Is postoperative arteriovenous fistula still a concern after en bloc stapling of the renal hilum during laparoscopic nephrectomy?

Purpose: To report our experience with en bloc stapling of the renal hilum during laparoscopic nephrectomy (LN) and nephroureterectomy and to compare it with separate stapling performed during the same period at the same institution. Patients and Methods: We conducted a retrospective review of 125 laparoscopic nephrectomies and nephroureterectomies performed between November 2003 and September 2006 for benign and malignant conditions. The main outcome was assessment of complications, with special emphasis on postoperative arteriovenous fistula. Secondary outcomes included operative blood loss and operative time. Statistical analysis was performed using two-sided parametric, nonparametric, or categorical tests as appropriate. Statistical significance was set at P0.05. Results: The transperitoneal approach and 2.5mM vascular titanium clips were used in all cases. En bloc stapling (group 1) was performed in 65 patients and individual stapling (group 2) in 60. There was a significantly higher proportion of right-side surgeries in group 1 than in group 2 (51 vs 25%, P=0.05). Overall complications were 31% vs 32%, P=0.91; mean operative time (confidence interval [CI]) 130 (95% 119, 141) vs 125min (95% 115, 136), P=0.3; and mean operative blood loss (CI) 100 (95% 39, 160) vs 135mL (95% 76, 193), P=0.33 did not differ for groups 1 and 2, respectively. After a median follow-up (interquartile range) of 25 (24.7) vs 30 (30.0) months, P=0.14, no cases of arteriovenous fistula were detected. Conclusions: En bloc stapling of the renal hilum is as safe and effective as individual stapling. Arteriovenous fistula after LN does not seem to be a concern with the use of modern inorganic titanium staplers.