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UroToday.com - This is an important manuscript that documents the incidence of postoperative bleeding (overall 0.4%) with upper retroperitoneal laparoscopic surgery (nephrectomy = 3.3%, adrenalectomy = 5.4%, and partial nephrectomy = 9.9%). Risk factors included patient age and ASA classification; surgeon experience, standard vs. hand-assist approach, gender, body mass index, and prior surgery did not correlate with an increased risk of hemorrhage. Over half of these patients (56%), required only a 1-2 unit transfusion; almost all of the remainder received anywhere from 3- 6 units. There were two patients who required 11 and 12 units; one had portal hypertension and was converted to an open procedure and the other was on chronic anticoagulation therapy and bled at postoperative day 4 after restarting coumadin; this individual was readmitted with a PTT > 100 seconds. Of note, only 12% (0.4% overall) required surgical management and among these 4 patients, one would not be explored today (venous oozing) and one was for a late splenic bleed. The average hospital stay was increased by 4 days among the patients with postoperative hemorrhage. A similar report on hemorrhage after upper retroperitoneal laparoscopy was recently published by Bhayani, Kavoussi, and colleagues; however, in this article twice as many patients (0.8%) underwent exploration for postoperative hemorrhage.1 While in the Bhayani study, early exploration (0.4%) was justified by the operative findings (i.e. all due to arterial bleeding) in those with an acute problem (i.e. hypotension, greater than 10 unit drop in hematocrit from the initial postoperative hematocrit), such was not the case for patients with a more gradual decrease in the hematocrit (i.e. 5 point drop and > 5 unit transfusion over 24-36 hrs.). Among the latter patients undergoing exploration for a gradual fall in hematocrit, only a "diffuse oozing" was found at surgery; among these patients the hospital stay was prolonged to 12 days. Perhaps even a more conservative algorithm, as championed in the present article, should be considered in patients with a gradual hemorrhage picture. 1Bhayani, S. B., Link, R. E., Makarov, D. V., et al.: J. Urology 175: 2137-2139, 2006 H. M. Rosevear, J. S. Montgomery, W. W. Roberts, and J. S. Wolf, Jr. J. Urol. 176: 1458-1462, October 2006 Reviewed by UroToday.com Medical Editor Ralph Clayman, MD UroToday - the only urology website with original content written by global urology key opinion leaders actively engaged in clinical practice.
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