title: Use of Main Renal Artery Clamping Predominates Over Minimal Clamping Techniques During Robotic Partial Nephrectomy for Complex Tumors.
abstract: Hilar clamping is often performed to facilitate robotic partial nephrectomy (RPN). Minimal clamping techniques may reduce renal ischemia, including early unclamping, selective clamping, and off-clamp RPN. We assess the utilization of clamping techniques in a large international consortium of surgeons performing RPN for complex tumors.
  
  
  
  We retrospectively evaluated 721 patients with complex tumors, who underwent RPN at 11 centers worldwide between 2008 and 2014. Complex tumors were defined as renal masses with a nephrometry score >6. Total clamping was defined as complete clamping of the main renal artery. Minimal clamping techniques included early unclamping, selective clamping, and off-clamp RPN. Clamping techniques were additionally assessed in patients with estimated glomerular filtration rate (eGFR) <60 and in patients with a solitary kidney. Two-tailed t-tests (p < 0.05) were used to statistically analyze differences in mean warm ischemia time (WIT).
  
  
  
  Most patients underwent complete clamping (75.1%). Minimal clamping (24.9%) included early unclamping (10.8%), selective clamping (8.7%), and off-clamp (5.4%). Mean WIT of total clamping, selective clamping, and early unclamping was 22.2, 21.2, and 17.3 minutes, respectively. Of patients with an eGFR <60 (n = 90), 26.6% underwent minimal clamping, including 15.5% early unclamping, 4.4% selective clamping, and 6.7% off-clamp. Of patients with solitary kidneys (n = 12), 10 (83%) were performed with total clamping with mean WIT of 14.9 minutes.
  
  
  
  In this large international series of RPN for complex tumors, most patients underwent total clamping of the main renal artery. Minimal clamping techniques, including early unclamping, selective clamping, and off-clamp techniques, were used in a minority of cases. There was no significant increase in use of minimal clamping, even in patients with chronic kidney disease or solitary kidneys. However, mean WIT was low (<23 minutes) in all patient groups.
authors.affiliation: 1 Wayne State University School of Medicine , Detroit, Michigan.|2 Vattikuti Urology Institute , Henry Ford Hospital, Detroit, Michigan.
authors.forename: Leedor
authors.initials: L
authors.lastname: Lieberman
authors.affiliation: 2 Vattikuti Urology Institute , Henry Ford Hospital, Detroit, Michigan.
authors.forename: Ravi
authors.initials: R
authors.lastname: Barod
authors.affiliation: 2 Vattikuti Urology Institute , Henry Ford Hospital, Detroit, Michigan.
authors.forename: Deepansh
authors.initials: D
authors.lastname: Dalela
authors.affiliation: 2 Vattikuti Urology Institute , Henry Ford Hospital, Detroit, Michigan.
authors.forename: Mireya
authors.initials: M
authors.lastname: Diaz-Insua
authors.affiliation: 3 Department of Urology, Ohio Health Dublin Methodist Hospital , Dublin, Ohio.
authors.forename: Ronney
authors.initials: R
authors.lastname: Abaza
authors.affiliation: 4 Hertfordshire and South Bedfordshire Urological Cancer Centre, Lister Hospital , Stevenage, United Kingdom .
authors.forename: James
authors.initials: J
authors.lastname: Adshead
authors.affiliation: 5 Division of Urology and Renal Transplantation, Medanta Kidney and Urology Institute , Medanta, The Medicity, Gurgaon, India .
authors.forename: Rajesh
authors.initials: R
authors.lastname: Ahlawat
authors.affiliation: 6 MRC Centre for Transplantation, King's College London , London, United Kingdom .
authors.forename: Benjamin
authors.initials: B
authors.lastname: Challacombe
authors.affiliation: 6 MRC Centre for Transplantation, King's College London , London, United Kingdom .
authors.forename: Prokar
authors.initials: P
authors.lastname: Dasgupta
authors.affiliation: 7 OLV Vattikuti Robotic Surgery Institute , Melle, Belgium .
authors.forename: Giogio
authors.initials: G
authors.lastname: Gandaglia
authors.affiliation: 8 Peter MacCallum Cancer Centre , Melbourne, Victoria, Australia .
authors.forename: Daniel A
authors.initials: DA
authors.lastname: Moon
authors.affiliation: 9 Oncological and Surgical Sciences, Urology Clinic, University of Padua , Padua, Italy .
authors.forename: Giacomo
authors.initials: G
authors.lastname: Novara
authors.affiliation: 10 San Luigi Gonzaga Hospital, University of Turin , Orbassano, Turin, Italy .
authors.forename: Francesco
authors.initials: F
authors.lastname: Porpiglia
authors.affiliation: 7 OLV Vattikuti Robotic Surgery Institute , Melle, Belgium .
authors.forename: Alexandre
authors.initials: A
authors.lastname: Mottrie
authors.affiliation: 2 Vattikuti Urology Institute , Henry Ford Hospital, Detroit, Michigan.
authors.forename: Mahendra
authors.initials: M
authors.lastname: Bhandari
authors.affiliation: 2 Vattikuti Urology Institute , Henry Ford Hospital, Detroit, Michigan.
authors.forename: Craig
authors.initials: C
authors.lastname: Rogers
mesh_terms: D000328:Adult; D000368:Aged; D003250:Constriction; D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D007511:Ischemia / Q000209:etiology / Q000517:prevention & control; D007680:Kidney Neoplasms / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000379:methods*; D012077:Renal Artery; D051436:Renal Insufficiency, Chronic / Q000209:etiology; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures / Q000379:methods*
keywords: clamping; renal ischemia; robotic partial nephrectomy