxidized; D015718:Fibrin Tissue Adhesive; D006490:Hemostatics; C013695:Surgicel