ENDOUROLOGY & LAPAROSCOPY

Prospective radiographic followup after en bloc ligation of the renal hilum
White WM, Klein FA, Gash J, Waters WB
Department of Urology, University of Tennessee Medical Center, Knoxville, Tennessee
J Urol. 2007; 178: 1888-91

• Purpose: We determined the risk of arteriovenous fistula after en bloc ligation of the renal hilum.
• Materials and Methods: A prospective evaluation of all patients who underwent en bloc ligation of the renal hilum during nephrectomy for malignant disease was performed. Pertinent operative data were recorded and patients were followed for clinical evidence of arteriovenous fistula formation, including hypertension, abdominal bruit and new onset congestive heart failure. Patients with at least 12 months of followup underwent computerized tomographic arteriography to assess arteriovenous fistula formation.
• Results: A total of 94 patients underwent en bloc renal hilar ligation during open (43) and laparoscopic (51) nephrectomy using a 45 mm titanium endovascular stapler. Of this cohort 11 patients were lost to followup and 3 died of disease. The remaining 80 patients were followed an average of 35.2 months with no clinical evidence of arteriovenous fistula formation. Specifically there was no statistically significant difference in preoperative and postoperative blood pressure (p = 0.18 and 0.62, respectively), no evidence of abdominal bruit on examination and no new onset congestive heart failure. A total of 32 had increased serum creatinine and, therefore, they were excluded from followup computerized tomographic arteriography. Eight patients had a followup of less than 1 year and they were not yet eligible for evaluation. In the 40 patients who underwent computerized tomographic arteriography no fistulas were noted.
• Conclusions: Based on clinical followup and prospective radiographic evaluation there appears to be a low risk of arteriovenous fistula formation after en bloc ligation of the renal hilum using a titanium endovascular stapler.
  
  
• Editorial Comment
  The authors should be congratulated to perform this prospective study. The first case of fistula formation after en bloc ligation of the renal pedicle was reported by Hollingsworth (1934) in a patient with tuberculosis renal disease. Few other cases of fistula formation after en bloc ligation of the renal pedicle were reported. Approximately 60 case reports of fistula formation after mass ligation of the renal pedicle were published of which most developed in the setting of infection or inflammation.
  The authors performed the “en bloc” endovascular renal hilar ligation using endovascular staplers during open and hand assisted laparoscopic nephrectomies. One should be careful and aware of possible misfiring and different types of laparoscopic endovascular staplers so possible complications can be minimized or completely avoided.
  In summary, “en bloc” renal hilar ligation using endovascular staplers could be considered in cases of renal cell carcinoma when the absence of infection and/or severe inflammation may contribute for possible arterio-venous fistula formation.

Dr. Fernando J. Kim
Chief of Urology, Denver Health Med Ctr
Director of Minimally Invasive Urological Oncology
Tony Grampsas Ca Ctr, Univ Colorado Health Sci Ctr