Impact of the off-clamp endoscopic robot-assisted simple enucleation (ERASE) of clinical T1 renal tumors on the postoperative renal function: Results from a matched-pair comparison

Abstract

a b s t r a c tPurpose: To evaluate the surgical and functional outcomes of a matched-paired series of on-clamp vs offclamp endoscopic robot-assisted simple enucleation (ERASE) and standardized renorraphy in a tertiary referral institution, to search for predictors of functional drop after surgery and to investigate the influence of off-clamp technique in patients presenting these characteristics. Materials and methods: A matched-pair comparison of 120 on-clamp vs 120 off-clamp over 491 patients treated with ERASE was performed. Perioperative and functional outcomes were compared between groups. Results: Patients treated with on-clamp and off-clamp technique had comparable complication and positive surgical margin rate. The off-clamp group had a significantly lower eGFR drop compared to the on-clamp group at 3rd postoperative day (POD) (1% vs 7%, p ¼ 0.0001) and at 30th POD (2.5% vs 9%, p ¼ 0.01) from baseline. This difference lost its statistical significance at 6th month and at last follow-up (median 40 months). At multivariable analysis the Charlson comorbidity index (OR 2.06, p < 0.0001), uncontrolled type 2 diabetes mellitus (OR 4.13, p < 0.001) were independent predictive factors of a >15% eGFR drop from baseline to last follow-up. In a subanalysis over 64 comorbid patients, those patients who underwent off-clamp ERASE had a significantly lower eGFR drop compared to the comorbid counterpart during the whole follow-up. Conclusions: The off-clamp ERASE is a safe surgical technique with a significantly lower renal function drop compared to on-clamp ERASE in the early perioperative time. Patients with comorbidity might represent a subgroup of patients having a functional benefit after off-clamp RAPN even in the long-term period.

On‐clamp versus off‐clamp partial nephrectomy: Propensity score‐matched comparison of long‐term functional outcomes

“…Nevertheless, the threshold for impaired eGFR was only one (reduction in eGFR >15%), not allowing to precisely distinguish the patients with severe reduction of RF from those with moderate impairment. In addition, even in this study the follow‐up period did not exceed 40 months …”

“…Conversely, a recent PSM analysis carried out with 240 Italian patients reported some benefits of the unclamping technique in postoperative RF outcomes . Pedicle clamping was found as an independent predictor of immediate (3 days after surgery) and early (1 month after) RF impairment, but the difference lost its statistical significance at the sixth month and at longer follow‐up periods (up to 40 months) .…”

“…Conversely, a recent PSM analysis carried out with 240 Italian patients reported some benefits of the unclamping technique in postoperative RF outcomes . Pedicle clamping was found as an independent predictor of immediate (3 days after surgery) and early (1 month after) RF impairment, but the difference lost its statistical significance at the sixth month and at longer follow‐up periods (up to 40 months) . However, in a subanalysis of 64 patients with Charlson Comorbidity Index ≥2 (all patients with uncontrolled diabetes type 2 belonged to this category by definition) despite normal eGFR at baseline, the Off‐C group showed a significantly lower rate of RF impairment (reduction in eGFR >15%) during the entire follow‐up period (at 6 months 4% vs 13.5%, P = 0.02; at last follow up 7.5% vs 15%, P = 0.01) .…”

“…Pedicle clamping was found as an independent predictor of immediate (3 days after surgery) and early (1 month after) RF impairment, but the difference lost its statistical significance at the sixth month and at longer follow‐up periods (up to 40 months) . However, in a subanalysis of 64 patients with Charlson Comorbidity Index ≥2 (all patients with uncontrolled diabetes type 2 belonged to this category by definition) despite normal eGFR at baseline, the Off‐C group showed a significantly lower rate of RF impairment (reduction in eGFR >15%) during the entire follow‐up period (at 6 months 4% vs 13.5%, P = 0.02; at last follow up 7.5% vs 15%, P = 0.01) . Nevertheless, the threshold for impaired eGFR was only one (reduction in eGFR >15%), not allowing to precisely distinguish the patients with severe reduction of RF from those with moderate impairment.…”

“…More recently, the impact of unclamping techniques was questioned. [19][20][21] Shah et al retrospectively analyzed data from 315 patients (209 On-C PN vs 106 Off-C PN). 19 A short-term benefit in RF was achieved in the unclamped cohort postoperatively; conversely there were no differences in functional outcomes between the On-C and Off-C cohorts beyond 6-month follow up.…”