Robotic partial nephrectomy with superselective versus main artery clamping: a retrospective comparison.
BACKGROUND
Concerns have been raised regarding partial nephrectomy (PN) techniques that do not occlude the main renal artery.


OBJECTIVE
Compare the perioperative outcomes of superselective versus main renal artery control during robotic PN.


METHODS
A retrospective analysis of 121 consecutive patients undergoing robotic PN using superselective control (group 1, n=58) or main artery clamping (group 2, n=63).


METHODS
Group 1 underwent tumor-specific devascularization, maintaining ongoing arterial perfusion to the renal remnant at all times. Group 2 underwent main renal artery clamping, creating global renal ischemia.


METHODS
Perioperative and functional data were evaluated. The Pearson chi-square or Fisher exact and Wilcoxon rank sum tests were used.


CONCLUSIONS
All robotic procedures were successful, all surgical margins were negative, and no kidneys were lost. Compared with group 2 tumors, group 1 tumors were larger (3.4 vs 2.6cm, p=0.004), more commonly hilar (24% vs 6%, p=0.009), and more complex (PADUA 10 vs 8, p=0.009). Group 1 patients had longer median operative time (p<0.001) and transfusion rates (24% vs 6%, p<0.01) but similar estimated blood loss (200 vs 150ml), perioperative complications (15% vs 13%), and hospital stay. Group 1 patients had less decrease in estimated glomerular filtration rate at discharge (0% vs 11%, p=0.01) and at last follow-up (11% vs 17%, p=0.03). On computed tomography volumetrics, group 1 patients trended toward greater parenchymal preservation (95% vs 90%, p=0.07) despite larger tumor size and volume (19 vs 8ml, p=0.002). Main limitations are the retrospective study design, small cohort, and short follow-up.


CONCLUSIONS
Robotic PN with superselective vascular control enables tumor excision without any global renal ischemia. Blood loss, complications, and positive margin rates were low and similar to main artery clamping. In this initial developmental phase, limitations included more perioperative transfusions and longer operative time. The advantage of superselective clamping for better renal function preservation requires validation by prospective randomized studies.


RESULTS
Preserving global blood flow to the kidney during robotic partial nephrectomy (PN) does not lead to a higher complication rate and may lead to better postoperative renal function compared with clamped PN techniques.
USC Institute of Urology, Catherine and Joseph Aresty Department of Urology, Keck Medical Center of USC, University of Southern California, Los Angeles, CA, USA. Electronic address: mihir.desai@usc.edu.
Mihir M
MM
Desai
USC Institute of Urology, Catherine and Joseph Aresty Department of Urology, Keck Medical Center of USC, University of Southern California, Los Angeles, CA, USA.
Andre Luis
AL
de Castro Abreu
USC Institute of Urology, Catherine and Joseph Aresty Department of Urology, Keck Medical Center of USC, University of Southern California, Los Angeles, CA, USA.
Scott
S
Leslie
USC Institute of Urology, Catherine and Joseph Aresty Department of Urology, Keck Medical Center of USC, University of Southern California, Los Angeles, CA, USA.
Jei
J
Cai
USC Institute of Urology, Catherine and Joseph Aresty Department of Urology, Keck Medical Center of USC, University of Southern California, Los Angeles, CA, USA.
Eric Yi-Hsiu
EY
Huang
USC Institute of Urology, Catherine and Joseph Aresty Department of Urology, Keck Medical Center of USC, University of Southern California, Los Angeles, CA, USA.
Pierre-Marie
PM
Lewandowski
USC Institute of Urology, Catherine and Joseph Aresty Department of Urology, Keck Medical Center of USC, University of Southern California, Los Angeles, CA, USA.
Dennis
D
Lee
USC Institute of Urology, Catherine and Joseph Aresty Department of Urology, Keck Medical Center of USC, University of Southern California, Los Angeles, CA, USA.
Arjuna
A
Dharmaraja
USC Institute of Urology, Catherine and Joseph Aresty Department of Urology, Keck Medical Center of USC, University of Southern California, Los Angeles, CA, USA.
Andre K
AK
Berger
USC Institute of Urology, Catherine and Joseph Aresty Department of Urology, Keck Medical Center of USC, University of Southern California, Los Angeles, CA, USA.
Alvin
A
Goh
USC Institute of Urology, Catherine and Joseph Aresty Department of Urology, Keck Medical Center of USC, University of Southern California, Los Angeles, CA, USA.
Osamu
O
Ukimura
USC Institute of Urology, Catherine and Joseph Aresty Department of Urology, Keck Medical Center of USC, University of Southern California, Los Angeles, CA, USA.
Monish
M
Aron
USC Institute of Urology, Catherine and Joseph Aresty Department of Urology, Keck Medical Center of USC, University of Southern California, Los Angeles, CA, USA.
Inderbir S
IS
Gill
D000293:Adolescent; D000328:Adult; D000368:Aged; D000792:Angiography / Q000379:methods; D016063:Blood Loss, Surgical / Q000503:physiopathology*; D016022:Case-Control Studies; D016009:Chi-Square Distribution; D003250:Constriction; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007680:Kidney Neoplasms / Q000473:pathology / Q000601:surgery; D007902:Length of Stay; D008297:Male; D009392:Nephrectomy / Q000009:adverse effects / Q000379:methods*; D061646:Operative Time; D018579:Patient Selection; D011183:Postoperative Complications / Q000453:epidemiology / Q000503:physiopathology; D012077:Renal Artery / Q000000981:diagnostic imaging / Q000601:surgery*; D012189:Retrospective Studies; D018570:Risk Assessment; D065287:Robotic Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D018709:Statistics, Nonparametric; D014057:Tomography, X-Ray Computed / Q000379:methods; D016896:Treatment Outcome; D052096:Warm Ischemia; D055815:Young Adult
Nephron-sparing surgery; Partial nephrectomy; Robotic; Superselective clamping; Warm ischemia time; Zero-ischemia