Adjunctive topical hemostatic agents combined with renorrhaphy versus renorrhaphy alone during partial nephrectomy: a systematic review and meta-analysis.

Partial nephrectomy (PN) is the standard of care for T1 renal tumors, offering oncological outcomes equivalent to radical nephrectomy while preserving renal function. Intraoperative hemostasis remains a critical challenge, as warm ischemia time is independently associated with postoperative renal functional decline. Topical hemostatic agents have been increasingly adopted as adjuncts to renorrhaphy; however, their incremental benefit over suture alone remains unestablished. This study aimed to compare the efficacy and safety of hemostatic agents combined with renorrhaphy versus renorrhaphy alone in patients undergoing PN. This systematic review and meta-analysis followed PRISMA guidelines and the Cochrane Handbook, with prospective registration in PROSPERO (CRD420261396802). MEDLINE, Embase, CENTRAL, Web of Science, and Scopus were searched from inception to March 15, 2026, for RCTs and comparative observational studies comparing hemostatic agents combined with renorrhaphy versus renorrhaphy alone in adult PN patients. The primary outcome was blood transfusion rate (BTR); secondary outcomes included estimated blood loss (EBL), hemorrhagic complications (HC), and urinary leakage (UL). A random-effects model with REML estimation was used. Risk of bias was assessed with RoB 2 and ROBINS-I V2; certainty of evidence was graded using GRADE. Fifteen studies (2 RCTs, 13 observational) comprising 3,408 patients were included from 2,281 identified (1,265 screened after duplicate removal). No significant difference was observed for BTR (RR 0.96; 95% CI 0.59-1.57; I2 = 44.7%; 95% prediction interval 0.24-3.90), HC (RR 0.73; 95% CI 0.40-1.35; I2 = 47.6%; PI 0.14-3.83), or UL (RR 1.36; 95% CI 0.56-3.28; I2 = 0.0%; PI 0.45-4.09). EBL heterogeneity was considerable (I2 = 97.8%) and irreducible on leave-one-out (lowest I2 = 84.1%); it is therefore reported narratively, with study-level differences ranging from - 120 to + 57 mL. No publication bias was detected (Egger p = 0.598). Current evidence does not demonstrate a benefit of adjunctive hemostatic agents over renorrhaphy alone. With wide intervals and low certainty for most outcomes, these data reflect an absence of evidence of benefit rather than evidence of absence, and a clinically relevant effect cannot be excluded. Routine use is not supported; adequately powered trials stratified by tumor complexity and agent class are warranted.