Nephron sparing surgery for renal tumors-comparison of off-clamp partial nephrectomy with hilar clamping

Abstract

Background and Objective: Open partial nephrectomy (PN) is still considered gold standard procedure for T1 localized renal tumors. Conventional technique involves clamping of the renal artery with or without vein however, renal ischemia produces a certain level of damage to the kidneys. This study aims to investigate potential effect of off-clamp vs. hilar clamping PN on renal function.
 Methods: This is a retrospective cohort study of patients who underwent unilateral, open partial nephrectomy for renal tumors b/w January 2009 December 2016 at our institution. A total of 90 partial nephrectomies were performed of which 65 cases were eligible for analysis. Non clamping technique was used in 43 while clamp was applied in 22 patients. Variables studied were patients’ demographics, clinical variables, the laterality, tumors size and location, R.E.N.A.L nephrometry score, blood loss, tumor histology and surgical margins. Patients’ renal function (serum creatinine and eGFR) were determined pre-operatively, at 3 and 12 months follow up. Data was analyzed on SPSS v. 22.
 Results: Both the groups were comparable with regards to pre-operative renal function. Mean radiological size of tumor was 4.71±1.31 and 3.81±1.0 (0.003) in two groups respectively. Mean R.E.N.A.L nephrometry score was 6.1±1.5 in off-clamp group compared to 7.05±1.7 in clamp group (p=0.04). No statistically significant difference was found in operative duration, blood loss, positive surgical margins and intra/ peri-operative complications. At three months and one year, renal function was better preserved in non-clamp group compared to clamp group (p=0.001 and 0.007 respectively).
 Conclusion: Off clamp open partial nephrectomy is safe and feasible option leading to less decline in renal function.
 doi: https://doi.org/10.12669/pjms.36.3.1533
 How to cite this:Jalbani IK, Nazim SM, Ahmed M, Abbas F. Nephron sparing surgery for renal tumors- comparison of off-clamp partial nephrectomy with hilar clamping. Pak J Med Sci. 2020;36(3):---------. doi: https://doi.org/10.12669/pjms.36.3.1533
 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Re: Zhang Y, Long G, Shang H, Ding B, Sun G, Ouyang W, et al. Comparison of the oncological, perioperative and functional outcomes of partial nephrectomy versus radicalnephrectomy for clinical T1b renal cellcarcinoma: a systematic review and meta-analysis of retrospective studies. Asian J Urol 2021;8: 117–25.

“…This is confirmed by the results of Imran Khan et al. [ 7 ] in a very interesting study, comparing the results of PN on RF with or without pedicle clamping. They noticed an increase in the postoperative RF (group without clamping) at 3 months compared to the preoperative RF (93.14±40.70 vs. 88.00±36.11 mL/min) before decreasing at 1 year (91.93±39.60 mL/min).…”

Nefrectomia parcial sem isquemia é segura? Pontos sob a lesão controlam o sangramento em abordagem minimamente invasiva

“…As cirurgias minimamente invasivas apresentam inúmeros benefícios como redução da dor, tempo de recuperação mais rápido para os pacientes e internações hospitalares mais curtas. (9) Este procedimento consiste em promover uma ressecção da massa renal com margens adequadas e tentar poupar o máximo possível de néfrons. Para obter uma correta extração do tumor, é possível isolar os vasos renais e pinçá-los (veia e artéria juntas ou pinçamento seletivo da artéria) para ressecção da massa sem sangramento (10).…”

Interobserver Reliability of the RENAL Nephrometry Scoring System: Experience From a Developing Nation

“…In one such study, patients with 81% of unresectable RCC were categorized as high complexity, and the post neoadjuvant of 46% was downgraded to moderately complex, which aided in surgery [15]. Another study by urologists of our institute also implemented the RENAL-NS to investigate the potential effect of off-clamp vs. hilar clamping partial nephrectomy on renal function [16]. Therefore, our data highlight the fact that the RENAL-NS system is an easy method to assess the complexity of renal tumors while facilitating treatment decision-making by multidisciplinary teams.…”