Laparoscopic and Robotic Urology
Perioperative outcomes of off-clamp vs complete hilar control laparoscopic partial nephrectomy
Article first published online: 6 NOV 2012
© 2012 THE AUTHORS. BJU INTERNATIONAL © 2012 BJU INTERNATIONAL
Volume 111, Issue 4b, pages E235–E241, April 2013
How to Cite
George, A. K., Herati, A. S., Srinivasan, A. K., Rais-Bahrami, S., Waingankar, N., Sadek, M. A., Schwartz, M. J., Okhunov, Z., Richstone, L., Okeke, Z. and Kavoussi, L. R. (2013), Perioperative outcomes of off-clamp vs complete hilar control laparoscopic partial nephrectomy. BJU International, 111: E235–E241. doi: 10.1111/j.1464-410X.2012.11573.x
- Issue published online: 22 MAR 2013
- Article first published online: 6 NOV 2012
- Accepted for publication 11 July 2012
- renal cell carcinoma;
- renal ischemia;
- laparoscopic partial nephrectomy;
- ischaemia-reperfusion injury
What's known on the subject? and What does the study add?
Off-clamp laparoscopic partial nephrectomy (LPN) is thought to preserve renal function by limiting warm ischaemia time (WIT) and consequently reperfusion injury. To date, studies using the off-clamp technique represent a heterogeneous group, with limited follow-up showing feasibility and safety in a restricted number of cases.
We report the largest experience of off-clamp vs on-clamp LPN with perioperative outcomes and intermediate follow-up of renal functional outcomes with stratification by WIT.
- • To evaluate perioperative and 6-month renal functional outcomes of patients undergoing off-clamp vs complete hilar control laparoscopic partial nephrectomy (LPN).
PATIENTS AND METHODS
- • A retrospective review of 489 patients undergoing LPN was completed.
- • Preoperative imaging assessed tumour characteristics.
- • Patient demographics, perioperative parameters, and postoperative outcomes were documented.
- • Multivariable regression analysis was used to assess factors contributing to changes in postoperative renal function between off-clamp and clamped LPN.
- • In all, 289 LPNs were performed on-clamp and 150 were performed off-clamp.
- • Tumours in the on-clamp group were larger than those in the off-clamp group (mean [range] 3.3 [0.5–13.5] vs 2.7 [0.4–9] cm, P= 0.003).
- • Univariable analysis comparing off-clamp to on-clamp cohorts showed that estimated glomerular filtration rate (eGFR) was better preserved in the off-clamp cohort at 6 months (−5.8% vs –11.4%, P= 0.046). Multivariable analysis of the groups showed that estimate blood loss (P= 0.015) and warm ischaemia time (WIT, P< 0.001) were the only significant predictors of decreased eGFR in the postoperative period.
- • Difference in eGFR at 6 months was not significant when WIT was limited to 30 min. The complication rate was greater in the clamped cohort (10% vs 20%, P= 0.012).
- • There was no difference in transfusion rate or positive margin status.
- • LPN without hilar clamping is feasible, safe and associated with less renal injury as assessed by postoperative GFR in select patients.
- • With experience, it can be applied to complex renal lesions.