Commentary on “Off-clamp vs. complete hilar control laparoscopic partial nephrectomy: Comparison by clinical stage.” Rais-Bahrami S, George AK, Herati AS, Srinivasan AK, Richstone L, Kavoussi LR, Arthur Smith Institute for Urology, North Shore-Long Island Jewish Health System, New Hyde Park, NY: BJU Int 2012;109(9):1376–81 (Epub 2011 Oct 12)

Abstract

Study type-therapy (case series). Level of evidence 4. What's known on the subject? And what does the study add? Minimizing renal ischemia and reperfusion injury is an area of active investigation and is particularly significant in cases of laparoscopic renal surgery where the kidney experiences warm ischemia. Reports of partial clamping, early unclamping, and off-clamp (OC) laparoscopic partial nephrectomy (LPN) have demonstrated potential technical modifications that can offer a protective role in preserving renal function. We investigated OC LPN for tumors with varying clinical stage to determine feasibility, perioperative outcomes, and renal functional changes when compared with a contemporary cohort of standard LPN with complete hilar clamping performed by a single surgeon. To compare the operative outcomes and oncological efficacy of OC LPN vs. complete hilar control (HC) LPN for stage T1a-T2 renal cell carcinoma. Retrospective review of all LPNs between June 2006 and March 2010 was performed, stratifying 390 patients by clinical T stage (cT1a = 313, cT1b = 62, cT2 = 15). Perioperative and postoperative parameters were analyzed comparing patients who underwent OC LPN (n = 126) with those who had HC LPN (n = 264) collectively and within each clinical stage cohort. There was no significant difference in the proportion of OC LPN for cT1a tumors compared with cT1b and cT2, P = 0.21. OC vs. HC LPN patients had a greater estimated blood loss but with no significant difference in perioperative blood transfusion rates. When compared by clinical stage, estimated blood loss was greater only for clinical stage T1a disease (P = 0.02) but not cT1b (P = 0.91) or cT2 (P = 0.42) tumors. There was no difference in the operative time or length of hospitalization between OC and HC LPN by stage: cT1a (P = 0.77 and P = 0.17), cT1b (P = 0.77 and P = 0.07) and cT2 (P = 0.42 and P = 0.66), respectively. In our series, 1 case (0.3%) of HC LPN had a positive margin on final pathology, 1 case was converted to open partial nephrectomy (0.3%), and 2 cases of OC LPN (1.6%) were intraoperatively converted to HC LPN. OC LPN is a feasible surgical option for patients with cT1-T2 renal cell carcinoma that completely avoids renal ischemic injury, with the benefits of minimally invasive surgery. LPN can be performed OC in patients with larger, more complex renal tumors without compromising the operative time, blood loss requiring transfusions, length of hospitalization, complication rates, or positive surgical margin rates compared with HC LPN.