Renal function is the same 6 months after robot‐assisted partial nephrectomy regardless of clamp technique: analysis of outcomes for off‐clamp, selective arterial clamp and main artery clamp techniques, with a minimum follow‐up of 1 year

Abstract

ObjectiveTo compare the renal functional outcomes, with >1 year of follow-up, of patients who underwent robot-assisted partial nephrectomy (RAPN) performed with different clamping techniques. Patients and MethodsThe peri-operative data of patients undergoing RAPN performed with different clamping techniques were retrospectively analysed (group 1: off-clamp, n = 23; group 2: selective clamp, n = 25; group 3: main artery clamp, n = 114). The main outcome measures were postoperative serum creatinine level, estimated glomerular filtration rate (eGFR) and percentage change in eGFR, the data for which were collected at periodic intervals during the first 12 months and annually thereafter, in addition to late eGFR value. Only patients with >1 year of follow-up were included in the analysis. ResultsThe baseline characteristics of groups 2 and 3 were similar, while patients in group 1 had smaller sized tumours and lower tumour complexity. The median follow-up periods were 45 (group 1), 20 (group 2) and 47 (group 3) months. The median clamping times were 24.8 min in the main artery clamp and 18 min in the selective artery clamp groups. Group 2 had greater median blood loss volume (100 vs 500 vs 200 mL for groups 1, 2 and 3, respectively; P < 0.01) and a longer length of hospital stay (3 vs 4 vs 3 days for groups 1, 2 and 3, respectively; P = 0.02). No significant differences were found among the groups with regard to transfusion rates, positive surgical margin rates, complications, recurrence or mortality rates. Groups 1 and 2 had significantly less deterioration of postoperative renal function during the first 3 months after surgery (P = 0.04; percent change in eGFR À1.5, À2 and À8% for groups 1, 2 and 3, respectively), but this beneficial outcome was not observed after 6 months or for the latest eGFR measurement (P = 0.48; latest percent change in eGFR À3, À6 and À3.5% for groups 1, 2 and 3, respectively). In regression analysis, baseline eGFR, type of clamp procedure and tumour complexity score were predictive of normal renal function 7 days after surgery, while only baseline eGFR and age could predict it 1 year postoperatively. ConclusionsOff-clamp and selective artery clamp techniques result in superior short-term renal functional outcomes compared with the main artery clamp approach; however, after the 6th postoperative month, there were no significant differences regarding the functional outcome among the above surgical techniques, as long as the warm ischaemia time was 20-30 min.

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

“…Concordantly, Komninos et al reported that the off-clamp and selective artery clamp techniques during RAPN had a significantly lower eGFR drop compared to on-clamp cases at 7th POD (p < 0.01) [10]. However, after the sixth postoperative month, the global RF was not significantly influenced by the hilum management (as long as WIT was <30 min).…”

“…However, the use of off-clamp procedures is increasingly adopted to maximize the functional outcome after conservative surgery as prolonged ischemia time has been associated with a significantly higher RF impairment [8]. Nevertheless, a definitive functional benefit of offclamp PN has not been proved yet [3,9,10]. Beyond a possible protective effect on postoperative RF, off-clamp PN could be associated with a higher complication and positive surgical margin (SM) rate due to a higher bleeding and a subsequent suboptimal vision [11].…”

The Impact of Arterial Clamping Technique in Robot-Assisted Partial Nephrectomy on Renal Function and Surgical Outcomes: Six-Year Experience at Siriraj Hospital, Thailand

“…Komninos et al [9] reported less deterioration in renal function during the first 3 months after SAC and OCT compared with MAC ( p  = 0.04), while there was no beneficial outcomes after 6 months ( p  = 0.48). Martin et al [10] also showed no significant changes in renal function between clamping techniques after 1-year follow-up period.…”

To clamp or not to clamp in robotic partial nephrectomy?

“…This is a useful reference on penile size, flaccid, stretched and erect [1]. It is interesting to note that the stretch length is quite a useful surrogate for erect length.…”

“…The article by Komninos et al [1], in this issue of the BJUI has looked into the importance of warm ischaemia techniques in robot-assisted partial nephrectomy (RAPN) on the deterioration in short-and longer-term renal function. A case series of 162 procedures undertaken by a single surgeon over a 7-year period was analysed.…”