Use of gelatin matrix thrombin tissue sealant as an effective hemostatic agent during laparoscopic partial nephrectomy.

PURPOSE: We describe a technique for achieving effective hemostasis during laparoscopic partial nephrectomy using gelatin matrix thrombin tissue sealant. MATERIALS AND METHODS: Between June 2002 and April 2003, 6 patients underwent laparoscopic partial nephrectomy using the 2-component tissue sealant. Median patient age was 59 years (range 28 to 71) and followup time ranged from 1 to 10 months (median 4.3). The tumor was at least 50% exophytic on preoperative computerized tomography and the diameter ranged from 2 to 3 cm (median 2.5). The 2-component tissue sealant, consisting of a gelatin matrix granula component and a thrombin component, was applied after resection of the tumor and before reperfusion of the kidney. Time until complete hemostasis was achieved, postoperative bleeding, estimated blood loss, warm ischemia time and length of surgery were recorded. RESULTS: Hemostasis was immediate in all cases after application of the tissue sealant for 1 to 2 minutes to the moist resection site. The laparoscopic applicator was used to apply the material to the renal parenchyma. Hemostasis was maintained when reperfusion of the kidney was established. Estimated blood loss ranged from 50 to 350 cc (median 200), and no patient required blood transfusion. Length of surgery ranged from 89 to 230 minutes (median 189), and warm ischemia time ranged from 10 to 14 minutes (median 13). No postoperative bleeding occurred. CONCLUSIONS: The 2-component tissue sealant provided immediate and durable hemostasis in laparoscopic partial nephrectomy. It is a safe and time sparing alternative adjunct to currently available means of achieving hemostasis. In a select patient population use of this agent may reduce warm ischemia time by circumventing the need to perform laparoscopic suturing.

Characterization of prostate cancer missed by sextant biopsy.

There is a trend to increase the number of prostate biopsies taken to increase the detection rate of prostate cancer. We examined radical prostatectomy specimens and correlated the findings to those of preoperative sextant biopsy in an effort to identify the characteristics of tumors that went undetected by our biopsy regimen. Seventy-one patients diagnosed with prostate cancer based on sextant biopsy who underwent radical prostatectomy at our institution from June 1995 to November 2001 had prostatectomy specimens and biopsy slides reviewed. These specimens were step-sectioned and whole-mounted. The location, size, and grade of individual cancer foci in the prostatectomy specimens were correlated with results of the original sextant biopsies. Clinically significant tumors were defined as those with volume > 0.5 mL or Gleason score > or= 7 and extracapsular extension. In 33 patients (46%), there was concordance of biopsy and prostatectomy findings. In 38 patients (54%), additional lesions were demonstrated in the prostatectomy specimens that were not detected by our sextant biopsies. These included 13 cases (34%) with tumors > 0.5 mL and 25 cases in which the lesions were < 0.5 mL in size. However, 7 of these cases contained tumors with Gleason score > or =7. Tumors were located in the transition zone in 8 of these 38 cases (21%), and the remaining tumors were located in the peripheral zone (79%). No tumors with extracapsular extension were missed. Thus, 20 of the 71 cases (28%) had clinically significant cancers that went undetected by the traditional sextant biopsy method. Greater than 50% of patients who underwent sextant biopsy of the prostate had additional tumors that were missed when compared to the pathologic specimen. As many as 28% of these patients had clinically significant cancer based on size and grade criteria. A strategy of increased numbers of biopsies would improve the detection rate of these clinically important tumors. However, the ideal strategy for optimizing cancer detection requires further investigation because increased numbers of biopsies would also increase detection of clinically insignificant tumors.