To Clamp or Not to Clamp? Long-Term Functional Outcomes for Elective Off-Clamp Laparoscopic Partial Nephrectomy

To evaluate whether elective off-clamp laparoscopic partial nephrectomy affords long-term renal functional benefit compared to the on-clamp approach.

This is a retrospective review of patients who underwent elective laparoscopic partial nephrectomy between 2006 and 2011.

Patients were followed longitudinally for up to 5 years. 315 patients with radiographic evidence of a solitary renal mass and normal-appearing contralateral kidney underwent elective laparoscopic partial nephrectomy; 209 were performed on-clamp versus 106 off-clamp. One patient who required conversion from laparoscopic to open partial nephrectomy was excluded from the study. Additionally, 4 patients in the on-clamp cohort who underwent subsequent radical nephrectomy for local-regional recurrence were excluded from longitudinal functional evaluation after their procedure. The primary objective was to evaluate differences in postoperative estimated glomerular filtration rate between hilar clamping groups. Subgroup analyses were performed for patients with clamp times >30 minutes and those with baseline renal insufficiency (estimated glomerular filtration rate <60ml/min/1. 73m2). Risk of developing worsened or new-onset renal insufficiency was also compared.

Mean preoperative estimated glomerular filtration rate was similar between on-clamp and off-clamp cohorts (80. 7mL/min/1. 73m2 vs. 84. 1mL/min/1. 73m2, p>0. 05). Univariable and multivariable analyses did not demonstrate significant differences in postoperative estimated glomerular filtration rate between both groups among all-comers, those with clamp times >30 min, and patients w/ baseline renal insufficiency. Risk of chronic kidney disease was not diminished by the off-clamp approach with up to 5 years of follow-up.

Progressive recovery of renal function after hilar clamping in the elective setting eclipses short-term functional benefit achieved with off-clamp laparoscopic partial nephrectomy by 6 months; no significant difference in estimated glomerular filtration rate or percent incidence of chronic kidney disease exists between on-clamp and off-clamp cohorts with up to 5-year follow-up. As such, eliminating transient ischemia during elective laparoscopic partial nephrectomy does not confer clinical benefit. This article is protected by copyright. All rights reserved.

BJU international. 2015 Sep 08 [Epub ahead of print]

Paras H Shah, Arvin K George, Daniel M Moreira, Manaf Alom, Zhamshid Okhunov, Simpa Salami, Nikhil Waingankar, Michael J Schwartz, Manish A Vira, Lee Richstone, Louis R Kavoussi

Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, NY. , Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, NY. , Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, NY. , Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, NY. , Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, NY. , Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, NY. , Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, NY. , Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, NY. , Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, NY. , Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, NY. , Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, NY.

PubMed

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