Do patients with Stage 3–5 chronic kidney disease benefit from ischaemia‐sparing techniques during partial nephrectomy?

Abstract

Objective To analyse whether selective arterial clamping (SAC) and off‐clamp (OC) techniques during robot‐assisted partial nephrectomy (RPN) are associated with a renal functional benefit in patients with Stage 3–5 chronic kidney disease (CKD). Patients and methods The change in estimated glomerular filtration rate (eGFR) over time was compared between 462 patients with baseline CKD 3–5 that underwent RPN with main arterial clamping (MAC) (n = 375, 81.2%), SAC (n = 48, 10.4%) or OC (n = 39, 8.4%) using a multivariable linear mixed‐effects model. All follow‐up eGFRs, including baseline and follow‐up between 3 and 24 months, were included in the model for analysis. The median follow‐up was 12.0 months (interquartile range 6.7–16.5; range 3.0–24.0 months). Results In the multivariable linear mixed‐effects model adjusting for characteristics including tumour size and the R.E.N.A.L. (Radius; Exophytic/Endophytic; Nearness; Anterior/Posterior; Location) Nephrometry Score, the change in eGFR over time was not significantly different between SAC and MAC RPN (β = −1.20, 95% confidence interval [CI] −5.45, 3.06; P = 0.582) and OC and MAC RPN (β = −1.57, 95% CI −5.21, 2.08; P = 0.400). Only 20 (15 MAC, two SAC, three OC) patients overall had progression of their CKD stage at last follow‐up. The mean ischaemia time was 17 min for MAC and 15 min for SAC. There was no benefit to SAC or OC in terms of blood loss, perioperative complications, length of stay, or surgical margins. Conclusion SAC and OC techniques during RPN were not associated with benefit in preservation of eGFR in patients with baseline CKD.

Comparison of Perioperative, Renal Functional, and Oncological Outcomes Between Off-Clamp and On-Clamp Robot-Assisted Partial Nephrectomy for Renal Tumors: An Updated Evidence-Based Analysis

“…Finally, 21 full-text articles involving 4,493 patients (1,274 off-clamp versus 3,219 on-clamp) were included for the pooled analysis ( 9 – 29 ). Of these articles, 7 were prospective cohort studies ( 9 , 10 , 12 , 13 , 16 , 18 , 25 , 27 ), 10 were retrospective cohort studies ( 11 , 14 , 15 , 17 , 19 – 21 , 23 , 24 , 29 ), and 3 were prospective randomized studies ( 22 , 26 , 28 ). Table 1 shows the characteristics, level of evidence, and quality score of each included study.…”

“…Data of operating time were synthesized from 17 studies including 2,636 patients (833 off-clamp versus 1,803 on-clamp) ( 9 – 16 , 18 – 24 , 26 , 27 ). Pooled analysis revealed a significant shorter operating time in the off-clamp group (WMD: -18.93; 95% CI: -33.87, -4.00; p = 0.01) with a significant heterogeneity ( I 2 = 96%, p < 0.00001) ( Figure 2A ).…”

“…Analysis of EBL was conducted in 16 studies with 3,338 patients (835 off-clamp versus 2503 on-clamp) ( 9 , 11 – 16 , 18 – 22 , 24 , 26 , 27 , 29 ). Pooled analysis detected a significantly higher EBL in the off-clamp group (WMD: 20.27; 95% CI: 6.11, 34.44; p = 0.005) with a statistically significant heterogeneity ( I 2 = 79%, p < 0.00001) ( Figure 2B ).…”

“…Data of the complication rate (including intraoperative and/or postoperative complications) were available in 19 studies with a total of 3,847 patients (1,061 off-clamp versus 2,786 on-clamp) ( 9 – 11 , 13 – 27 , 29 ). Pooled analysis revealed a significantly lower rate of complication in the off-clamp group compared with the on-clamp group (OR: 0.72; 95% CI: 0.57, 0.92; p = 0.009) ( Figure 2E ).…”

“…Eighteen studies with 3,664 patients (1,000 off-clamp versus 2,664 on-clamp) were included in the analysis for positive surgical margin rate ( 9 – 11 , 13 – 15 , 17 – 27 , 29 ). Pooled analysis indicated that the off-clamp group had a significantly lower positive surgical margin rate (OR: 0.54; 95% CI: 0.36, 0.79; p = 0.002) ( Figure 4A ).…”