Giovanni E Cacciamani1, Luis G Medina2, Tania S Gill2, Alec Mendelsohn2, Fatima Husain2, Lokesh Bhardwaj2, Walter Artibani3, Renè Sotelo2, Inderbir S Gill4. 1. USC Institute of Urology & the Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Urology, University of Verona, Verona, Italy. 2. USC Institute of Urology & the Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA. 3. Department of Urology, University of Verona, Verona, Italy. 4. USC Institute of Urology & the Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA. Electronic address: igill@med.usc.edu.
Abstract
CONTEXT: During robotic partial nephrectomy (RPN), various techniques of hilar control have been described, including on-clamp, early unclamping, selective/super-selective clamping, and completely-unclamped RPN. OBJECTIVE: To evaluate the impact of various hilar control techniques on perioperative, functional, and oncological outcomes of RPN for tumors. EVIDENCE ACQUISITION: We conducted a systematic literature review and meta-analysis of all comparative studies on various hilar control techniques during RPN using PubMed, Scopus, and Web of Science according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement, and Methods and Guide for Effectiveness and Comparative Effectiveness Review of the Agency for Healthcare Research and Quality. Cumulative meta-analysis of comparative studies was conducted using Review Manager 5.3. EVIDENCE SYNTHESIS: Of 987 RPN publications in the literature, 19 qualified for this analysis. Comparison of off-clamp versus on-clamp RPN (n=9), selective clamping versus on-clamp RPN (n=3), super selective clamping versus on-clamp RPN (n=5), and early unclamped versus on-clamp (n=3) were reported. Patients undergoing RPN using off-clamp, selective/super selective, or early unclamp techniques had higher estimated blood loss compared with on-clamp RPN (weight mean difference [WMD]: 47.83, p=0.000, WMD: 41.06, p=0.02, and WMD: 37.50, p=0.47); however, this did not seem clinically relevant, since transfusion rates were similar (odds ratio [OR]: 0.98, p=0.95, OR: 0.72, p=0.7, and OR: 1.36, p=0.33, respectively). All groups appeared similar with regards to hospital stay, transfusions, overall and major complications, and positive cancer margin rates. Short- and long-term renal functional outcomes appeared superior in the off-clamp and super selective clamp groups compared with the on-clamp RPN cohort. CONCLUSIONS: Off-clamp, selective/super selective clamp, and early unclamp hilar control techniques are safe and feasible approaches for RPN surgery, with similar perioperative and oncological outcomes compared with on-clamp RPN. Minimizing global renal ischemia may provide superior renal function preservation. However, higher quality data are necessary for definitive conclusions in this regard. PATIENT SUMMARY: The objective of partial nephrectomy is to treat the cancer while maximizing renal function preservation. Clamping the main vessels is done primarily to reduce the blood loss during partial nephrectomy; however, vascular clamping can compromise kidney function. In order to avoid clamping, various techniques have been described. Our analysis showed that techniques that avoid main renal artery clamping during RPN are associated with better renal function preservation, yet deliver non-inferior perioperative and oncological outcomes as compared with RPN procedures that clamp the main vessels.
CONTEXT: During robotic partial nephrectomy (RPN), various techniques of hilar control have been described, including on-clamp, early unclamping, selective/super-selective clamping, and completely-unclamped RPN. OBJECTIVE: To evaluate the impact of various hilar control techniques on perioperative, functional, and oncological outcomes of RPN for tumors. EVIDENCE ACQUISITION: We conducted a systematic literature review and meta-analysis of all comparative studies on various hilar control techniques during RPN using PubMed, Scopus, and Web of Science according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement, and Methods and Guide for Effectiveness and Comparative Effectiveness Review of the Agency for Healthcare Research and Quality. Cumulative meta-analysis of comparative studies was conducted using Review Manager 5.3. EVIDENCE SYNTHESIS: Of 987 RPN publications in the literature, 19 qualified for this analysis. Comparison of off-clamp versus on-clamp RPN (n=9), selective clamping versus on-clamp RPN (n=3), super selective clamping versus on-clamp RPN (n=5), and early unclamped versus on-clamp (n=3) were reported. Patients undergoing RPN using off-clamp, selective/super selective, or early unclamp techniques had higher estimated blood loss compared with on-clamp RPN (weight mean difference [WMD]: 47.83, p=0.000, WMD: 41.06, p=0.02, and WMD: 37.50, p=0.47); however, this did not seem clinically relevant, since transfusion rates were similar (odds ratio [OR]: 0.98, p=0.95, OR: 0.72, p=0.7, and OR: 1.36, p=0.33, respectively). All groups appeared similar with regards to hospital stay, transfusions, overall and major complications, and positive cancer margin rates. Short- and long-term renal functional outcomes appeared superior in the off-clamp and super selective clamp groups compared with the on-clamp RPN cohort. CONCLUSIONS: Off-clamp, selective/super selective clamp, and early unclamp hilar control techniques are safe and feasible approaches for RPN surgery, with similar perioperative and oncological outcomes compared with on-clamp RPN. Minimizing global renal ischemia may provide superior renal function preservation. However, higher quality data are necessary for definitive conclusions in this regard. PATIENT SUMMARY: The objective of partial nephrectomy is to treat the cancer while maximizing renal function preservation. Clamping the main vessels is done primarily to reduce the blood loss during partial nephrectomy; however, vascular clamping can compromise kidney function. In order to avoid clamping, various techniques have been described. Our analysis showed that techniques that avoid main renal artery clamping during RPN are associated with better renal function preservation, yet deliver non-inferior perioperative and oncological outcomes as compared with RPN procedures that clamp the main vessels.
Authors: Rachel Melnyk; Yuxin Chen; Tyler Holler; Nathan Schuler; Patrick Saba; Scott Quarrier; Jonathan Bloom; William Tabayoyong; Thomas Frye; Hani Rashid; Jean Joseph; Ahmed Ghazi Journal: World J Urol Date: 2022-01-23 Impact factor: 4.226
Authors: Karl-Friedrich Kowalewski; Marie Angela Sidoti Abate; Manuel Neuberger; Marietta Kirchner; Regina Krisam; Luisa Egen; Caelan Max Haney; Fabian Siegel; Maurice-Stephan Michel; Patrick Honeck; Philipp Nuhn; Niklas Westhoff; Maximilian Christian Kriegmair Journal: BMJ Open Date: 2021-11-03 Impact factor: 2.692
Authors: Aditya P Sharma; Ravimohan S Mavuduru; Girdhar S Bora; Sudheer K Devana; Shrawan K Singh; Arup K Mandal Journal: Investig Clin Urol Date: 2018-08-21