The aim of this study was to assess the real impact of ischemia during robotic-assisted partial nephrectomy (RAPN) in high-risk patients, this study focused on ischemia-sensitive populations such as those with a solitary kidney (SK) or chronic kidney disease (CKD), who may benefit from off-clamp (OfC) nephron-sparing surgery.
We retrospectively analyzed all RAPN cases performed at 16 centers of the UroCCR network (2011-2024), in patients with a SK or stage 3b CKD (eGFR≤45 mL/min/m2). Patients were prospectively enrolled in the UroCCR project after signed consent. Our cohort was divided into two subgroups of SK and CKD. A propensity score matching adjusted on preoperative eGFR and RENAL score was used in SK subgroup and on baseline creatinine in CKD subgroup. We compared OfC RAPN and on-clamp RAPN (OnC) in terms of perioperative outcomes. Our main objective was to assess post-operative evolution of renal function.
Among 251 RAPN, 144 were performed OnC and 107 OfC. After matching, OfC SK had less eGFR variation between pre-operative level and day 1 (-19.5 vs. -27.6 mL/min/1.73 m2; P=0.001) or discharge (-6.7 vs. -15.0 mL/min/1.73 m2; P=0.001). This difference was no longer observed beyond 3 months. SK operated OfC presented less AKI at day 1 and at discharge (67.6% vs. 86.8%; P=0.01). They were discharged significantly more often at D0/D1, with a lower length of stay (3.4 vs. 6.4 days; P=0.001). There was no significant difference in terms of complications, bleeding, locoregional recurrence and positive margins. We found no significant difference in the CKD subgroup.
OfC RAPN offers significant short-term functional advantages in ischemia-sensitive patients with a solitary kidney. By avoiding warm ischemia, the OfC approach reduces the incidence of acute kidney injury and shortens hospital stays, without increasing surgical morbidity or compromising oncologic outcomes.
Minerva urology and nephrology. 2026 Jun [Epub]
Léo Schurdi-Levraud, Gaëlle Margue, Arna Geshkovska, Karim Bensalah, Coline Ricolleau, Franck Bruyere, Cécile Champy, Constance Michel, Louis Surlemont, Jean-Christophe Fantoni, Alexis Fontenil, Clément Sarrazin, Jean-Baptiste Beauval, Bastien Parier, Frédéric Panthier, Jean-Jacques Patard, Olivier Belas, Pierre Bigot, Jean-Christophe Bernhard
Department of Urology, Andrology and Kidney Transplantation, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France - ., Department of Urology, Andrology and Kidney Transplantation, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France., Department of Urology, Rennes University Hospital, Rennes, France., Department of Urology, Rangueil University Hospital, Toulouse, France., Department of Urology, Tours University Hospital, Tours, France., INSERM, Clinical Investigation Center 1430, Henri Mondor University Hospital, AP-HP, Créteil, France., Department of Urology, St Joseph Hospital, Paris, France., Department of Urology, Rouen University Hospital, Rouen, France., Department of Urology, Lille University Hospital, Lille, France., Department of Urology, Nîmes University Hospital, Nîmes, France., Department of Urology, Grenoble University Hospital, Grenoble, France., Department of Urology, La Croix du Sud Clinic, Quint-Fonsegrives, France., Department of Urology, Bicêtre University Hospital, AP-HP, Paris, France., Department of Urology, Tenon University Hospital, AP-HP, Paris, France., Department of Urology, Mont-de-Marsan Hospital, Mont-de-Marsan, France., Department of Urology, Pôle Santé Sud, Le Mans, France., Kidney Cancer Group of the French Association of Urology Cancer Committee, Paris, France.