The Evolution of Tumor Enucleation Partial Nephrectomy: A Comparison of Perioperative Outcomes for Sutureless Hemostatic Bandage as an Alternative to Standard Renorrhaphy

The Evolution of Tumor Enucleation Partial Nephrectomy: A Comparison of Perioperative Outcomes for Sutureless Hemostatic Bandage as an Alternative to Standard Renorrhaphy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Evolution of Tumor Enucleation Partial Nephrectomy: A Comparison of Perioperative Outcomes for Sutureless Hemostatic Bandage as an Alternative to Standard Renorrhaphy Goran Rac, Jeffrey L. Ellis, Nicholas J. Lanzotti, Mallory E. McCormick, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3876931/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The standard approach to hemostasis during partial nephrectomy (PN) is to perform suture renorrhaphy (SR). Application of a hemostatic bandage (HB) is an alternative maneuver to minimize blood loss and devitalized renal parenchyma. We aim to evaluate perioperative outcomes of PN with tumor enucleation (TE) comparing SR to HB. Methods We analyzed a retrospective cohort of 195 patients undergoing robot-assisted laparoscopic PN with TE performed by a single surgeon at a tertiary referral center (2012–2022). Hemostasis of the enucleation bed was obtained with SR in 54 patients while 141 patients underwent application of HB consisting of Surgicel®, Gelfoam® soaked in thrombin, and Floseal®. Patient factors, tumor characteristics, and perioperative outcomes were compared using Student’s t-tests and chi-squared tests. Temporal trends were evaluated using Spearman coefficients. Results Over time, there was a significant decrease in utilization of SR in favor of HB (p < 0.001). SR patients had tumors of greater complexity by RENAL nephrometry score compared to HB patients (p < 0.001). Operative time (141 vs 183 min, p < 0.001), warm ischemia time (11.6 vs 24.2 min, p < 0.001), estimated blood loss (37 vs 214 mL, p < 0.001), and length of stay (1.2 vs 1.8 days, p < 0.001) favored the HB group. There was no significant difference in major Clavien-Dindo grade ≥ 3 complications (p = 0.22). Renal function was comparable with mean estimated glomerular filtration rate decrease of 0.66 and 0.54 mL/min/1.73m2 at 3-months postoperatively for HB and SR, respectively (p = 0.93). Conclusions Application of a HB is a safe alternative to SR for hemostasis following PN with TE in appropriately selected patients. partial nephrectomy sutureless hemostatic bandage tumor enucleation outcomes Figures Figure 1 Figure 2 INTRODUCTION Partial nephrectomy (PN) represents the guideline-recommended treatment for T1a sporadic renal masses in addition to multifocal lesions, lesions in young patients, and lesions in those with medical comorbidities precluding one to future kidney disease or radical nephrectomy.( 1 ) This comes from its ability to minimize the risk of chronic kidney disease (CKD) onset or progression. PN has also been demonstrated to be a safe and effective means of obtaining oncologic control for T1b lesions and even appropriately selected larger, exophytic lesions.( 2 , 3 , 4 ) Most surgeons utilize a standard margin partial nephrectomy technique in which a rim of healthy parenchyma around the mass is sacrificed to obtain a negative surgical margin. However, concerns have been raised by this loss of healthy parenchyma contributing to renal function decline and development of CKD in some patients. Indeed, the fact that a decrease in estimated glomerular filtration rate (eGFR) is associated with higher all-cause mortality has prompted interest in ways to maximally preserve renal function.( 5 ) Tumor enucleation (TE) has emerged as a means of preserving renal function while maintaining optimal oncologic outcomes. TE consists of incision along the tumor pseudocapsule, which is characterized by an avascular plane between the parenchyma-mass interface.( 6 , 7 ) One study centered on histologic analysis of enucleated tumors found that all assessed cases of renal cell carcinoma had a distinct peritumoral pseudocapsule and that in all cases surrounding the capsule there exists areas of chronic inflammatory tissue creating a “buffer zone” between the cancer and healthy parenchyma.( 6 ) Following the tumor pseudocapsule allows for reliable visualization of the true mass contour, which may result in lower positive surgical margins rates based on some experiences.( 8 ) Overall, TE has been shown to have equivalent oncologic outcomes as the standard technique with the additional benefit of preservation of renal function, lower perioperative complication rates, and comparable recurrence and overall survival outcomes.( 7 , 9 ) Beyond maintenance of a rim of healthy parenchymal tissue usually excised with the standard technique, an additional benefit of TE is the potential to reduce or avoid the amount of subsequent devascularized parenchymal mass (DPM). Standard partial nephrectomy generally consists of sharp incision into the vascular renal parenchyma that necessitates a suture renorrhaphy (SR) for hemostasis in the defect. This leads to a surrounding region of DPM which has been shown to be the greatest contributor to parenchymal mass loss.( 10 , 11 ) SR may also contribute to the development of pseudoaneurysms. TE can obviate the need for renorrhaphy as the pseudocapsule plane is relatively avascular. It remains an open question, however, as to what the optimal means of achieving hemostasis is when a SR is not performed. Some have reported the usage of hemostatic agents along the tumor bed.( 12 , 13 , 14 ) We have previously described one such methodology that employs a combination of these in the form of a hemostatic bandage (HB).( 14 ) The goal of utilizing a HB rather than SR is to minimize DPM when performing TE, thus allowing for truly minimally invasive renal mass resection with maximal renal function preservation. Here, we aim to compare perioperative outcomes and post-operative complication rates between SR and HB for PN with TE. METHODS We conducted a retrospective, comparative cohort study of patients undergoing robotic-assisted laparoscopic PN utilizing the TE technique at Loyola University Medical Center between 2012–2022. All cases performed by a single surgeon (GNG) were included. Baseline demographics, comorbidities, and perioperative details were collected. This study was exempt from review by the Institutional Review Board due to its retrospective nature. The technique for TE utilized has been previously described.( 7 ) Prior to initiating mass excision, the HB was constructed within the abdomen adjacent to the kidney. This HB consists of Surgicel®, Gelfoam® soaked in thrombin, and Floseal® arranged superficial to deep in that order, as can be seen in Fig. 1. After mass excision, patients underwent either SR or application of HB. SR was performed in two layers utilizing a sliding clip technique in a running fashion for the deep layer and an interrupted fashion for the superficial layer. In cases where HB was utilized, pressure was applied to a gauze sponge overlying the HB for 5 minutes with insufflation. Following inspection, the abdomen was de-insufflated for an additional 5 minutes without applied pressure. After removal of the gauze sponge and reinspection to ensure hemostasis, the robot was undocked, and the incisions were closed. Postoperative complications and changes in kidney function as measured by eGFR at 3-months postoperatively were captured. Patient and tumor characteristics as well as perioperative outcomes were tabulated by utilization of HB. Continuous and categorical variables were compared using Student’s t-tests and chi-squared tests, respectively. Temporal trends in HB and SR utilization were tabulated and compared using Spearman coefficients. Statistical analyses were completed using STATA version 15.0 (Stata Corp, College Station, TX). RESULTS A total of 195 patients that underwent robotic-assisted laparoscopic PN with TE between 2012 and 2022 were identified. Of these, 141 underwent application of HB alone while 54 underwent SR. There was no significant difference in patient demographics between the two groups [Table 1] . 11 patients underwent SR either in conjunction with or immediately following failure of the HB for an overall conversion rate for intended HB of 11/152 (7.2%). There was a significant shift towards HB instead of SR over this time period (p=0.0031) [Figure 2] . HB was utilized in only 27.3% of TE procedures in 2012, increasing to 100% of procedures from 2018 to 2022. Patients in the SR cohort were noted to have tumors of greater complexity by RENAL nephrometry score (p=0.003) compared to those that underwent HB. This included greater tumor size (3.3 cm vs 2.6 cm, p<0.001), nearness to the collecting system (p=0.002), and more central position (p=0.009). There was no statistically significant difference in endophytic nature of the masses excised by either approach (p=0.069). Perioperative outcomes can be seen in Table 2. Operative time (141 vs 185 min, p<0.001), warm ischemia time (11.6 vs 24.2 min, p<0.001), estimated blood loss (37 vs 211 mL, p<0.001), and length of stay (1.2 vs 1.8 days, p<0.001) favored the HB group. There was no difference in need for blood transfusion (p=0.1) or Clavien-Dindo grade ≥3 complications (p=0.12) between the two approaches. Of the three total Clavien-Dindo grade ≥3 complications, one patient in the SR group experienced a postoperative bleed necessitating embolization, one SR patient experienced transient ureteral obstruction necessitating ureteral stent placement, and one patient in the HB group died secondary to ventricular arrhythmia. Renal function was comparable between the HB and SR groups with a mean eGFR decrease of 0.66 and 0.54 mL/min/1.73m 2 at 3 months postoperatively, respectively (p=0.97). On subanalyses stratifying patients by tumor complexity, several significant differences in postoperative outcomes between the HB and SR cohorts remained, overall favoring the HB group [Table 3] . DISCUSSION 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. CONCLUSION Application of a HB is a safe alternative to SR for hemostasis following PN with TE in appropriately selected patients. HB has favorable perioperative outcomes compared to SR without any significant differences in postoperative complications. This technique should be considered for maximal renal parenchymal preservation. Declarations Author Contribution All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Goran Rac, Nicholas Lanzotti, Michael Felice, Sarang Janakiraman, Shalin Desai, Whitney Halgrimson, and Hiten Patel. The first draft of the manuscript was written by Goran Rac, Jeffrey Ellis, and Natalie Hartman and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. References Campbell SC, Clark PE, Chang SS, Karam JA, Souter L, Uzzo RG. Renal Mass and Localized Renal Cancer: Evaluation, Management, and Follow-Up: AUA Guideline: Part I. J Urol. 2021;206(2):199-208. Sharafeldeen M, Sameh W, Mehrnoush V, Alaref A, Rozenberg R, Ismail A, et al. Partial Nephrectomy for T1b/T2 Renal Mass: An Added Shift from Radical Nephrectomy. J Kidney Cancer VHL. 2022;9(4):1-5. Kim DK, Kim LH, Raheem AA, Shin TY, Alabdulaali I, Yoon YE, et al. Comparison of Trifecta and Pentafecta Outcomes between T1a and T1b Renal Masses following Robot-Assisted Partial Nephrectomy (RAPN) with Minimum One Year Follow Up: Can RAPN for T1b Renal Masses Be Feasible? PLoS One. 2016;11(3):e0151738. Patel HD, Pierorazio PM, Johnson MH, Sharma R, Iyoha E, Allaf ME, et al. Renal Functional Outcomes after Surgery, Ablation, and Active Surveillance of Localized Renal Tumors: A Systematic Review and Meta-Analysis. Clin J Am Soc Nephrol. 2017;12(7):1057-69. Guo Y, Cui L, Ye P, Li J, Wu S, Luo Y. Change of Kidney Function Is Associated With All-Cause Mortality and Cardiovascular Diseases: Results From the Kailuan Study. J Am Heart Assoc. 2018;7(21):e010596. Minervini A, di Cristofano C, Lapini A, Marchi M, Lanzi F, Giubilei G, et al. Histopathologic analysis of peritumoral pseudocapsule and surgical margin status after tumor enucleation for renal cell carcinoma. Eur Urol. 2009;55(6):1410-8. Patel HD, Koehne EL, Gali K, Lanzotti NJ, Rac G, Desai S, et al. Robotic-assisted tumor enucleation versus standard margin partial nephrectomy: Perioperative, renal functional, and oncologic outcomes for low and intermediate complexity renal masses. Urol Oncol. 2022;40(7):347 e9- e16. Longo N, Minervini A, Antonelli A, Bianchi G, Bocciardi AM, Cunico SC, et al. Simple enucleation versus standard partial nephrectomy for clinical T1 renal masses: perioperative outcomes based on a matched-pair comparison of 396 patients (RECORd project). Eur J Surg Oncol. 2014;40(6):762-8. Yasuda Y, Saito K, Tanaka H, Uehara S, Kijima T, Yoshida S, et al. Outcomes of gasless laparoendoscopic single-port partial nephrectomy in 356 consecutive patients: Feasibility of a clampless and sutureless technique. Int J Urol. 2021;28(3):302-7. Dong W, Gupta GN, Blackwell RH, Wu J, Suk-Ouichai C, Shah A, et al. Functional Comparison of Renal Tumor Enucleation Versus Standard Partial Nephrectomy. Eur Urol Focus. 2017;3(4-5):437-43. Dong W, Wu J, Suk-Ouichai C, Caraballo Antonio E, Remer E, Li J, et al. Devascularized Parenchymal Mass Associated with Partial Nephrectomy: Predictive Factors and Impact on Functional Recovery. J Urol. 2017;198(4):787-94. Tiscione D, Cai T, Luciani LG, Puglisi M, Mattevi D, Nesi G, et al. Sutureless laparoscopic partial nephrectomy using fibrin gel reduces ischemia time while preserving renal function. Arch Ital Urol Androl. 2019;91(1):30-4. Erne E, Kruck S, Todenhoefer T, Aufderklamm S, Amend B, Bedke J, et al. Versatility and clinical effectiveness of a synthetic sealing hemostatic patch as alternative to parenchyma suturing in laparoscopic partial nephrectomy. Surg Endosc. 2022;36(1):663-9. Nelson M, Shah A, Elliott N, Gupta G. The Hemostatic Bandage: Suture-Less Enucleation Partial Nephrectomy. Videourology. 2019;33(4). Liu P, Li Y, Shi B, Zhang Q, Guo H. The Outcome of Sutureless in Partial Nephrectomy: A Systematic Review and Meta-Analysis. Biomed Res Int. 2022;2022:5260131. Jin D, Ren D, Zhang J, Xu G, Ge C, Jiang Q, et al. A Propensity Score-Matched Comparison Between Sutureless and Suture Techniques in Laparoscopic Nephron-Sparing Surgery: A Retrospective Non-Randomized Observational Study. J Laparoendosc Adv Surg Tech A. 2020;30(12):1314-9. Farinha R, Rosiello G, Paludo AO, Mazzone E, Puliatti S, Amato M, et al. Selective Suturing or Sutureless Technique in Robot-assisted Partial Nephrectomy: Results from a Propensity-score Matched Analysis. Eur Urol Focus. 2022;8(2):506-13. Tables Table 1. Patient demographics and tumor characteristics. Hemostatic Bandage (N=141) Suture Renorrhaphy (N=54) p-value Age [years], mean (SD) 58.1 (12.8) 56.5 (12.9) 0.44 Sex, n (%) Male 93 (66.0) 32 (59.3) 0.38 Female 48 (34.0) 22 (40.7) Race, n (%) White 104 (73.8) 39 (72.2) 0.63 Black 12 (8.5) 3 (5.6) Hispanic 18 (12.8) 10 (18.5) Asian 4 (2.8) 2 (3.7) Other 3 (2.1) --- BMI [kg/m 2 ], mean (SD) 31.4 (6.4) 31.5 (7.7) 0.90 Diabetes mellitus, n (%) 23 (16.3) 11 (20.4) 0.50 CKD stage ≥3, n (%) 14 (9.9) 3 (5.6) 0.33 Tumor size [cm], mean (SD) 2.6 (1.1) 3.3 (1.0) <0.001 *** Tumor laterality, n (%) Left 67 (47.5) 26 (48.1) 0.94 Right 74 (52.5) 28 (51.9) Clinical T stage, n (%) cT1a 127 (90.1) 43 (79.6) 0.064 cT1b 13 (9.2) 11 (20.4) cT2a 1 (0.7) --- RENAL nephrometry score, n (%) ≥4 and <7 66 (46.8) 15 (27.8) 0.003 ** ≥7 and <10 51 (36.2) 31 (57.4) ≥10 6 (4.3) 6 (11.1) Missing 18 (12.8) 2 (3.7) SD = standard deviation; BMI = Body Mass Index; CKD = chronic kidney disease Table 2. Operative and perioperative factors. Hemostatic Bandage (N=141) Suture Renorrhaphy (N=54) p-value Approach, n (%) Transperitoneal 33 (23.4) 21 (38.9) 0.031 * Retroperitoneal 108 (76.6) 33 (61.1) Hilum clamped, n (%) Yes 86 (61.0) 43 (79.6) 0.014 * No 55 (39.0) 11 (20.4) Operative time [min], mean (SD) 141.2 (39.5) 183.0 (51.4) <0.001 *** Warm ischemia time † [min], mean (SD) 11.6 (4.4) 24.2 (6.7) <0.001 *** Length of stay [days], mean (SD) 1.2 (0.6) 1.8 (1.0) <0.001 *** Major complications ‡ , n (%) 1 (0.7) 2 (3.6) 0.12 Estimated blood loss [mL], mean (SD) 36.5 (47.2) 214.3 (344.3) <0.001 *** Transfusions, n (%) --- 1 (1.8) 0.10 eGFR change § [mL/min/1.73m 2 ], mean (SD) -0.66 (19.4) -0.54 (15.9) 0.97 † Warm ischemia time included only for cases in which hilar clamping was performed. ‡ Clavien-Dindo grade ≥3 complications within 90 days. § eGFR change at 3 months following surgery compared to preoperative value. SD = standard deviation; eGFR = estimated glomerular filtration rate Table 3. Postoperative outcomes stratified by RENAL nephrometry score. RENAL score ≥4 and <7 (N=81) RENAL score ≥7 and <10 (N=82) RENAL score ≥10 (N=12) HB (N=66) SR (N=15) p-value HB (N=51) SR (N=31) p-value HB (N=6) SR (N=6) p-value Length of stay [days], mean (SD) 1.2 (0.6) 2.2 (1.1) 0.006 ** 1.2 (0.7) 1.6 (1.0) 0.083 1.3 (0.8) 1.8 (0.75) 0.30 Major complications † , n (%) 0 (0.0) 1 (6.7) 0.035 * 0 (0.0) 1 (3.2) 0.20 1 (16.7) 0 (0.0) 0.30 Estimated blood loss [mL], mean (SD) 31.4 (37.6) 149.7 (140.2) 0.005 ** 44.4 (58.3) 204.0 (355.5) 0.019 * 56.7 (71.1) 475.0 (583.8) 0.14 eGFR change ‡ [mL/min/1.73m 2 ], mean (SD) -3.4 (12.2) 0.4 (16.8) 0.44 5.3 (26.5) -4.9 (12.4) 0.056 8.9 (10.2) 14.5 (19.9) 0.58 † Clavien-Dindo grade ≥3 complications within 90 days. ‡ eGFR change at 3 months following surgery compared to preoperative value. HB = hemostatic bandage; SR = suture renorrhaphy; SD = standard deviation; eGFR = estimated glomerular filtration rate Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3876931","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":268263282,"identity":"cc92d54b-ec79-42ad-bf4d-1074b41c699f","order_by":0,"name":"Goran Rac","email":"","orcid":"","institution":"Loyola University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Goran","middleName":"","lastName":"Rac","suffix":""},{"id":268263283,"identity":"21481312-fb78-421e-8c0d-c44b3bd4846d","order_by":1,"name":"Jeffrey L. 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Felice","email":"","orcid":"","institution":"Loyola University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"D.","lastName":"Felice","suffix":""},{"id":268263288,"identity":"22105e09-65bb-4e4d-9382-e3c9850636b2","order_by":6,"name":"Natalie Hartman","email":"","orcid":"","institution":"Loyola University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Natalie","middleName":"","lastName":"Hartman","suffix":""},{"id":268263289,"identity":"c5577460-b6bc-4b5e-aadc-3427025861a6","order_by":7,"name":"Sarang Janakiraman","email":"","orcid":"","institution":"Loyola University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Sarang","middleName":"","lastName":"Janakiraman","suffix":""},{"id":268263290,"identity":"4b1502e3-b8cb-4a7c-9654-8420a7e6e896","order_by":8,"name":"Shalin Desai","email":"","orcid":"","institution":"Loyola University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Shalin","middleName":"","lastName":"Desai","suffix":""},{"id":268263291,"identity":"07c9203b-dc30-4918-940a-dd6036fa8080","order_by":9,"name":"Whitney Halgrimson","email":"","orcid":"","institution":"Loyola University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Whitney","middleName":"","lastName":"Halgrimson","suffix":""},{"id":268263292,"identity":"8bd27972-28ab-4664-87b8-5651ac372dbe","order_by":10,"name":"Hiten D. Patel","email":"","orcid":"","institution":"Northwestern University","correspondingAuthor":false,"prefix":"","firstName":"Hiten","middleName":"D.","lastName":"Patel","suffix":""},{"id":268263293,"identity":"be104d66-1469-4141-8d11-48826c06187f","order_by":11,"name":"Gopal N. Gupta","email":"","orcid":"","institution":"Loyola University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Gopal","middleName":"N.","lastName":"Gupta","suffix":""}],"badges":[],"createdAt":"2024-01-18 21:29:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3876931/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3876931/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49991905,"identity":"8e998dd0-72be-4a62-8e81-7f74527ae919","added_by":"auto","created_at":"2024-01-22 18:50:10","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2131218,"visible":true,"origin":"","legend":"\u003cp\u003eDiagram of the constructed hemostatic bandage (superficial to deep): Surgicel®,\u003c/p\u003e\n\u003cp\u003eGelfoam® soaked in thrombin, and Floseal®.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3876931/v1/1f96b292645512800fe72d84.png"},{"id":49991904,"identity":"cf36c887-cc46-4640-b52f-b47e3cc85938","added_by":"auto","created_at":"2024-01-22 18:50:10","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":214854,"visible":true,"origin":"","legend":"\u003cp\u003eTemporal trends in utilization of hemostatic bandage versus suture renorrhaphy.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3876931/v1/0f3f39855625e8ac4c31cb85.png"},{"id":50274167,"identity":"3d9e2b76-1a3b-4142-9ea3-052c1192468f","added_by":"auto","created_at":"2024-01-28 22:22:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2388771,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3876931/v1/ae019f7f-d667-48cc-8f59-4a1337b43146.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Evolution of Tumor Enucleation Partial Nephrectomy: A Comparison of Perioperative Outcomes for Sutureless Hemostatic Bandage as an Alternative to Standard Renorrhaphy","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003e Partial nephrectomy (PN) represents the guideline-recommended treatment for T1a sporadic renal masses in addition to multifocal lesions, lesions in young patients, and lesions in those with medical comorbidities precluding one to future kidney disease or radical nephrectomy.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) This comes from its ability to minimize the risk of chronic kidney disease (CKD) onset or progression. PN has also been demonstrated to be a safe and effective means of obtaining oncologic control for T1b lesions and even appropriately selected larger, exophytic lesions.(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) Most surgeons utilize a standard margin partial nephrectomy technique in which a rim of healthy parenchyma around the mass is sacrificed to obtain a negative surgical margin. However, concerns have been raised by this loss of healthy parenchyma contributing to renal function decline and development of CKD in some patients. Indeed, the fact that a decrease in estimated glomerular filtration rate (eGFR) is associated with higher all-cause mortality has prompted interest in ways to maximally preserve renal function.(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eTumor enucleation (TE) has emerged as a means of preserving renal function while maintaining optimal oncologic outcomes. TE consists of incision along the tumor pseudocapsule, which is characterized by an avascular plane between the parenchyma-mass interface.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) One study centered on histologic analysis of enucleated tumors found that all assessed cases of renal cell carcinoma had a distinct peritumoral pseudocapsule and that in all cases surrounding the capsule there exists areas of chronic inflammatory tissue creating a \u0026ldquo;buffer zone\u0026rdquo; between the cancer and healthy parenchyma.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) Following the tumor pseudocapsule allows for reliable visualization of the true mass contour, which may result in lower positive surgical margins rates based on some experiences.(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eOverall, TE has been shown to have equivalent oncologic outcomes as the standard technique with the additional benefit of preservation of renal function, lower perioperative complication rates, and comparable recurrence and overall survival outcomes.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) Beyond maintenance of a rim of healthy parenchymal tissue usually excised with the standard technique, an additional benefit of TE is the potential to reduce or avoid the amount of subsequent devascularized parenchymal mass (DPM). Standard partial nephrectomy generally consists of sharp incision into the vascular renal parenchyma that necessitates a suture renorrhaphy (SR) for hemostasis in the defect. This leads to a surrounding region of DPM which has been shown to be the greatest contributor to parenchymal mass loss.(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) SR may also contribute to the development of pseudoaneurysms. TE can obviate the need for renorrhaphy as the pseudocapsule plane is relatively avascular. It remains an open question, however, as to what the optimal means of achieving hemostasis is when a SR is not performed. Some have reported the usage of hemostatic agents along the tumor bed.(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) We have previously described one such methodology that employs a combination of these in the form of a hemostatic bandage (HB).(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) The goal of utilizing a HB rather than SR is to minimize DPM when performing TE, thus allowing for truly minimally invasive renal mass resection with maximal renal function preservation. Here, we aim to compare perioperative outcomes and post-operative complication rates between SR and HB for PN with TE.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eWe conducted a retrospective, comparative cohort study of patients undergoing robotic-assisted laparoscopic PN utilizing the TE technique at Loyola University Medical Center between 2012\u0026ndash;2022. All cases performed by a single surgeon (GNG) were included. Baseline demographics, comorbidities, and perioperative details were collected. This study was exempt from review by the Institutional Review Board due to its retrospective nature.\u003c/p\u003e \u003cp\u003eThe technique for TE utilized has been previously described.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) Prior to initiating mass excision, the HB was constructed within the abdomen adjacent to the kidney. This HB consists of Surgicel\u0026reg;, Gelfoam\u0026reg; soaked in thrombin, and Floseal\u0026reg; arranged superficial to deep in that order, as can be seen in Fig.\u0026nbsp;1. After mass excision, patients underwent either SR or application of HB. SR was performed in two layers utilizing a sliding clip technique in a running fashion for the deep layer and an interrupted fashion for the superficial layer. In cases where HB was utilized, pressure was applied to a gauze sponge overlying the HB for 5 minutes with insufflation. Following inspection, the abdomen was de-insufflated for an additional 5 minutes without applied pressure. After removal of the gauze sponge and reinspection to ensure hemostasis, the robot was undocked, and the incisions were closed. Postoperative complications and changes in kidney function as measured by eGFR at 3-months postoperatively were captured.\u003c/p\u003e \u003cp\u003ePatient and tumor characteristics as well as perioperative outcomes were tabulated by utilization of HB. Continuous and categorical variables were compared using Student\u0026rsquo;s t-tests and chi-squared tests, respectively. Temporal trends in HB and SR utilization were tabulated and compared using Spearman coefficients. Statistical analyses were completed using STATA version 15.0 (Stata Corp, College Station, TX).\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 195 patients that underwent robotic-assisted laparoscopic PN with TE between 2012 and 2022 were identified. Of these, 141 underwent application of HB alone while 54 underwent SR. There was no significant difference in patient demographics between the two groups\u0026nbsp;\u003cstrong\u003e[Table 1]\u003c/strong\u003e. 11 patients underwent SR either in conjunction with or immediately following failure of the HB for an overall conversion rate for intended HB of 11/152 (7.2%).\u003cbr\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;There was a significant shift towards HB instead of SR over this time period (p=0.0031) \u003cstrong\u003e[Figure 2]\u003c/strong\u003e. HB was utilized in only 27.3% of TE procedures in 2012, increasing to 100% of procedures from 2018 to 2022.\u0026nbsp;Patients in the SR cohort were noted to have tumors of greater complexity by RENAL nephrometry score (p=0.003) compared to those that underwent HB. This included greater tumor size (3.3 cm vs 2.6 cm, p\u0026lt;0.001), nearness to the collecting system (p=0.002), and more central position (p=0.009). There was no statistically significant difference in endophytic nature of the masses excised by either approach (p=0.069).\u003c/p\u003e\n\u003cp\u003ePerioperative outcomes can be seen in Table 2. Operative time (141 vs 185 min, p\u0026lt;0.001), warm ischemia time (11.6 vs 24.2 min, p\u0026lt;0.001), estimated blood loss (37 vs 211 mL, p\u0026lt;0.001), and length of stay (1.2 vs 1.8 days, p\u0026lt;0.001) favored the HB group. There was no difference in need for blood transfusion (p=0.1) or Clavien-Dindo grade \u0026ge;3 complications (p=0.12) between the two approaches. Of the three total Clavien-Dindo grade \u0026ge;3 complications, one patient in the SR group experienced a postoperative bleed necessitating embolization, one SR patient experienced transient ureteral obstruction necessitating ureteral stent placement, and one patient in the HB group died secondary to ventricular arrhythmia. Renal function was comparable between the HB and SR groups with a mean eGFR decrease of 0.66 and 0.54 mL/min/1.73m\u003csup\u003e2\u003c/sup\u003e at 3 months postoperatively, respectively (p=0.97). On subanalyses stratifying patients by tumor complexity, several significant differences in postoperative outcomes between the HB and SR cohorts remained, overall favoring the HB group \u003cstrong\u003e[Table 3]\u003c/strong\u003e.\u0026nbsp;\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe 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.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) 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.\u003c/p\u003e \u003cp\u003eIndeed, 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.(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) 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.\u003c/p\u003e \u003cp\u003eWithin 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.(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) Another study, which utilized a Fibrin gel (Tissucol\u0026reg;), 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 \u0026le;\u0026thinsp;7 and by the fact that only 65 patients underwent sutureless PN.(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) The final study utilized a TachoSil\u0026reg; 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.(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) However, the study was also small with 29 patients receiving HB and 29 receiving SR.(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) 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.\u003c/p\u003e \u003cp\u003eAmong 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\u0026ndash;2022. Of these, three had a renorrhaphy given the depth of the defect despite perceived adequate hemostasis. The remainder were classified as \u0026ldquo;bandage failures\u0026rdquo; 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.\u003c/p\u003e \u003cp\u003eLimitations 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.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eApplication of a HB is a safe alternative to SR for hemostasis following PN with TE in appropriately selected patients. HB has favorable perioperative outcomes compared to SR without any significant differences in postoperative complications. This technique should be considered for maximal renal parenchymal preservation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Goran Rac, Nicholas Lanzotti, Michael Felice, Sarang Janakiraman, Shalin Desai, Whitney Halgrimson, and Hiten Patel. The first draft of the manuscript was written by Goran Rac, Jeffrey Ellis, and Natalie Hartman and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCampbell SC, Clark PE, Chang SS, Karam JA, Souter L, Uzzo RG. Renal Mass and Localized Renal Cancer: Evaluation, Management, and Follow-Up: AUA Guideline: Part I. J Urol. 2021;206(2):199-208.\u003c/li\u003e\n\u003cli\u003eSharafeldeen M, Sameh W, Mehrnoush V, Alaref A, Rozenberg R, Ismail A, et al. Partial Nephrectomy for T1b/T2 Renal Mass: An Added Shift from Radical Nephrectomy. J Kidney Cancer VHL. 2022;9(4):1-5.\u003c/li\u003e\n\u003cli\u003eKim DK, Kim LH, Raheem AA, Shin TY, Alabdulaali I, Yoon YE, et al. Comparison of Trifecta and Pentafecta Outcomes between T1a and T1b Renal Masses following Robot-Assisted Partial Nephrectomy (RAPN) with Minimum One Year Follow Up: Can RAPN for T1b Renal Masses Be Feasible? PLoS One. 2016;11(3):e0151738.\u003c/li\u003e\n\u003cli\u003ePatel HD, Pierorazio PM, Johnson MH, Sharma R, Iyoha E, Allaf ME, et al. Renal Functional Outcomes after Surgery, Ablation, and Active Surveillance of Localized Renal Tumors: A Systematic Review and Meta-Analysis. Clin J Am Soc Nephrol. 2017;12(7):1057-69.\u003c/li\u003e\n\u003cli\u003eGuo Y, Cui L, Ye P, Li J, Wu S, Luo Y. Change of Kidney Function Is Associated With All-Cause Mortality and Cardiovascular Diseases: Results From the Kailuan Study. J Am Heart Assoc. 2018;7(21):e010596.\u003c/li\u003e\n\u003cli\u003eMinervini A, di Cristofano C, Lapini A, Marchi M, Lanzi F, Giubilei G, et al. Histopathologic analysis of peritumoral pseudocapsule and surgical margin status after tumor enucleation for renal cell carcinoma. Eur Urol. 2009;55(6):1410-8.\u003c/li\u003e\n\u003cli\u003ePatel HD, Koehne EL, Gali K, Lanzotti NJ, Rac G, Desai S, et al. Robotic-assisted tumor enucleation versus standard margin partial nephrectomy: Perioperative, renal functional, and oncologic outcomes for low and intermediate complexity renal masses. Urol Oncol. 2022;40(7):347 e9- e16.\u003c/li\u003e\n\u003cli\u003eLongo N, Minervini A, Antonelli A, Bianchi G, Bocciardi AM, Cunico SC, et al. Simple enucleation versus standard partial nephrectomy for clinical T1 renal masses: perioperative outcomes based on a matched-pair comparison of 396 patients (RECORd project). Eur J Surg Oncol. 2014;40(6):762-8.\u003c/li\u003e\n\u003cli\u003eYasuda Y, Saito K, Tanaka H, Uehara S, Kijima T, Yoshida S, et al. Outcomes of gasless laparoendoscopic single-port partial nephrectomy in 356 consecutive patients: Feasibility of a clampless and sutureless technique. Int J Urol. 2021;28(3):302-7.\u003c/li\u003e\n\u003cli\u003eDong W, Gupta GN, Blackwell RH, Wu J, Suk-Ouichai C, Shah A, et al. Functional Comparison of Renal Tumor Enucleation Versus Standard Partial Nephrectomy. Eur Urol Focus. 2017;3(4-5):437-43.\u003c/li\u003e\n\u003cli\u003eDong W, Wu J, Suk-Ouichai C, Caraballo Antonio E, Remer E, Li J, et al. Devascularized Parenchymal Mass Associated with Partial Nephrectomy: Predictive Factors and Impact on Functional Recovery. J Urol. 2017;198(4):787-94.\u003c/li\u003e\n\u003cli\u003eTiscione D, Cai T, Luciani LG, Puglisi M, Mattevi D, Nesi G, et al. Sutureless laparoscopic partial nephrectomy using fibrin gel reduces ischemia time while preserving renal function. Arch Ital Urol Androl. 2019;91(1):30-4.\u003c/li\u003e\n\u003cli\u003eErne E, Kruck S, Todenhoefer T, Aufderklamm S, Amend B, Bedke J, et al. Versatility and clinical effectiveness of a synthetic sealing hemostatic patch as alternative to parenchyma suturing in laparoscopic partial nephrectomy. Surg Endosc. 2022;36(1):663-9.\u003c/li\u003e\n\u003cli\u003eNelson M, Shah A, Elliott N, Gupta G. The Hemostatic Bandage: Suture-Less Enucleation Partial Nephrectomy. Videourology. 2019;33(4).\u003c/li\u003e\n\u003cli\u003eLiu P, Li Y, Shi B, Zhang Q, Guo H. The Outcome of Sutureless in Partial Nephrectomy: A Systematic Review and Meta-Analysis. Biomed Res Int. 2022;2022:5260131.\u003c/li\u003e\n\u003cli\u003eJin D, Ren D, Zhang J, Xu G, Ge C, Jiang Q, et al. A Propensity Score-Matched Comparison Between Sutureless and Suture Techniques in Laparoscopic Nephron-Sparing Surgery: A Retrospective Non-Randomized Observational Study. J Laparoendosc Adv Surg Tech A. 2020;30(12):1314-9.\u003c/li\u003e\n\u003cli\u003eFarinha R, Rosiello G, Paludo AO, Mazzone E, Puliatti S, Amato M, et al. Selective Suturing or Sutureless Technique in Robot-assisted Partial Nephrectomy: Results from a Propensity-score Matched Analysis. Eur Urol Focus. 2022;8(2):506-13.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Patient demographics and tumor characteristics.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"547\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.63985374771481%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"bottom\"\u003e\n \u003cp\u003eHemostatic Bandage\u003c/p\u003e\n \u003cp\u003e(N=141)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"bottom\"\u003e\n \u003cp\u003eSuture Renorrhaphy\u003c/p\u003e\n \u003cp\u003e(N=54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"bottom\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.63985374771481%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eAge [years], mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e58.1 (12.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e56.5 (12.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.63985374771481%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eSex, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.9250457038391224%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.714808043875685%\" valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e93 (66.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e32 (59.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.9250457038391224%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.714808043875685%\" valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e48 (34.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e22 (40.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.63985374771481%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eRace, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.9250457038391224%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.714808043875685%\" valign=\"top\"\u003e\n \u003cp\u003eWhite\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e104 (73.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e39 (72.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.9250457038391224%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.714808043875685%\" valign=\"top\"\u003e\n \u003cp\u003eBlack\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e12 (8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e3 (5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.9250457038391224%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.714808043875685%\" valign=\"top\"\u003e\n \u003cp\u003eHispanic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e18 (12.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e10 (18.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.9250457038391224%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.714808043875685%\" valign=\"top\"\u003e\n \u003cp\u003eAsian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e4 (2.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e2 (3.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.9250457038391224%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.714808043875685%\" valign=\"top\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e3 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.63985374771481%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eBMI [kg/m\u003csup\u003e2\u003c/sup\u003e], mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e31.4 (6.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e31.5 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.63985374771481%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eDiabetes mellitus, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e23 (16.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e11 (20.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.63985374771481%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eCKD stage \u0026ge;3, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e14 (9.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e3 (5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.63985374771481%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eTumor size [cm], mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e2.6 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e3.3 (1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001 ***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.63985374771481%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eTumor laterality, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.9250457038391224%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.714808043875685%\" valign=\"top\"\u003e\n \u003cp\u003eLeft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e67 (47.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e26 (48.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.9250457038391224%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.714808043875685%\" valign=\"top\"\u003e\n \u003cp\u003eRight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e74 (52.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e28 (51.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.63985374771481%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eClinical T stage, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.9250457038391224%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.714808043875685%\" valign=\"top\"\u003e\n \u003cp\u003ecT1a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e127 (90.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e43 (79.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e0.064\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.9250457038391224%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.714808043875685%\" valign=\"top\"\u003e\n \u003cp\u003ecT1b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e13 (9.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e11 (20.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.9250457038391224%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.714808043875685%\" valign=\"top\"\u003e\n \u003cp\u003ecT2a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e1 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.63985374771481%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eRENAL nephrometry score, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.9250457038391224%\" valign=\"top\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.714808043875685%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026ge;4 and \u0026lt;7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e66 (46.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e15 (27.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e0.003 **\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.9250457038391224%\" valign=\"top\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.714808043875685%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026ge;7 and \u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e51 (36.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e31 (57.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.9250457038391224%\" valign=\"top\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.714808043875685%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026ge;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e6 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e6 (11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.9250457038391224%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.714808043875685%\" valign=\"top\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e18 (12.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e2 (3.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eSD = standard deviation; BMI = Body Mass Index; CKD = chronic kidney disease\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Operative and perioperative factors.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"547\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.63985374771481%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"bottom\"\u003e\n \u003cp\u003eHemostatic Bandage\u003c/p\u003e\n \u003cp\u003e(N=141)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"bottom\"\u003e\n \u003cp\u003eSuture Renorrhaphy\u003c/p\u003e\n \u003cp\u003e(N=54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"bottom\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.63985374771481%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eApproach, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.9250457038391224%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.714808043875685%\" valign=\"top\"\u003e\n \u003cp\u003eTransperitoneal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e33 (23.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e21 (38.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;0.031 *\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.9250457038391224%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.714808043875685%\" valign=\"top\"\u003e\n \u003cp\u003eRetroperitoneal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e108 (76.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e33 (61.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.63985374771481%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eHilum clamped, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.9250457038391224%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.714808043875685%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e86 (61.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e43 (79.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;0.014 *\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.9250457038391224%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.714808043875685%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e55 (39.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e11 (20.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.63985374771481%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eOperative time [min], mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e141.2 (39.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e183.0 (51.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001 ***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.63985374771481%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eWarm ischemia time\u003csup\u003e\u0026dagger;\u003c/sup\u003e [min], mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e11.6 (4.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e24.2 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001 ***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.63985374771481%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eLength of stay [days], mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e1.2 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e1.8 (1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001 ***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.63985374771481%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eMajor complications\u003csup\u003e\u0026Dagger;\u003c/sup\u003e, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e1 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e2 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.63985374771481%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eEstimated blood loss [mL], mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e36.5 (47.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e214.3 (344.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001 ***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.63985374771481%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eTransfusions, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.63985374771481%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eeGFR change\u003csup\u003e\u0026sect;\u003c/sup\u003e [mL/min/1.73m\u003csup\u003e2\u003c/sup\u003e], mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e-0.66 (19.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.550274223034734%\" valign=\"top\"\u003e\n \u003cp\u003e-0.54 (15.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.259597806215723%\" valign=\"top\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003csup\u003e\u0026dagger;\u0026nbsp;\u003c/sup\u003eWarm ischemia time included only for cases in which hilar clamping was performed.\u003c/p\u003e\n \u003cp\u003e\u003csup\u003e\u0026Dagger;\u003c/sup\u003e Clavien-Dindo grade \u0026ge;3 complications within 90 days.\u003c/p\u003e\n \u003cp\u003e\u003csup\u003e\u0026sect;\u003c/sup\u003e eGFR change at 3 months following surgery compared to preoperative value.\u003c/p\u003e\n \u003cp\u003eSD = standard deviation; eGFR = estimated glomerular filtration rate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e Postoperative outcomes stratified by RENAL nephrometry score.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"664\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"null\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 25.6024%;\" colspan=\"3\"\u003e\n \u003cp\u003eRENAL score \u0026ge;4 and \u0026lt;7\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(N=81)\u003c/p\u003e\u003cbr\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28.6145%;\" colspan=\"3\"\u003e\n \u003cp\u003eRENAL score \u0026ge;7 and \u0026lt;10\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(N=82)\u003c/p\u003e\u003cbr\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.0542%;\" colspan=\"3\"\u003e\n \u003cp\u003eRENAL score \u0026ge;10\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(N=12)\u003c/p\u003e\u003cbr\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.28935532233883%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.545727136431784%\" valign=\"bottom\"\u003e\n \u003cp\u003eHB\u003c/p\u003e\n \u003cp\u003e(N=66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.545727136431784%\" valign=\"bottom\"\u003e\n \u003cp\u003eSR\u0026nbsp;(N=15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.845577211394303%\" valign=\"bottom\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.44527736131934%\" valign=\"bottom\"\u003e\n \u003cp\u003eHB\u0026nbsp;(N=51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.545727136431784%\" valign=\"bottom\"\u003e\n \u003cp\u003eSR\u0026nbsp;(N=31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.845577211394303%\" valign=\"bottom\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.545727136431784%\" valign=\"bottom\"\u003e\n \u003cp\u003eHB\u0026nbsp;(N=6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.545727136431784%\" valign=\"bottom\"\u003e\n \u003cp\u003eSR\u0026nbsp;(N=6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.845577211394303%\" valign=\"bottom\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.28935532233883%\" valign=\"top\"\u003e\n \u003cp\u003eLength of stay [days], mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.545727136431784%\" valign=\"top\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003cp\u003e(0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.545727136431784%\" valign=\"top\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003cp\u003e(1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.845577211394303%\" valign=\"top\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003cp\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.44527736131934%\" valign=\"top\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003cp\u003e(0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.545727136431784%\" valign=\"top\"\u003e\n \u003cp\u003e1.6\u003c/p\u003e\n \u003cp\u003e(1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.845577211394303%\" valign=\"top\"\u003e\n \u003cp\u003e0.083\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.545727136431784%\" valign=\"top\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003cp\u003e(0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.545727136431784%\" valign=\"top\"\u003e\n \u003cp\u003e1.8\u003c/p\u003e\n \u003cp\u003e(0.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.845577211394303%\" valign=\"top\"\u003e\n \u003cp\u003e0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.28935532233883%\" valign=\"top\"\u003e\n \u003cp\u003eMajor complications\u003csup\u003e\u0026dagger;\u003c/sup\u003e,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.545727136431784%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.545727136431784%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e(6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.845577211394303%\" valign=\"top\"\u003e\n \u003cp\u003e0.035\u003c/p\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.44527736131934%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.545727136431784%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e(3.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.845577211394303%\" valign=\"top\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.545727136431784%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e(16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.545727136431784%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.845577211394303%\" valign=\"top\"\u003e\n \u003cp\u003e0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.28935532233883%\" valign=\"top\"\u003e\n \u003cp\u003eEstimated blood loss [mL], mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.545727136431784%\" valign=\"top\"\u003e\n \u003cp\u003e31.4\u003c/p\u003e\n \u003cp\u003e(37.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.545727136431784%\" valign=\"top\"\u003e\n \u003cp\u003e149.7\u003c/p\u003e\n \u003cp\u003e(140.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.845577211394303%\" valign=\"top\"\u003e\n \u003cp\u003e0.005\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.44527736131934%\" valign=\"top\"\u003e\n \u003cp\u003e44.4\u003c/p\u003e\n \u003cp\u003e(58.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.545727136431784%\" valign=\"top\"\u003e\n \u003cp\u003e204.0\u003c/p\u003e\n \u003cp\u003e(355.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.845577211394303%\" valign=\"top\"\u003e\n \u003cp\u003e0.019\u003c/p\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.545727136431784%\" valign=\"top\"\u003e\n \u003cp\u003e56.7\u003c/p\u003e\n \u003cp\u003e(71.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.545727136431784%\" valign=\"top\"\u003e\n \u003cp\u003e475.0\u003c/p\u003e\n \u003cp\u003e(583.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.845577211394303%\" valign=\"top\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.28935532233883%\" valign=\"top\"\u003e\n \u003cp\u003eeGFR change\u003csup\u003e\u0026Dagger;\u003c/sup\u003e [mL/min/1.73m\u003csup\u003e2\u003c/sup\u003e],\u0026nbsp;\u003c/p\u003e\n \u003cp\u003emean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.545727136431784%\" valign=\"top\"\u003e\n \u003cp\u003e-3.4\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(12.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.545727136431784%\" valign=\"top\"\u003e\n \u003cp\u003e0.4\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(16.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.845577211394303%\" valign=\"top\"\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.44527736131934%\" valign=\"top\"\u003e\n \u003cp\u003e5.3\u003c/p\u003e\n \u003cp\u003e(26.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.545727136431784%\" valign=\"top\"\u003e\n \u003cp\u003e-4.9\u003c/p\u003e\n \u003cp\u003e(12.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.845577211394303%\" valign=\"top\"\u003e\n \u003cp\u003e0.056\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.545727136431784%\" valign=\"top\"\u003e\n \u003cp\u003e8.9\u003c/p\u003e\n \u003cp\u003e(10.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.545727136431784%\" valign=\"top\"\u003e\n \u003cp\u003e14.5\u003c/p\u003e\n \u003cp\u003e(19.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.845577211394303%\" valign=\"top\"\u003e\n \u003cp\u003e0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"10\" valign=\"top\"\u003e\n \u003cp\u003e\u003csup\u003e\u0026dagger;\u003c/sup\u003e Clavien-Dindo grade \u0026ge;3 complications within 90 days.\u003c/p\u003e\n \u003cp\u003e\u003csup\u003e\u0026Dagger;\u003c/sup\u003e eGFR change at 3 months following surgery compared to preoperative value.\u003c/p\u003e\n \u003cp\u003eHB = hemostatic bandage; SR = suture renorrhaphy; SD = standard deviation; eGFR = estimated glomerular filtration rate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"partial nephrectomy, sutureless, hemostatic bandage, tumor enucleation, outcomes","lastPublishedDoi":"10.21203/rs.3.rs-3876931/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3876931/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe standard approach to hemostasis during partial nephrectomy (PN) is to perform suture renorrhaphy (SR). Application of a hemostatic bandage (HB) is an alternative maneuver to minimize blood loss and devitalized renal parenchyma. We aim to evaluate perioperative outcomes of PN with tumor enucleation (TE) comparing SR to HB.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe analyzed a retrospective cohort of 195 patients undergoing robot-assisted laparoscopic PN with TE performed by a single surgeon at a tertiary referral center (2012\u0026ndash;2022). Hemostasis of the enucleation bed was obtained with SR in 54 patients while 141 patients underwent application of HB consisting of Surgicel\u0026reg;, Gelfoam\u0026reg; soaked in thrombin, and Floseal\u0026reg;. Patient factors, tumor characteristics, and perioperative outcomes were compared using Student\u0026rsquo;s t-tests and chi-squared tests. Temporal trends were evaluated using Spearman coefficients.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOver time, there was a significant decrease in utilization of SR in favor of HB (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). SR patients had tumors of greater complexity by RENAL nephrometry score compared to HB patients (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Operative time (141 vs 183 min, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), warm ischemia time (11.6 vs 24.2 min, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), estimated blood loss (37 vs 214 mL, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and length of stay (1.2 vs 1.8 days, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) favored the HB group. There was no significant difference in major Clavien-Dindo grade\u0026thinsp;\u0026ge;\u0026thinsp;3 complications (p\u0026thinsp;=\u0026thinsp;0.22). Renal function was comparable with mean estimated glomerular filtration rate decrease of 0.66 and 0.54 mL/min/1.73m2 at 3-months postoperatively for HB and SR, respectively (p\u0026thinsp;=\u0026thinsp;0.93).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eApplication of a HB is a safe alternative to SR for hemostasis following PN with TE in appropriately selected patients.\u003c/p\u003e","manuscriptTitle":"The Evolution of Tumor Enucleation Partial Nephrectomy: A Comparison of Perioperative Outcomes for Sutureless Hemostatic Bandage as an Alternative to Standard Renorrhaphy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-22 18:50:05","doi":"10.21203/rs.3.rs-3876931/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"27749df8-4137-4f41-a955-190701bf7837","owner":[],"postedDate":"January 22nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-01-28T22:14:50+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-22 18:50:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3876931","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3876931","identity":"rs-3876931","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}