Evolution of Technique from Minimally Ischemic to Pure Off-Clamp Partial Nephrectomy: 15-Year Learning Curve and Outcomes of 1083 Patients

Abstract

Introduction and Objective: There is a growing interest in surgical techniques aimed at minimizing ischemia during partial nephrectomy (PN). The aim of this video is to report surgical tips, perioperative, functional, and oncologic outcomes of first 1083 patients treated with laparoscopic or robotic minimally ischemic1,2 or pure off-clamp (Off-C) PN treated between 2002 and 2015 in a high-volume center. Materials and Methods: Patients were placed in an extended flank position and a four-port or five-port access was performed for laparoscopic or robotic approach, respectively. Hilar vessels were not clamped in any case; pure or hybrid tumor enucleation was the resection technique used. The first case shows a robotic PN with the “sutureless technique” for more exophytic masses, which can also be performed with a laparoscopic approach.3 The second video shows a 4 cm left mesorenal tumor treated with laparoscopic PN after superselective transarterial embolization.4–6 This original technique, first used in 2003, at the beginning of the learning curve, has been no longer used since 2010. The third video shows a robotic PN in a right solitary kidney, affected by a 4.3 cm tumor involving the medial aspect of the upper pole. Small arterial feeders identified or transected during the enucleation of the tumor were selectively coagulated. Two suction devices were used simultaneously to maintain a bloodless surgical field. A point-specific hemostasis was performed before starting a sliding clip renorrhaphy. Results: Overall complication rate was 15.7% with a transfusion rate of 7.8%. Only 4.25% of complications were severe with a Clavien grade equal to or greater than 3. Five-year local recurrence-free survival and cancer-specific survival rates were 98.1% and 98%, respectively. The 5-year risk of severe renal function (RF) deterioration (chronic kidney disease (CKD) stage 4) was 0%, 0.9%, 7.5%, and 10.7% for patients with stages 1, 2, 3A, and 3B CKD, respectively. At multivariable analysis, baseline RF (p = 0.001) and postoperative RF decrease ≥10% (p = 0.048) independently predicted a new onset stage 4 or 5 CKD. Conclusions: Off-C PN is a challenging surgical procedure. At the beginning of learning curve, a stepwise adoption of pure Off-C approach is mandatory and preparing hilar vessels for intermediate and high nephrometry score renal tumors is recommended. Oncologic outcomes were comparable with on-clamp PN series and excellent functional outcomes of our series support Off-C as a first line treatment option in high-volume tertiary referral centers. No competing financial interests exist. Runtime of video: 5 mins 5 secs Presented at the World Congress of Endourology in Cape Town, South Africa, November 2016.