Off-clamp Laparoscopic Partial Nephrectomy Research Articles

Feasibility of Microwave Scissors-Based Off-Clamp Laparoscopic Partial Nephrectomy in a Porcine Model.

To assess the feasibility of off-clamp laparoscopic partial nephrectomy using microwave scissors. We performed transperitoneal laparoscopic partial nephrectomy, without hilar clamping or renorrhaphy, using only microwave scissors for renal resection in a porcine model. For each kidney, 2 types of procedures were performed: a middle pole resection excising an area of 2-cm diameter and approximately 1-cm depth and a lower pole resection at the level of the lower polar line. The renal calyces exposed during renal resection were sealed and transected using microwave scissors. After 3days of follow-up, the pigs were reoperated to inspect for postoperative complications. Euthanasia was performed to collect the remaining kidneys for histopathological examination. Ten procedures were successfully performed, without hilar clamping or suturing of the renal calyces and parenchyma, in 5 kidneys from 3 pigs. The median resecting time, blood loss, and lateral thermal injury were 23.2min, 47.1mL, and 6.8mm in the middle pole resection, and were 15.1min, 26.5mL, and 6.9mm in the lower pole resection, respectively. No complications were noted during reoperation, such as postoperative hemorrhage and major urine leakage. Extravasation occurred in 2 middle pole resections and 3 lower pole resections during retrograde pyelogram. Hematoxylin and eosin staining revealed thermal injury characterized by tissue microwave fixation in the near zone and acute coagulative necrosis in the intermediate zone. Microwave scissors-based off-clamp laparoscopic partial nephrectomy is feasible in pigs and can be used for clinical applications.

Purely Off-Clamp Laparoscopic Partial Nephrectomy Stands the Test of Time: 15 Years Functional and Oncologic Outcomes from a Single Center Experience.

Nephron-sparing surgery represents the gold standard treatment for organ-confined renal tumors. We present 15-years of outcomes after off-clamp laparoscopic partial nephrectomy (ocLPN). a retrospective analysis was performed on patients who underwent ocLPN between May 2001 and December 2005. Baseline demographic, clinical, pathologic, surgical, functional and survival data were collected. The Kaplan-Meier method evaluated group-specific oncologic outcomes at 5, 10 and 15 years and the log rank test assessed differences between groups. The same analysis investigated the probabilities of developing a significant renal function impairment (sRFI) and achieving ROMeS. Cox analyses identified predictors of this latter tricomposite outcome. We included 63 patients whose median tumor size was 3 cm (IQR:2-4). At 15 years, the chances of developing local recurrence, metachronous renal cancers or distant metastases were 2 ± 2%, 23 ± 6% and 17 ± 5%, respectively. Consequently, disease-free, cancer-specific and overall-survival probabilities were 68 ± 6%, 90 ± 4% and 72 ± 6%. MCRSS and UCISS well predicted oncologic outcomes. Overall, nine (14%) patients experienced an sRFI and 33 (52%) achieved ROMeS. Age (HR: 1.046; p = 0.033) and malignant histology (low-risk cancers HR: 3.233, p = 0.048) (intermediate/high risk cancers HR: 5.721, p = 0.023) were independent predictors of ROMeS non-achievement. At 15 years from ocLPN, most of patients will experience both excellent functional and oncologic outcomes.

Randomized Clinical Trial Comparing On-clamp Versus Off-clamp Laparoscopic Partial Nephrectomy for Small Renal Masses (CLOCK II Laparoscopic Study): A Intention-to-treat Analysis of Perioperative Outcomes

BackgroundRecent randomized trials (RCTs) in the field of robotic partial nephrectomy (PN) showed no significant differences in perioperative outcomes between the off- and on-clamp approaches. ObjectiveTo compare the perioperative outcomes of on- versus off-clamp pure laparoscopic PN (LPN). Design, setting, and participantsA multi-institutional analysis of the on- versus off-clamp approach during LPN in the setting of an RCT (CLOCK II trial; ClinicalTrials.gov NCT02287987) was performed. InterventionOff- versus on-clamp LPN. Outcome measurements and statistical analysisBaseline patient and tumor variables, and peri- and postoperative data were collected. Randomized allocation with a 1:1 ratio was assigned. Surgical strategy for managing the renal pedicle was dictated by the study protocol. In the off-clamp arm, the renal artery had to remain unclamped for the duration of the whole procedure. Reporting the intention-to-treat analysis is the purpose of the study. Results and limitationsThe study recruited 249 patients. Of them, 123 and 126 were randomized and allocated into the on- and off-clamp treatment groups, respectively. Treatment groups were comparable at baseline after randomization with respect to patients’ demographics, comorbidities, renal function, and tumor size and complexity. A univariable analysis found no differences in the perioperative outcomes between the groups, including median (interquartile range) estimated blood loss (150 [100–200] vs 150 [100–250] ml, p = 0.2), grade ≥2 complication rate as classified according to the Clavien-Dindo system (5.7% vs 4.8%, p = 0.6), and positive surgical margin rate (8.2% vs 3.5% for the on- vs off-clamp group, p = 0.1). No differences were found in terms of the 1st (81.3 [66.7–94.3] vs 85.3 [71.0–97.7] ml/min, p = 0.2) and 5th postoperative days estimated glomerular filtration rate (83.3 [70.5–93.7] vs 83.4 [68.6–139.3] ml/min, p = 0.2). A multivariable analysis found each +1 increase in RENAL score corresponded to an increase in the protection from the occurrence of complications (odds ratio [OR] 0.72, 95% confidence interval [CI] 0.54–0.97, p = 0.034), while each +1 cm increase in tumor size corresponded to an increase in the risk of blood transfusion (OR 1.39, 95% CI 1.14–1.70, p = 0.001). ConclusionsIn the setting of an RCT, no differences were found in the perioperative and early functional outcomes between on- and off-clamp LPN. Patient summaryIn this study, we investigated, by means of a randomized trial, whether avoiding the clamping of renal artery during laparoscopic resection of renal mass is able to translate into benefits. We found no differences in terms of safety, efficacy, and renal function from the standard approach, which includes arterial clamping.

Nefrectomía parcial laparoscópica off-clamp tras la embolización del tumor en sala híbrida frente a nefrectomía parcial convencional: un análisis de pares emparejados por puntuación de propensión

ObjectiveOff-clamp laparoscopic partial nephrectomy in a hybrid operating room after superselective arterial embolization (hLPN) is a promising minimally invasive approach. In this study, we compared the perioperative surgical outcomes of this innovative technique with the conventional standard of care laparoscopic partial nephrectomy (cLPN) technique. Patients and methodsOverall, 86 and 127 patients treated with hLPN and cLPN, respectively, were included. These two techniques were compared in terms of surgical complications, estimated blood loss (EBL), operative time, length of stay (LOS), surgical margins, and Trifecta achievement rate (defined as warm ischemia duration <25min, negative surgical margins and absence of complications). A propensity score based on age, gender, BMI, preoperative eGFR and tumor size was used for a 1:1 matching of patients of each group. After matching, two groups of 67 patients with similar characteristics were obtained. ResultsConversion rate to open surgery, complications and EBL were similar in both groups. Conversely, operative time, LOS and Trifecta rates favored hLPN. The multivariate analysis showed that hLPN had a 70% higher chance of Trifecta achievement than cLPN in all age groups and for all tumor size across the study population. ConclusionCompared to a conventional approach, off-clamp laparoscopic partial nephrectomy in a hybrid room after superselective arterial embolization showed satisfying immediate surgical outcomes and reached a higher rate of Trifecta achievement. Mid and long-term functional and oncological results are needed to establish this minimally invasive surgical alternative.

Off-clamp laparoscopic partial nephrectomy in a hybrid room after tumor embolization versus conventional partial nephrectomy: A propensity score matched pair analysis

ObjectiveOff-clamp laparoscopic partial nephrectomy in a hybrid operating room after superselective arterial embolization (hLPN) is a promising minimally invasive approach. In this study, we compared the perioperative surgical outcomes of this innovative technique with the conventional standard of care laparoscopic partial nephrectomy (cLPN) technique. Patients and methodsOverall, 86 and 127 patients treated with hLPN and cLPN, respectively, were included. These two techniques were compared in terms of surgical complications, estimated blood loss (EBL), operative time, length of stay (LOS), surgical margins, and Trifecta achievement rate (defined as warm ischemia duration <25 min, negative surgical margins and absence of complications). A propensity score based on age, gender, BMI, preoperative eGFR and tumor size was used for a 1:1 matching of patients of each group. After matching, 2 groups of 67 patients with similar characteristics were obtained. ResultsConversion rate to open surgery, complications and EBL were similar in both groups. Conversely, operative time, LOS and Trifecta rates favored hLPN. The multivariate analysis showed that hLPN had a 70% higher chance of Trifecta achievement than cLPN in all age groups and for all tumor size across the study population. ConclusionCompared to a conventional approach, off-clamp laparoscopic partial nephrectomy in a hybrid room after superselective arterial embolization showed satisfying immediate surgical outcomes and reached a higher rate of Trifecta achievement. Mid and long-term functional and oncological results are needed to establish this minimally invasive surgical alternative.

SC265 - Cross-analysis of two randomized trials to compare pure versus robot-assisted off-clamp laparoscopic partial nephrectomy

SC265 - Cross-analysis of two randomized trials to compare pure versus robot-assisted off-clamp laparoscopic partial nephrectomy

PD12-05 PER-PROTOCOL ANALYSIS FROM THE CLOCK II RANDOMIZED CLINICAL TRIAL COMPARING OFF-CLAMP VERSUS ON-CLAMP PURE LAPAROSCOPIC PARTIAL NEPHRECTOMY

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy I (PD12)1 Sep 2021PD12-05 PER-PROTOCOL ANALYSIS FROM THE CLOCK II RANDOMIZED CLINICAL TRIAL COMPARING OFF-CLAMP VERSUS ON-CLAMP PURE LAPAROSCOPIC PARTIAL NEPHRECTOMY Riccardo Bertolo, Pierluigi Bove, Marco Sandri, Chiara Cipriani, Luca Cindolo, Costantino Leonardo, Paolo Parma, Mario Falsaperla, Domenico Veneziano, Antonio Celia, Andrea Minervini, and Alessandro Antonelli Riccardo BertoloRiccardo Bertolo More articles by this author , Pierluigi BovePierluigi Bove More articles by this author , Marco SandriMarco Sandri More articles by this author , Chiara CiprianiChiara Cipriani More articles by this author , Luca CindoloLuca Cindolo More articles by this author , Costantino LeonardoCostantino Leonardo More articles by this author , Paolo ParmaPaolo Parma More articles by this author , Mario FalsaperlaMario Falsaperla More articles by this author , Domenico VenezianoDomenico Veneziano More articles by this author , Antonio CeliaAntonio Celia More articles by this author , Andrea MinerviniAndrea Minervini More articles by this author , and Alessandro AntonelliAlessandro Antonelli More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001987.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Comprehensive systematic literature reviews including pure laparoscopic partial nephrectomy (LPN) showed no impact on either surgical or oncological outcomes by the off-clamp technique. This finding is debatable and based on the pooled analysis of mostly small sample size studies, affected by several bias. We aimed to report a comparative analysis of perioperative outcomes of on-clamp vs off-clamp LPN in the setting of a randomized controlled trial. METHODS: 217 patients with RENAL masses ≤10 were randomized to on-clamp (106) vs off-clamp (111) LPN (The CLOCK II trial - ClinicalTrials.gov NCT 02287987). Data were collected at 5 participating institutions. One experienced surgeon per institution performed all the surgeries. Baseline and perioperative outcomes were collected and analyzed. The per-protocol analysis (patients who actually received an on-clamp or an off-clamp approach) is herein reported. RESULTS: After randomization, treatment groups were comparable at baseline in age, body mass index, comorbidities, clinical tumor size, RENAL score, serum creatinine, hemoglobin. A total of 189 patients actually underwent surgery as assigned (82 vs 107 on-clamp vs off-clamp, respectively). Tumors treated by an on-clamp approach were significantly bigger (4.0, IQR 3.0-5.0, vs 3.0, IQR 2.2-4.0 cm) but no difference was found in the baseline RENAL score. Regarding the perioperative outcomes, significant differences were found in the resection technique, the renorrhaphy technique, the use of hemostatic agents, the complications’ and transfusions’ rates, the operative time and the hospital stay, favoring the off-clamp approach. Groups were comparable in the blood loss. No significant differences were found in the positive surgical margins rate. CONCLUSIONS: When analyzing the patients who actually received an on-clamp or an off-clamp approach in the setting of a randomized trial, off-clamp LPN resulted in at least non inferior perioperative outcomes. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e204-e204 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Riccardo Bertolo More articles by this author Pierluigi Bove More articles by this author Marco Sandri More articles by this author Chiara Cipriani More articles by this author Luca Cindolo More articles by this author Costantino Leonardo More articles by this author Paolo Parma More articles by this author Mario Falsaperla More articles by this author Domenico Veneziano More articles by this author Antonio Celia More articles by this author Andrea Minervini More articles by this author Alessandro Antonelli More articles by this author Expand All Advertisement Loading ...

Comparison of functional outcomes of off-clamp laparoscopic partial nephrectomy access techniques: A preliminary report.

ABSTRACTObjective:This study aims to compare renal functional outcomes of access techniques in patients who underwent off-clamp (Off-C) laparoscopic partial nephrectomy (LPN).Materials and Methods:Thirty-four Off-C LPNs in patients with functioning contralateral kidney from March 2011 to June 2018 were included in the study. Twenty-two patients underwent transperitoneal, 12 patients underwent retroperitoneal Off-C LPN. The primary outcome was glomerular filtration rate changes over time, postoperatively. The secondary outcome was the evaluation of trifecta and pentafecta rate.Results:Preoperative demographics, tumor size (26.59 vs. 22.83mm, p=0.790), RENAL score (5.45 vs. 5.33, p=0.990), operation time (79.95 vs. 81.33 min, p=0.157), blood loss (170.23 vs. 150.83mL, p=0.790) were similar in both groups. Although preservation of renal function was better in group 2 in the early period, similar results were found in both groups at the end of the first year, postoperatively. No positive surgical margin and postoperative major complications were detected in any patient. While trifecta goals were achieved in all the patients in the cohort, pentafecta rates were 90.9% and 91.7% in the transperitoneal and retroperitoneal groups, respectively.Conclusions:Transperitoneal and retroperitoneal access were found to have similar outcomes in terms of preservation of renal function at the end of the first year postoperatively. Off-C LPN may be considered as a safe and effective treatment option in patients having non-complex renal tumors.

SC217 - Real-life analysis of the Clock II randomized clinical trial comparing on-clamp versus off-clamp laparoscopic partial nephrectomy

SC217 - Real-life analysis of the Clock II randomized clinical trial comparing on-clamp versus off-clamp laparoscopic partial nephrectomy

SC208 - On-Clamp versus Off-Clamp laparoscopic partial nephrectomy: intention-to-treat analysis of peri-operative outcomes from the clock II randomized clinical trial

SC208 - On-Clamp versus Off-Clamp laparoscopic partial nephrectomy: intention-to-treat analysis of peri-operative outcomes from the clock II randomized clinical trial

Three-dimensional reconstruction facilitates off-clamp laparoscopic partial nephrectomy for stage cT1b renal tumors.

BackgroundThis study aimed to evaluate the role of three-dimensional (3D) reconstruction of T1b renal tumors in the off-clamp laparoscopic partial nephrectomy (LPN).MethodsA total of 40 consecutive patients undergoing LPN for stage cT1b renal tumor between January 2018 and July 2018 were included. Twenty received off-clamp LPN under the guidance of 3D reconstruction (3D group), and remaining 20 underwent off-clamp LPN under the guidance of conventional computer tomography arteriography (CTA group). The demographics, perioperative characteristics and renal function were compared between groups.ResultsAll the procedures were performed successfully without conversion to main renal artery clamping. There were no significant differences in the age, gender, body mass index (BMI), tumor size, and RENAL score between two groups. The mean operation time (OT) was significantly shorter and estimated blood loss markedly less in the 3D group than in the CTA group. Incidence of postoperative complications was 5% in the 3D group and 10% in the CTA group (P>0.05). 3D reconstruction of renal tumors resulted in more accurate dissection of the tumor artery (90.9%) as compared to conventional CTA (81.5%). All the patients had negative surgical margins. There was no significant difference in the estimated glomerular filtration rate (eGFR) before and after surgery between two groups.Conclusions3D reconstruction is beneficial for the resection of cT1b renal tumor and tumor-specific feeding arteries in the off-clamp LPN.

SC52 - On-clamp vs off-clamp laparoscopic partial nephrectomy: An intention-to-treat analysis from the Clock II randomized trial

SC52 - On-clamp vs off-clamp laparoscopic partial nephrectomy: An intention-to-treat analysis from the Clock II randomized trial

1183 - Off-clamp laparoscopic partial nephrectomy in a hybrid room after tumor embolization versus conventional laparoscopic approach: A propensity-matched analysis

1183 - Off-clamp laparoscopic partial nephrectomy in a hybrid room after tumor embolization versus conventional laparoscopic approach: A propensity-matched analysis

Comparative study of off-clamp, laparoscopic partial nephrectomy (OCLPN) and conventional hilar control, laparoscopic partial nephrectomy (HCLPN) for renal tumors: One-year follow-up results of renal function change

We designed the study to compare the oncologic and renal function outcomes of off-clamp, laparoscopic partial nephrectomy (OCLPN) and conventional laparoscopic partial nephrectomy (HCLPN) for renal tumors. Methods Between March 2008 and July 2015, 114 patients who underwent laparoscopic partial nephrectomy (LPN) of a renal neoplasm were studied. We performed LPN without hilar clamp on 40 patients (OCLPN, Group 1), and conventional LPN with hilar control and renorrhaphy on another 40 patients (HCLPN, Group 2). We retrospectively reviewed the medical records of each patient's age, sex, R.E.N.A.L. nephrometry score (RNS), operation time, complications, hospitalization period, tumor size, positive resection margin, histologic classification of tumor, pathologic stage, Fuhrman grade, estimated blood loss (EBL), warm ischemic time (WIT), and estimated glomerular filtration rate (eGFR) before and one year after surgery. Results There were no significant differences in age, sex, preoperative eGFR, EBL, surgical (anesthesia) time, and tumor size between the two groups. The mean eGFR was not significantly different between the OCLPN and HCLPN groups 1 month (95 and 86.2 mL/min/1.73 m2, respectively; P = 0.106), 6 months (92.9 and 83.6 mL/min/1.73 m2, respectively; P = 0.151) and 12 months (93.8 and 84.7 mL/min/1.73 m2, respectively; P = 0.077) postoperatively. The change in eGFR after one year was 3.9% in the OCLPN group and −7.9% in the HCLPN group. Conclusions OCLPN was superior to HCLPN in preserving renal function one year after surgery, and there was no statistically significant difference in tumor treatment results.

V36 - Off-clamp laparoscopic partial nephrectomy: Preoperative imaging and tumor enucleation

V36 - Off-clamp laparoscopic partial nephrectomy: Preoperative imaging and tumor enucleation

P139 - Intraoperative and perioperative outcomes of clamp vs off-clamp laparoscopic partial nephrectomy: Preliminary results from a multicentre randomized clinical trial (The Clock2 Study)

P139 - Intraoperative and perioperative outcomes of clamp vs off-clamp laparoscopic partial nephrectomy: Preliminary results from a multicentre randomized clinical trial (The Clock2 Study)

Off-Clamp Laparoscopic Partial Nephrectomy for High-Complexity Tumor: Step-by-Step of Our Technique

Abstract Background: Laparoscopic partial nephrectomy (LPN) utilizes warm ischemia to temporally reduce the renal blood perfusion to perform a precise tumoral excision and kidney reconstruction. Ho...

V27 - Off-clamp laparoscopic partial nephrectomy for hilar renal cell carcinoma: Surgical description

V27 - Off-clamp laparoscopic partial nephrectomy for hilar renal cell carcinoma: Surgical description

The Piezo Actuator-Driven Pulsed Water Jet System for Minimizing Renal Damage after Off-Clamp Laparoscopic Partial Nephrectomy.

In the setting of partial nephrectomy (PN) for renal cell carcinoma, postoperative renal dysfunction might be caused by surgical procedure. The aim of this study was to clarify the technical safety and renal damage after off-clamp laparoscopic PN (LPN) with a piezo actuator-driven pulsed water jet (ADPJ) system. Eight swine underwent off-clamp LPN with this surgical device, while off-clamp open PN was also performed with radio knife or soft coagulation. The length of the removed kidney was 40 mm, and the renal parenchyma was dissected until the renal calyx became clearly visible. The degree of renal degeneration from the resection surface was compared by Hematoxylin-Eosin staining and immunostaining for 1-methyladenosine, a sensitive marker for the ischemic tissue damage. The mRNA levels of neutrophil gelatinase-associated lipocalin (Ngal), a biomarker for acute kidney injury, were measured by quantitative real-time PCR. Off-clamp LPN with ADPJ system was successfully performed while preserving fine blood vessels and the renal calix with little bleeding. In contrast to other devices, the resection surface obtained with the ADPJ system showed only marginal degree of ischemic changes. Indeed, the expression level of Ngal mRNA was lower in the resection surface obtained with the ADPJ system than that with soft coagulation (p = 0.02). Furthermore, using the excised specimens of renal cell carcinoma, we measured the breaking strength at each site of the human kidney, suggesting the applicability of this ADPJ to clinical trials. In conclusion, off-clamp LPN with the ADPJ system could be safely performed with attenuated renal damage.

Nephrometry score-guided off-clamp laparoscopic partial nephrectomy: patient selection and short-time functional results.

BackgroundLaparoscopic partial nephrectomy (LPN) is not a novel but a relatively technically challenging surgical procedure. Off-clamp LPN with zero ischemia can completely eliminate ischemic reperfusion injury to the kidney. The purpose of this study was to evaluate the safety and functional outcome of nephrometry score-guided off-clamp technique in LPN.MethodsA total of 44 patients underwent LPN between January 2015 and July 2015 for renal mass with radius, exophytic/endophytic, nearness to sinus, anterior/posterior location (RENAL) score 4 were enrolled. Twenty-two of them underwent off-clamp LPN with zero ischemia, and the other 22 received standard LPN with common renal artery clamp. Estimate blood loss (EBL), total operation time, resection time, renorrhaphy time, preoperative estimated glomerular filtration rate (eGFR), postoperative eGFR, eGFR change, and drainage after surgery were compared between these two groups using t test.ResultsPatients’ characteristics including gender, age, BMI, tumor size, and RENAL score were balanced between the two groups. Average EBL was more in the off-clamp group than in the on-clamp group (134.32 versus 70.23 ml, p = 0.001). Average eGFR change was less in the off-clamp group than in the on-clamp group (−1.56 versus −6.45, p < 0.001). Average drainage after surgery was 203.41 ml for the off-clamp group and 145.46 ml for the on-clamp group, p = 0.062. No urinary leakage and hematuria occurred in both groups. There were no statistical difference in total operation time, resection time, renorrhaphy time, preoperative eGFR, and postoperative eGFR between the two groups.ConclusionsOff-clamp LPN is a safe and feasible approach to excise certain kidney tumors with RENAL score 4. This technique can better preserve kidney function without ischemic reperfusion injury.