title: Selective arterial clamping does not improve outcomes in robot-assisted partial nephrectomy: a propensity-score analysis of patients without impaired renal function.
abstract: To assess the benefit of selective arterial clamping (SAC) as an alternative to main renal artery clamping (MAC) during robot-assisted partial nephrectomy (RAPN) in patients without underlying chronic kidney disease (CKD).
  
  
  
  Our study cohort comprised 665 patients without impaired renal function undergoing MAC (n = 589) or SAC (n = 76) during RAPN from four medical institutions in the period 2008-2015. We compared complication rates, positive surgical margin (PSM) rates, and peri-operative and intermediate-term renal functional outcome between 132 patients undergoing MAC and 66 undergoing SAC after 2-to-1 nearest-neighbour propensity-score matching for age, sex, body mass index, RENAL nephrometry score, tumour size, baseline estimated glomerular filtration rate (eGFR), American Society of Anesthesiologists (ASA) score, Charlson comorbidity index (CCI) and warm ischaemia time (WIT).
  
  
  
  In propensity-score-matched patients, PSM (5.7 vs 3.0%; P = 0.407) and complication rates (13.8 vs 10.6%; P = 0.727) did not differ between the MAC and SAC groups. The incidence of acute kidney injury for MAC vs SAC (25.0 vs 32.0%; P = 0.315) within the first 30 days was similar. At a median follow-up of 7.5 months, the percentage reduction in eGFR (-9.3 vs -10.4%; P = 0.518) and progression to CKD ≥ stage 3 (7.2 vs 8.5%; P = 0.792) showed no difference.
  
  
  
  Our study findings show no difference in PSM rates, complication rates or intermediate-term renal functional outcomes between patients with unimpaired renal function who underwent SAC vs those who underwent MAC. When expected WIT is low, the routine use of SAC may not be necessary. Further studies will need to determine the role of SAC in patients with a solitary kidney or with significantly impaired renal function.
authors.affiliation: Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA.
authors.forename: David J
authors.initials: DJ
authors.lastname: Paulucci
authors.affiliation: Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA.
authors.forename: Daniel C
authors.initials: DC
authors.lastname: Rosen
authors.affiliation: Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA.
authors.forename: John P
authors.initials: JP
authors.lastname: Sfakianos
authors.affiliation: Department of Urology, Yale New Haven Hospital, New Haven, CT, USA.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Whalen
authors.affiliation: Robotic Urologic Surgery, OhioHealth Dublin Methodist Hospital, Columbus, OH, USA.
authors.forename: Ronney
authors.initials: R
authors.lastname: Abaza
authors.affiliation: Temple University School of Medicine, Philadelphia, PA, USA.
authors.forename: Daniel D
authors.initials: DD
authors.lastname: Eun
authors.affiliation: Wake Forest School of Medicine, Winston-Salem, NC, USA.
authors.forename: Louis S
authors.initials: LS
authors.lastname: Krane
authors.affiliation: Wake Forest School of Medicine, Winston-Salem, NC, USA.
authors.forename: Ashok K
authors.initials: AK
authors.lastname: Hemal
authors.affiliation: Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA.
authors.forename: Ketan K
authors.initials: KK
authors.lastname: Badani
mesh_terms: D000368:Aged; D003250:Constriction; D005260:Female; D006801:Humans; D007680:Kidney Neoplasms / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000379:methods*; D057216:Propensity Score; D012077:Renal Artery; D051436:Renal Insufficiency, Chronic; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures; D016896:Treatment Outcome
keywords: kidney cancer; nephrectomy; robot-assisted surgical procedure; selective arterial clamping; warm ischaemia time