Leedor Lieberman1,2, Ravi Barod2, Deepansh Dalela2, Mireya Diaz-Insua2, Ronney Abaza3, James Adshead4, Rajesh Ahlawat5, Benjamin Challacombe6, Prokar Dasgupta6, Giogio Gandaglia7, Daniel A Moon8, Giacomo Novara9, Francesco Porpiglia10, Alexandre Mottrie7, Mahendra Bhandari2, Craig Rogers2. 1. 1 Wayne State University School of Medicine , Detroit, Michigan. 2. 2 Vattikuti Urology Institute , Henry Ford Hospital, Detroit, Michigan. 3. 3 Department of Urology, Ohio Health Dublin Methodist Hospital , Dublin, Ohio. 4. 4 Hertfordshire and South Bedfordshire Urological Cancer Centre, Lister Hospital , Stevenage, United Kingdom . 5. 5 Division of Urology and Renal Transplantation, Medanta Kidney and Urology Institute , Medanta, The Medicity, Gurgaon, India . 6. 6 MRC Centre for Transplantation, King's College London , London, United Kingdom . 7. 7 OLV Vattikuti Robotic Surgery Institute , Melle, Belgium . 8. 8 Peter MacCallum Cancer Centre , Melbourne, Victoria, Australia . 9. 9 Oncological and Surgical Sciences, Urology Clinic, University of Padua , Padua, Italy . 10. 10 San Luigi Gonzaga Hospital, University of Turin , Orbassano, Turin, Italy .
Abstract
INTRODUCTION: Hilar clamping is often performed to facilitate robotic partial nephrectomy (RPN). Minimal clamping techniques may reduce renal ischemia, including early unclamping, selective clamping, and off-clamp RPN. We assess the utilization of clamping techniques in a large international consortium of surgeons performing RPN for complex tumors. METHODS: We retrospectively evaluated 721 patients with complex tumors, who underwent RPN at 11 centers worldwide between 2008 and 2014. Complex tumors were defined as renal masses with a nephrometry score >6. Total clamping was defined as complete clamping of the main renal artery. Minimal clamping techniques included early unclamping, selective clamping, and off-clamp RPN. Clamping techniques were additionally assessed in patients with estimated glomerular filtration rate (eGFR) <60 and in patients with a solitary kidney. Two-tailed t-tests (p < 0.05) were used to statistically analyze differences in mean warm ischemia time (WIT). RESULTS: Most patients underwent complete clamping (75.1%). Minimal clamping (24.9%) included early unclamping (10.8%), selective clamping (8.7%), and off-clamp (5.4%). Mean WIT of total clamping, selective clamping, and early unclamping was 22.2, 21.2, and 17.3 minutes, respectively. Of patients with an eGFR <60 (n = 90), 26.6% underwent minimal clamping, including 15.5% early unclamping, 4.4% selective clamping, and 6.7% off-clamp. Of patients with solitary kidneys (n = 12), 10 (83%) were performed with total clamping with mean WIT of 14.9 minutes. CONCLUSIONS: In this large international series of RPN for complex tumors, most patients underwent total clamping of the main renal artery. Minimal clamping techniques, including early unclamping, selective clamping, and off-clamp techniques, were used in a minority of cases. There was no significant increase in use of minimal clamping, even in patients with chronic kidney disease or solitary kidneys. However, mean WIT was low (<23 minutes) in all patient groups.
INTRODUCTION: Hilar clamping is often performed to facilitate robotic partial nephrectomy (RPN). Minimal clamping techniques may reduce renal ischemia, including early unclamping, selective clamping, and off-clamp RPN. We assess the utilization of clamping techniques in a large international consortium of surgeons performing RPN for complex tumors. METHODS: We retrospectively evaluated 721 patients with complex tumors, who underwent RPN at 11 centers worldwide between 2008 and 2014. Complex tumors were defined as renal masses with a nephrometry score >6. Total clamping was defined as complete clamping of the main renal artery. Minimal clamping techniques included early unclamping, selective clamping, and off-clamp RPN. Clamping techniques were additionally assessed in patients with estimated glomerular filtration rate (eGFR) <60 and in patients with a solitary kidney. Two-tailed t-tests (p < 0.05) were used to statistically analyze differences in mean warm ischemia time (WIT). RESULTS: Most patients underwent complete clamping (75.1%). Minimal clamping (24.9%) included early unclamping (10.8%), selective clamping (8.7%), and off-clamp (5.4%). Mean WIT of total clamping, selective clamping, and early unclamping was 22.2, 21.2, and 17.3 minutes, respectively. Of patients with an eGFR <60 (n = 90), 26.6% underwent minimal clamping, including 15.5% early unclamping, 4.4% selective clamping, and 6.7% off-clamp. Of patients with solitary kidneys (n = 12), 10 (83%) were performed with total clamping with mean WIT of 14.9 minutes. CONCLUSIONS: In this large international series of RPN for complex tumors, most patients underwent total clamping of the main renal artery. Minimal clamping techniques, including early unclamping, selective clamping, and off-clamp techniques, were used in a minority of cases. There was no significant increase in use of minimal clamping, even in patients with chronic kidney disease or solitary kidneys. However, mean WIT was low (<23 minutes) in all patient groups.