Off-clamp Versus On-clamp Robot-assisted Partial Nephrectomy: A Systematic Review and Quantitative Synthesis by the European Association of Urology Young Academic Urologists Renal Cancer Study Group

Sutureless versus conventional suture renorrhaphy in clampless robotic partial nephrectomy: A single center propensity score matching analysis

INTRODUCTION AND OBJECTIVES

Suture renorrhaphy remains as time-consuming in partial nephrectomy (PN) and carries the risk of renal arterial damage and renal functional loss. This study aims to compare the functional and oncological outcomes of the clampless and sutureless robotic PN (sRPN) with clampless conventional suture renorrhaphy RPN (cRPN).

PATIENTS

A total of 173 consecutive patients who underwent RPN between January 2019 and December 2023 were identified from our center's database and reviewed. Seventy-six clampless (sutureless: 23, conventional suture renorrhaphy: 53) RPN were identified. A propensity score-matchedpair analysis (PSM) was performed to homogenize the characteristics of the groups. Comprehensive evaluations of perioperative variables, functional and oncological results were performed before and after the PSM between the sRPN and cRPN.

RESULTS

Before the PSM, median console time was 10 min shorter in the sRPN group but was not statistically significant. Estimated median blood loss was significantly lower in the sRPN group (p < 0.05). After PSM, 22 patients were matched in each group and all of the preoperative baseline characteristics were similar. Ratio of interpolar lines located tumors was higher in sRPN group (68.2% vs. 31.2%) (p < 0.05). Median tumor diameter was 3 (1.5-7) cm in each group. The trifecta achievement rates were 90.9% and 77.2% for the sRPN and cRPN groups, respectively (p > 0.05). There were no differences in terms of median console times, estimated blood loss, drain removal times or eGFR changes.

CONCLUSIONS

In the treatment of small renal masses with clampless RPN, the sutureless technique can be applied with similar complication rates and functional, oncological outcomes as conventional sutured renorrhaphy.

Three-dimensional visualization techniques improve surgical Decision Making of robotic-assisted partial nephrectomy

Background

Complete preoperative comprehension of the adjacent structures of the kidney and location of renal vessels is essential for robot-assisted partial nephrectomy (RAPN). The effectiveness of three-dimensional (3D) visualization techniques in improving perioperative outcomes of RAPN has been inconsistent and has not been reported in Northeastern China.

Methods

In this cohort study, we reviewed patients with renal tumours who underwent RAPN between April 2019 and April 2024. Three-dimensional visualization models were reconstructed to evaluate resectability parameters, including vascular variations, collection system infiltration, and lymphatic involvement. Subsequently, a meta-analysis combining previous studies utilising 3D visualization techniques for partial nephrectomy was conducted.

Results

Of the 324 patients in the cohort, 147 were preoperatively evaluated using the 3D technology. Group 3D had significantly less estimated blood loss (P < 0.001) and a shorter operative time (P = 0.016) than in group No 3D. We also found that the rates of intraoperative ultrasound use (P = 0.015), intraoperative complications (P = 0.007), intraoperative transfusions (P = 0.007), and postoperative Clavien complications (P < 0.001) in group 3D were significantly lower than in group No 3D. The above findings were consistent in the subgroup with R.E.N.A.L. ≥ 8 points partly. Furthermore, a meta-analysis identified 11 studies that included 1522 patients who underwent RAPN. Use of 3D visualization technology resulted in decreased 55 % risk of opening the collecting system (Risk Ratio [RR] = 0.45[0.22-0.92], P = 0.030) and 79 % incidence of conversion to radical nephrectomy (RR = 0.21[0.08-0.57], P = 0.002). The RAPN group assisted by 3D visualization techniques showed an 81 % reduction in the risk of blood transfusion than in the control group (RR = 0.19[0.08-0.44], P < 0.001).

Conclusions

The application of 3D technology in RAPN appears to be superior for improving precise tumour removal and reducing adverse perioperative outcomes and should be considered for wide use in clinical practice.

Surgery or Comorbidities: What Is the Primum Movens of Kidney Dysfunction After Nephrectomy? A Multicenter Study in Living Donors and Cancer Patients

Background and Hypothesis: Acute Kidney Injury (AKI) and Chronic Kidney Disease (CKD) are significant risks for kidney cancer (KC) patients undergoing partial (PN) or radical nephrectomy (RN) and for living kidney donors (LKD). This study compares AKI and CKD incidence in these groups with a pre-operative glomerular filtration rate (GFR) over 60 mL/min/1.73 m2. Methods: This study included 465 KC patients with cT1-2N0M0 kidney mass and 256 LKD who underwent nephrectomy at four Italian institutions from 2014 to 2021. Data on demographics, comorbidities, and therapies were analyzed. Serum creatinine and estimated GFR (eGFR) were measured before and after surgery. Outcomes were AKI (per KDIGO guidelines) and CKD stage progression. Analyses included descriptive statistics, ANOVA, logistic regression, and Kaplan-Meier survival. Results: Among 721 patients, significant age and gender differences were noted. Hypertension (41%) and diabetes (7.1%) were prevalent in RN and PN groups. Post-surgery AKI was more common in donors (84%), while CKD stage progression varied by surgery type (CKD stage G3 after 60 months: RN 48.91%, PN 18.22%, LKD 26.56%). Age, pre-surgery CKD, and surgery type predicted CKD progression. Limitations include retrospective design and bias. Conclusions: Both LKD and KC patients face similar AKI and CKD risks. Surgery type significantly influences AKI and CKD incidence, highlighting the importance of approach.

Meta-analysis and systematic review of factors predicting conversion to radical nephrectomy following robotic-assisted partial nephrectomy in renal cancer patients

Evaluating the risk factors for the conversion from robotic-assisted partial nephrectomy (RAPN) to radical nephrectomy (RN). Through a comprehensive database search encompassing PubMed, Web of Science, Embase, and the Cochrane Library, we identified pertinent English-language research published by June 2024. We utilized the NOS scale for quality assessment. The aggregate effect was quantified via the odds ratio (OR), alongside a 95% confidence interval (CI). Sensitivity analyses were conducted using both fixed-effects and random-effects models to evaluate reliability. The meta-analytical process was facilitated by the Stata 18 software suite. Our meta-analysis encompassed a total of 8 retrospective studies and 3 prospective studies, totaling 4056 patients. We found that increasing patient age (OR: 1.04; 95% CI 1.00-1.08; P = 0.005), higher American Society of Anesthesiologists (ASA) scores (3 or above) (OR: 2.74; 95% CI 1.52-4.93; P = 0.001), elevated R.E.N.A.L. scores (7 or above) (OR: 2.49; 95% CI 1.57-3.95; P < 0.001), and the use of off-clamp RAPN (OR: 7.21; 95% CI 2.60-19.93; P < 0.001) significantly raised the odds of surgical conversion. On the other hand, male sex (OR: 1.04; 95% CI 0.67-1.62; P = 0.858), the side of the tumor (OR: 0.97; 95% CI 0.48-1.95; P = 0.936), tumor size (OR: 3.43; 95% CI 0.57-20.55; P = 0.177), body mass index (BMI) (OR: 1.03; 95% CI 0.96-1.11; P = 0.426), clinical stage (OR: 3.78; 95% CI 0.46-30.70; P = 0.214), and the use of single-port RAPN (OR: 0.54; 95% CI 0.16-1.78; P = 0.31) did not show a statistically significant link to an increased conversion risk. This meta-analysis elucidates the critical risk factors for the conversion from robotic-assisted partial nephrectomy to radical nephrectomy, providing significant guidance for preoperative risk assessment and clinical decision-making. However, our findings necessitate validation through studies with larger sample sizes.

Impact of No-Clamping Partial Nephrectomy on Early Estimated Glomerular Filtration Rate Preservation

Incidences of kidney cancers are steadily increasing. The surgical resection of renal tumors remains the treatment of choice, and different techniques provide similar oncological outcomes. Minimally invasive methods, especially partial nephrectomy (PN), have emerged as the preferred method of tumor resection, both in traditional and robot-assisted laparoscopy. PN may be performed as an open or laparoscopic operation. On-clamp PN is a variant of PN that includes the clamping of renal vessels; off-clamp PN is performed without any ischemia. Objectives: To assess the short-term loss of eGFR after on-clamp and off-clamp PN. Methods: Data from 2021 to 2024 were retrospectively collected from a hospital database. The patients included in the study had a diagnosed kidney tumor that was confirmed by MRI or CT imaging. The patients were divided into two groups depending on the type of treatment they received: on-clamp PN or off-clamp PN. Hematocrit (HCT), hemoglobin (Hb) and eGFR were measured and compared. Results: Both groups had comparable preoperative HTC, Hb, and eGFR. eGFR loss 24 h after the procedure was 35.4% lower in the off-clamp group compared to the on-clamp group (p = 0.027). Conclusions: Off-clamp PN is a safe and viable method for kidney tumor resection, both in traditional and robot-assisted laparoscopy. This technique results in a smaller perioperative loss of eGFR, which relates to better short-term functional outcomes than on-clamp PN.

Off-clamp robotic partial nephrectomy is a safe and effective approach for patients with T1b or greater renal tumors

Robotic partial nephrectomy (RPN) is a gold standard treatment for focal kidney tumors. Off-clamp RPN avoids prolonged ischemia times. We sought to evaluate the safety and efficacy of off-clamp RPN in patients with renal tumors > 4 centimeters (cm). From 2007 to 2021, we examined patients who underwent RPN for cT1b-T2N0M0 renal tumors. Preoperative, intraoperative, and postoperative outcomes were examined for patients who underwent on or off-clamp RPN. Patients with cT1b tumors (4-7 cm) who underwent either approach were retrospectively propensity-matched based on renal function and tumor size. Of 225 patients, on-clamp RPN was employed in 147 patients, while 78 patients underwent an off-clamp approach. Preoperative estimated glomerular filtration rate (eGFR) was significantly lower in the off-clamp group (p = 0.026). Mean nephrometry scores and mean tumor sizes were similar between cohorts. Average estimated blood loss (EBL) and operative times were similar. Major complication risk was 4.4% lower in the off-clamp group. Blood transfusion rate was 5.6% lower in the off-clamp group. Patients in the off-clamp cohort experienced a < 2% higher risk of positive margins. Postoperative eGFR was more favorable for off-clamp RPN following surgery at 1 year. The propensity-matched analysis demonstrated similar intraoperative outcomes. Blood transfusion rate was significantly lower at 1.5% for patients who underwent off-clamp RPN (p = 0.03). Risk of a major complication was 6.1% lower in the off-clamp RPN cohort, while postoperative eGFR and positive margin rates were similar between off and on-clamp groups. A non-inferior approach for patients with cT1b-T2N0M0 and moderately complex localized renal masses is off-clamp RPN.

Off-clamp Versus On-clamp Partial Nephrectomy: Re-envision of a Dilemma

We contextualize controversial evidence on the impact of warm ischemia on functional outcomes after partial nephrectomy for localized renal tumors and provide a holistic framework for re-envisioning the dilemma of off-clamp versus on-clamp surgery. The focus should shift away from the surgeon towards patient- and kidney-related characteristics.

Comparing Perioperative Complications of Off-Clamp versus On-Clamp Partial Nephrectomy for Renal Cancer Using a Novel Energy Balancing Weights Method

Partial nephrectomy (PN) is the primary surgical method for renal tumor treatment, typically involving clamping the renal artery during tumor removal, leading to warm ischemia and potential renal function impairment. Off-clamp approaches have been explored to mitigate organ damage, yet few results have emerged about the possible effects on hemoglobin loss. Most evidence comes from retrospective studies using propensity score matching, known to be sensitive to PS model misspecification. The energy balancing weights (EBW) method offers an alternative method to address bias by focusing on balancing all the characteristics of covariate distribution. We aimed to compare on- vs. off-clamp techniques in PN using EB-weighted retrospective patient data. Out of 333 consecutive PNs (275/58 on/off-clamp ratio), the EBW method achieved balanced variables, notably tumor anatomy and staging. No significant differences were observed in the operative endpoints between on- and off-clamp techniques, although off-clamp PNs showed slight reductions in hemoglobin loss and renal function decline, albeit with slightly higher perioperative blood loss. Our findings support previous evidence, indicating comparable surgical outcomes between standard and off-clamp procedures, with the EBW method proving effective in balancing baseline variables in observational studies comparing interventions.