Comparison of Selective Parenchymal Clamping to Hilar Clamping During Robotic-assisted Laparoscopic Partial Nephrectomy

Abstract

OBJECTIVE To compare perioperative outcomes after robotic-assisted laparoscopic partial nephrectomy (RALPN) with hilar clamping vs parenchymal clamping. METHODS A retrospective, single-institution review of the patients undergoing RALPN with hilar or parenchymal clamping was performed. Associations between perioperative factors and clinicopathologic outcomes were determined using the t test, Fisher’s exact test, and multivariate linear regression. RESULTS In 51 patients undergoing RALPN, 36 (71%) and 15 (29%) were performed with hilar and parenchymal clamping, respectively. Median tumor diameter was 2.8 cm for both groups (range, 1.1–6.1; P =.93). Tumor complexity by nephrometry score was mild (69% vs 80%), moderate (29% vs 20%), and high (2% vs 0%) in the respective groups (P =.65). Operative time was significantly shorter in the parenchymal clamp group (median 245 vs 320 minutes; P <.0001). There was no difference in blood loss and need for transfusion. On multivariate analysis, hilar clamping (P <.01), higher body mass index (P =.01), and higher complexity tumors (P =.02) were significantly associated with longer operative times. The parenchymal clamp group had better preservation of immediate postoperative glomerular filtration rate (GFR) from baseline to postoperative day 2 (median ΔGFR 0 vs −18 mL/min/1.73 m2, P =.02). These differences from baseline did not persist (median ΔGFR −6 vs −7 mL/min/1.73 m2, P =.35) at a median follow-up of 6.6 months. Final pathology determination of malignancy (P =.51) and positive margin rates (P =.26) were similar in both groups. CONCLUSION Compared with hilar clamping, selective regional ischemia with the parenchymal clamp for mild-moderately complex tumors is feasible and safe during RALPN. Parenchymal clamping is associated with enhanced immediate preservation of GFR and shorter operative times.

A Novel Mathematical Model to Predict the Severity of Postoperative Functional Reduction before Partial Nephrectomy: The Importance of Calculating Resected and Ischemic Volume

“…WIT reduction techniques have expectedly led to better PRF recovery. 6,7,18 However, the safe duration of ischemia during PN remains controversial. 19e21 Several studies indicated that ischemia time has a secondary role and the quantity of preserved nephrons is the primary determinant of ultimate renal function after PN.…”

Open partial nephrectomy: current review

“…Off-clamp PN and parenchymal compression are both novel techniques being utilized which aim to avoid hilar clamping entirely (43). Regional ischemia by way of a parenchymal clamp or tourniquet may be feasible when the anatomy allows, particularly in the case of tumors in polar locations.…”

Preoperative evaluation of renal artery anatomy using computed tomography angiography to guide the superselective clamping of renal arterial branches during a laparoscopic partial nephrectomy

“…Loss of renal function occurs if the duration of warm ischemia is >28 min (5). A number of techniques have been developed with the aim of minimizing warm ischemic injury (2,6,7). The technique of renal segmental artery clamping involves the selective clamping of renal arterial branches, and may eliminate renal ischemia from the entire kidney and minimize renal functional loss (4).…”