Association between Ureteral Clamping Time and Acute Kidney Injury during Robot-Assisted Radical Cystectomy

Abstract

Robot-assisted radical cystectomy (RARC) is replacing open radical cystectomy (ORC) and requires clamping of the ureters, resulting in a predisposition to postrenal acute kidney injury (AKI). We investigated the association between ureteral clamping or its duration and acute/chronic postoperative kidney function. Patients who underwent radical cystectomy (robotic or open) at two tertiary institutions during 2002–2021 were retrospectively enrolled. In those who underwent RARC, the maximum postoperative percentage serum creatinine level (%sCre) change was plotted against ureteral clamping duration. They were divided into two groups using the median clamping time (210 min), and the maximum %sCre change and percentage estimated glomerular filtration rate (%eGFR) change at 3–6 months (chronic) were compared between the ORC (no clamp), RARC < 210, and RARC ≥ 210 groups. In 44 RARC patients, a weak correlation was observed between the duration of ureteral clamping and %Cre change (R2 = 0.22, p = 0.001). Baseline serum creatinine levels were comparable between the groups. However, %sCre change was significantly larger in the RARC ≥ 210 group (N = 17, +32.1%) than those in the RARC < 210 (N = 27, +6.1%) and ORC (N = 76, +9.5%) groups (both, p < 0.001). Chronic %eGFR change was comparable between the groups. Longer clamping of the ureter during RARC may precipitate AKI; therefore, the clamping duration should be minimized.

The Feasibility of Modified Laparoscopic Female Radical Cystectomy: A Procedural Guide and Comparison with Traditional Technique

“…Their ndings showed that early postoperative AKI occurred in 100 out of 912 patients (11%). The high incidence of AKI is thought to be due to prolonged surgical clamping of the ureter, which hinders urine drainage [32] . In the patients who underwent MLRC, ureters were not clamped immediately after the ureters were completely dissociated.…”

Acute Intraoperative Hyperkalemia During Robot-Assisted Radical Cystectomy: A Case Report

“…8 A retrospective study identified prolonged clamping of the ureters during robot-assisted radical cystectomy as a causative factor for acute kidney injury (AKI). 9 AKI may result in metabolic acidosis, hyperkalemia, and cardiovascular complications. 10 Additionally, pneumoperitoneum during robot-assisted radical cystectomy adversely affects renal function through its negative effects on renal blood flow.…”

Editorial Comment to Impact of early postoperative creatinine increase on mid‐term renal function after cystectomy

“…In addition to avoiding unnecessary manipulation of the ureters and minimizing operation length, minimization of ureteral clamping may contribute to better renal function preservation. 4 In contrast, the introduction of an enhanced recovery after surgery protocol, now widely utilized, may require extra caution to reduce the risk of AKI. 5 However, more data on intra-and pre/post-operative risk factors for renal function loss are needed, and such investigations are highly warranted.…”

“…Surgery itself also requires continuous refinement. In addition to avoiding unnecessary manipulation of the ureters and minimizing operation length, minimization of ureteral clamping may contribute to better renal function preservation 4 . In contrast, the introduction of an enhanced recovery after surgery protocol, now widely utilized, may require extra caution to reduce the risk of AKI 5 .…”