Comparison of hilar clamping and non-hilar clamping partial nephrectomy for tumours involving a solitary kidney.
OBJECTIVE
• To compare outcomes of hilar clamping and non-hilar clamping partial nephrectomy for tumours involving a solitary functional kidney.


METHODS
• Between 1990 and 2009, 104 partial nephrectomies, excluding bench and autotransplant procedures, were performed on solitary functional kidneys. • An institutional review board-approved retrospective review was performed analyzing patient demographics, operative data, complications, oncological outcomes and estimated glomerular filtration rate (GFR). • GFR was calculated using the abbreviated Modification of Diet in Renal Disease equation. • Preoperative GFR was compared to Early GFR (lowest measured GFR 7-100 days postoperatively) and to Late GFR (GFR 101-365 days postoperatively). • Multiple linear regression analysis was performed to assess covariates affecting Late GFR. • Kaplan-Meier estimator was utilized to compare renal cell carcinoma (RCC) specific survival and non-RCC-related survival.


RESULTS
• In total, 29 partial nephrectomies with hilar clamping and 75 partial nephrectomies without hilar clamping were performed in solitary kidneys. Median follow-up was 57 months. • There was no difference in tumour size, location and the number of tumours resected between the two groups. Mean ischaemia time for the clamping group was 25 min. • Some 97% of the clamping procedures were performed with cold ischaemia. • There was no difference in intra-operative estimated blood loss, transfusion requirement or length of hospital stay. • The complication rate and spectrum of complications were similar between the two groups. • The two groups had similar preoperative GFR and Early GFR. The non-clamping group had a significantly smaller percent decrease in Late GFR (11.8% vs 27.7%, P= 0.01) than the clamping group. • The non-clamping group was significantly more likely to have a less than 10% decrease in Late GFR compared to the clamping group (60.9% vs 17.7%, P= 0.002). • On multivariate analysis, only hilar clamping was significantly associated with decreased Late GFR (estimate 15.0, P= 0.02). • Surgical margin positivity rate was higher in the clamping group (21% vs 4%, P= 0.01); however, the local recurrence rate between the two groups was similar. • The clamping and non-clamping groups had similar 5-year RCC-specific survival and 5-year non-RCC-related survival.


CONCLUSIONS
• Partial nephrectomy without hilar clamping in solitary kidneys provides similar cancer control compared to partial nephrectomy with hilar clamping. • Partial nephrectomy without clamping was associated with superior preservation of Late GFR. • No difference was detected in GFR early after surgery, possibly indicating that there may be ongoing renal loss after hilar clamping.
Institute of Urology, Lahey Clinic Medical Center, Burlington, MA, USA.
Matthew F
MF
Wszolek
Patrick A
PA
Kenney
Yoojin
Y
Lee
John A
JA
Libertino
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002292:Carcinoma, Renal Cell / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D003250:Constriction; D004812:Epidemiologic Methods; D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D007680:Kidney Neoplasms / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000379:methods*; D051436:Renal Insufficiency, Chronic / Q000150:complications* / Q000401:mortality / Q000503:physiopathology; D016896:Treatment Outcome; D052096:Warm Ischemia