Partial nephrectomy (PN) is the best treatment for localised renal tumours. It provides favourable cancer control, while optimally preserving renal function. For that latter purpose, one of the key points of the surgical technique is to diminish the clamping time of the renal pedicle, as it has been shown that renal injury is directly related to the duration of ischaemia [1]. In an effort to minimise renal damage, PN without clamping of the pedicle has been described [2].

George et al. report their experience in 489 patients who underwent laparoscopic PN (LPN) for a renal tumour with or without clamping. Overall they found comparable operative outcomes, although blood loss was more important in the off-clamp group and complications more frequent in cases of clamping of the renal pedicle. Analysing renal function outcome, the authors found that the estimated GFR (eGFR) change at 6 months was significantly less in the off-clamp population but the benefit disappeared when restricting to patients with a warm ischemia time of <30 min.

This is a consequent series of LPN performed by one experienced surgeon. However, it is difficult to draw conclusions about the potential benefit of the non-clamping technique as to renal preservation. Tumours were smaller and less complex in the off-clamp group, which means that patients were selected. Furthermore, patients who underwent on-clamp LPN had twice as many complications, indicating that the surgery was more difficult. Finally, there were no imperative indications and it is therefore difficult to give any significance to the eGFR changes.

So the message of this article is that off-clamp LPN is feasible in selected patients. Knowing whether it provides any benefit compared with LPN with limited ischaemia time will require further studies with longer follow-up.


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