Comparison of total, selective, and nonarterial clamping techniques during laparoscopic and robot-assisted partial nephrectomy.
This study evaluates the feasibility, perioperative, and renal functional outcomes with total, selective, and nonarterial clamping techniques during minimally invasive partial nephrectomy. A retrospective review of laparoscopic and robot-assisted partial nephrectomies by a single surgeon from January 2007 to July 2010 was performed. Patients underwent total hilar clamping, selective (segmental) artery clamping, progressive clamping from segmental to main renal artery clamping, or resection without hilar clamping. Patient demographic, perioperative, and oncologic outcomes were analyzed. Change in renal function was assessed by glomerular filtration rate (GFR) calculation and differential function on pre- and postoperative renal scans. A total of 68 patients underwent laparoscopic or robot-assisted partial nephrectomy. Those with a history of surgery for renal masses and elective conversion to radical nephrectomy were excluded. A total of 57 patients were analyzed (32 total hilar, 8 progressive arterial clamping, 13 selective arterial, and 4 without clamping). There were no significant differences in preoperative patient or disease characteristics between the groups. The progressive clamping technique was found to significantly decrease the total renal ischemia time compared with the total hilar clamp technique. There was no other significant difference in transfusion rate, complications, or other postoperative outcomes. There were no significant differences between the groups in intermediate-term (mean 411 days) renal function changes. Minimally invasive partial nephrectomy without vascular occlusion and with selective arterial clamping is feasible and can be safely performed. With this intermediate-term follow-up there was no clinically significant benefit seen for selective regional or nonischemic techniques.