title: Early unclamping technique during robot-assisted laparoscopic partial nephrectomy can minimise warm ischaemia without increasing morbidity.
abstract: OBJECTIVE
  To compare perioperative outcomes of early unclamping (EUC) vs standard unclamping (SUC) during robot-assisted partial nephrectomy (RAPN), as early unclamping of the renal pedicle has been reported to decrease warm ischaemia time (WIT) during laparoscopic PN.
  
  
  METHODS
  A retrospective multi-institutional study was conducted at eight French academic centres between 2009 and 2013. Patients who underwent RAPN for a renal mass were included in the study. Patients without vascular clamping or for whom the decision to perform a radical nephrectomy was taken before unclamping were excluded. Perioperative outcomes were compared using the chi-squared and Fisher's exact tests for discrete variables and the Mann-Whitney test for continuous variables. Predictors of WIT and estimated blood loss (EBL) were assessed using multiple linear regression analysis.
  
  
  RESULTS
  In all, there were 430 patients: 222 in the EUC group and 208 in the SUC group. Tumours were larger (35.8 vs 32.3 mm, P = 0.02) and more complex (R.E.N.A.L. nephrometry score 6.9 vs 6.1, P < 0.001) in the EUC group but surgeons were more experienced (>50 procedures 12.2% vs 1.4%, P < 0.001). The mean WIT was shorter (16.7 vs 22.3 min, P < 0.001) and EBL was higher (369.5 vs 240 mL, P = 0.001) in the EUC group with no significant difference in complications or transfusion rates. The results remained the same when analysing subgroups of complex renal tumours (R.E.N.A.L. nephrometry score ≥7) or RAPN performed by less experienced surgeons (<20 procedures). In multivariable analysis, EUC was predictive of decreased WIT (β -0.34; P < 0.001) but was not associated with EBL (β -0.09, P = 0.16).
  
  
  CONCLUSIONS
  EUC can reduce WIT during RAPN without increasing morbidity even for complex renal tumours or when being performed by less experienced surgeons.
authors.affiliation: Departments of Urology, University of Rennes, Rennes, France.
authors.forename: Benoit
authors.initials: B
authors.lastname: Peyronnet
authors.forename: Hervé
authors.initials: H
authors.lastname: Baumert
authors.forename: Romain
authors.initials: R
authors.lastname: Mathieu
authors.forename: Alexandra
authors.initials: A
authors.lastname: Masson-Lecomte
authors.forename: Yohann
authors.initials: Y
authors.lastname: Grassano
authors.forename: Mathieu
authors.initials: M
authors.lastname: Roumiguié
authors.forename: Walid
authors.initials: W
authors.lastname: Massoud
authors.forename: Vincent
authors.initials: V
authors.lastname: Abd El Fattah
authors.forename: Franck
authors.initials: F
authors.lastname: Bruyère
authors.forename: Stéphane
authors.initials: S
authors.lastname: Droupy
authors.forename: Alexandre
authors.initials: A
authors.lastname: de la Taille
authors.forename: Nicolas
authors.initials: N
authors.lastname: Doumerc
authors.forename: Jean-Christophe
authors.initials: JC
authors.lastname: Bernhard
authors.forename: Christophe
authors.initials: C
authors.lastname: Vaessen
authors.forename: Morgan
authors.initials: M
authors.lastname: Rouprêt
authors.forename: Karim
authors.initials: K
authors.lastname: Bensalah
mesh_terms: D015331:Cohort Studies; D005919:Glomerular Filtration Rate; D006488:Hemostasis, Surgical / Q000379:methods*; D006801:Humans; D007511:Ischemia / Q000517:prevention & control*; D007668:Kidney / Q000098:blood supply*; D007680:Kidney Neoplasms / Q000503:physiopathology / Q000601:surgery*; D010535:Laparoscopy / Q000379:methods*; D008875:Middle Aged; D009017:Morbidity; D009392:Nephrectomy / Q000009:adverse effects / Q000379:methods*; D011183:Postoperative Complications; D012189:Retrospective Studies; D012371:Robotics / Q000379:methods*; D013997:Time Factors
keywords: complications; early unclamping; partial nephrectomy; robotic; warm ischemia time