Off-clamp Partial Nephrectomy Research Articles

On-clamp vs off-clamp robot-assisted partial nephrectomy for achieving modified trifecta: inverse probability of treatment weighting analysis from a high-volume tertiary robotic center.

On-clamp partial nephrectomy for the surgical treatment of renal masses poses the risk of ischemia and greater post-operative renal function loss. Conversely, the off-clamp technique might enhance renal function preservation by avoiding any ischemia time. Nevertheless, the debate persists regarding the efficacy of the on- versus off-clamp partial nephrectomy in achieving better surgical, functional, and oncological outcomes. We retrospectively assessed the data from patients undergoing Robot-Assisted Partial Nephrectomy (RAPN) from 2016 and 2023 in a tertiary robotic center. Inverse probability of treatment weighting (IPTW) was used to account for selection bias in treatment allocation. The main objective of the study was assessing the achievement rates of a modified trifecta within the two groups. Multivariable logistic regression analysis (MLRA) was employed to assess the predictors of trifecta achievement. 532 patients were included in the analysis, of whom 74.1% vs. 25.9% underwent on- and off-clamp, respectively. Balancing the two groups for the main predictors of on-clamp surgery, there were no significant differences between on- and off-clamp in terms of estimated blood loss, transfusion rate, intra- and post-operative complications, positive surgical margins, and post-operative mean reduction of eGFR. Finally, no differences were found in the rate of "trifecta" achievement between on-clamp and off-clamp RAPN (24.6% vs. 21%, p = 0.82). At MLRA, off-clamp technique was not a predictor of trifecta achievement compared to the on-clamp technique (off-clamp vs. on-clamp, aOR 1.24, 95% CIs [0.65-2.36], p = 0.58). Our study revealed that clamping technique does not imply clinically relevant differences in reaching trifecta outcomes.

Comparison of Perioperative, Functional, and Oncologic Outcomes of Open vs. Robot-Assisted Off-Clamp Partial Nephrectomy: A Propensity Scored Match Analysis.

Off-clamp partial nephrectomy represents one of the latest developments in nephron-sparing surgery, with the goal of preserving renal function and reducing ischemia time. The aim of this study was to evaluate and compare the functional, oncologic, and perioperative outcomes between off-clamp robot-assisted partial nephrectomy (off-C RAPN) and off-clamp open partial nephrectomy (off-C OPN) through a propensity score-matched (PSM) analysis. A 1:1 PSM analysis was used to balance variables potentially affecting postoperative outcomes. To report surgical quality, 1 year trifecta was used. Univariable Cox regression analysis was performed to identify predictors of trifecta achievement. The Kaplan-Meier method was used to compare cancer-specific survival (CSS), overall survival (OS), disease-free survival (DFS), and metastasis-free survival (MFS) probabilities between groups. Overall, 542 patients were included. After PSM analysis, two homogeneous cohorts of 147 patients were obtained. The off-C RAPN cohort experienced shorter length of stay (LoS) (3.4 days vs. 5.4 days; p < 0.001), increased likelihoods of achieving 1 year trifecta (89.8% vs. 80.3%; p = 0.03), lower postoperative Clavien-Dindo ≤ 2 complications (1.3% vs. 18.3%, p < 0.001), and lower postoperative transfusion rates (3.4% vs. 12.2%, p = 0.008). At univariable analysis, the surgical approach (off-C RAPN vs. off-C OPN, OR 2.22, 95% CI 1.09-4.46, p = 0.02) was the only predictor of 1 year trifecta achievement. At Kaplan-Meier analysis, no differences were observed between the two groups in terms of OS (log-rank p = 0.451), CSS (log-rank p = 0.476), DFS (log-rank p = 0.678), and MFS (log-rank p = 0.226). Comparing RAPN and OPN in a purely off-clamp scenario, the minimally invasive approach proved to be a feasible and safe surgical approach, with a significantly lower LoS and minor rate of postoperative complications and transfusions as a result of improved surgical quality expressed by higher 1 year trifecta achievement.

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.

Hugo RAS Robot-Assisted Partial Nephrectomy for High-Nephrometry Score Complex Renal Mass: Case Report and Surgical Technique

Hugo™ robot-assisted surgery (RAS) system has been conceived with enhanced modularity cart features and an independent arm-cart docking, nonetheless its role for nephron-sparing surgery has not been defined yet. From October 2022, 15, consecutive patients underwent off-clamp robot-assisted partial nephrectomy (RAPN) for T1 tumors. We are a solely off-clamp partial nephrectomy (PN) center, consequently the T2 RAPN was carried out clampless. Furthermore, we acquired experience and familiarity with Hugo RAS, thanks to an initial series of 15 robotic radical prostatectomies. We report the first RAPN with the new Hugo RAS system for a large highly complex right posterior hilar renal mass (8 cm, cT2) in a 63-year-old man with a BMI of 35.3 kg/m2. The choice to perform RAPN for high-nephrometry score renal mass without hilar clamping was because of the technique we usually perform at our center as we have never done on-clamp procedures. The purpose was to assess the feasibility and the modularity of Hugo RAS independent arm-cart docking even in complex posterior hilar renal tumor, and to explore its role in the setting of off-clamp RAPN. Preoperative hemoglobin, serum creatinine, and estimated glomerular filtration rate were 15.5 g/dL, 0.92 mg/dL, and 115.1 mL/min per 1.73 m2, respectively. The patient was placed on an extended flank position. A modified three-arm configuration was used by a conventional transperitoneal route. Port placement and docking time required 5 minutes. Complete kidney mobilization, identification of arterial branches feeding the tumor, and straightforward approach to the renal mass represented standard key steps of our off-clamp RAPN technique. Tumor enucleation was achieved developing an anatomical cleavage plane. Intraoperative bleeding was controlled with double suction, a slight increase of the pneumoperitoneum to 20 mm Hg, monopolar energy, and renorraphy with a 2/0 Monocryl single-running suture using a sliding-clip technique. No intraoperative complications occurred. No additional port placement was necessary. Console time was 110 minutes, estimated blood loss were ~500 mL. Patient was discharged on postoperative day 3 after bladder catheter and abdominal drain removal, with hemoglobin, serum creatinine, and eGFR of 11.8 g/dL (∆Hb 3.7 g/dL), 0.94 mg/dL, and 112.6 mL/min per 1.73 m2, respectively. Histologic evaluation revealed a chromophobe renal cell carcinoma. Considering the intra- and perioperative outcomes, the lack of complications, and the fast docking, this robotic platform seems to be an user-friendly technology. Currently, the small series considered as the granularity of data regarding the application of Hugo RAS in the RAPN setting hinder to assess that this novel platform is comparable with conventional robotic systems. Further studies with a larger cohort are needed to establish the noninferiority of this platform, but preliminary results seem encouraging. The authors declare no conflict of interest and any commercial associations during the past 3 years. No funding was received for this article. Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. Institutional Review Board Statement: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Source of Work: This study was carried out at Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy. Runtime of video: 4 mins 45 secs

Off-clamp Versus On-clamp Robot-assisted Partial Nephrectomy: A Propensity-matched Analysis

BackgroundPartial nephrectomy is the preferred treatment option for the management of small renal masses. On-clamp partial nephrectomy is associated with a risk of ischemia and a greater loss of postoperative renal function, while the off-clamp procedure decreases the duration of renal ischemia, leading to better renal function preservation. However, the efficacy of the off- versus on-clamp partial nephrectomy for renal function preservation remains debatable. ObjectiveTo compare perioperative and functional outcomes following off- and on-clamp robot-assisted partial nephrectomy (RAPN). Design, setting, and participantsThis study used the prospective multinational collaborative Vattikuti Collective Quality Initiative (VCQI) database for RAPN. Outcome measurements and statistical analysisThe primary objective of this study was the comparison of perioperative and functional outcomes between patients who underwent off- and on-clamp RAPN. Propensity scores were calculated for age, sex, body mass index (BMI), renal nephrometry score (RNS) and preoperative estimated glomerular filtration rate (eGFR). Results and limitationsOf the 2114 patients, 210 had undergone off-clamp RAPN and others on-clamp procedure. Propensity matching was possible for 205 patients in a 1:1 ratio. After matching, the two groups were comparable for age, sex, BMI, tumor size, multifocality, tumor side, face of tumor, RNS, polar location of the tumor, surgical access, and preoperative hemoglobin, creatinine, and eGFR. There was no difference between the two groups for intraoperative (4.8% vs 5.3%, p = 0.823) and postoperative (11.2% vs 8.3%, p = 0.318) complications. Need for blood transfusion (2.9% vs 0, p = 0.030) and conversion to radical nephrectomy (10.2% vs 1%, p < 0.001) were significantly higher in the off-clamp group. At the last follow-up, there was no difference between the two groups for creatinine and eGFR. The mean fall in eGFR at the last follow-up compared with that at baseline was equivalent between the two groups (–16.0 vs –17.3 ml/min, p = 0.985). ConclusionsOff-clamp RAPN does not result in better renal functional preservation. Alternatively, it may be associated with increased rates of conversion to radical nephrectomy and need for blood transfusion. Patient summaryWith this multicentric study, we noted that performing robotic partial nephrectomy without clamping the blood supply to the kidney is not associated with better preservation of renal function. However, off-clamp partial nephrectomy is associated with increased rates of conversion to radical nephrectomy and blood transfusion.

Perioperative, Functional, and Oncologic Outcomes of On-Clamp Versus Off-Clamp Partial Nephrectomy: An Updated Meta-analysis of 9027 Patients.

The aim of this study was to determine the comparative efficacy and safety between on-clamp and off-clamp partial nephrectomy in patients with renal masses. This systematic review was pre-registered on The International Prospective Register of Systematic Reviews (PROSPERO) (CRD42022339127). PubMed, Scopus, and Web of Science were searched. A manual search was also conducted to avoid missing relevant studies. All observational and experimental studies reporting the comparative efficacy and/or safety of on-clamp versus off-clamp partial nephrectomy were included. Outcomes were divided into 3 categories: perioperative, functional, and oncologic outcomes. Risk of bias was assessed using the The Risk Of Bias In Nonrandomized Studies of Interventions (ROBINS-I) and revised Cochrane ROB-II tool for nonrandomized and randomized studies, respectively. Fixed- and random-effect models were implemented to pool the mean difference and log odds ratio of continuous and dichotomous outcomes, respectively. A leave-one-out sensitivity analysis was conducted to determine if the effect size was driven by a single study, and Egger's regression test was used to assess publication bias. Forty-two studies were meta-analyzed. The on-clamping method showed greater benefit when compared to the off-clamping technique in terms of perioperative (estimated blood loss and blood transfusion), functional (estimated glomerular filtration rate), and oncologic outcomes (tumor resection time). However, it is associated with higher risk for complications. Most studies were of moderate-to-serious risk of bias. On-clamping shows superiority in terms of estimated blood loss, blood transfusion, estimated glomerular filtration rate, and tumor resection time. However, it is associated with increased risk of complications. The selection of the technique should be tailored per individual case based on their comorbidities and preoperative risk profile.

PD40-05 RECOVERY OF RENAL FUNCTION FOLLOWING PN IN SOLITARY KIDNEY: IMPACT OF PRE-OPERATIVE EGFR AND INTRAOPERATIVE CHARACTERISTICS ON RECOVERY OF RENAL FUNCTION

You have accessJournal of UrologyCME1 Apr 2023PD40-05 RECOVERY OF RENAL FUNCTION FOLLOWING PN IN SOLITARY KIDNEY: IMPACT OF PRE-OPERATIVE EGFR AND INTRAOPERATIVE CHARACTERISTICS ON RECOVERY OF RENAL FUNCTION Arnold Oparanozie, Stephen W. Reese, Stanley Weng, Lennert Eismann, Katiana Vasquez-Rivera, Jonathan Coleman, A. Ari Hakimi, and Paul Russo Arnold OparanozieArnold Oparanozie More articles by this author , Stephen W. ReeseStephen W. Reese More articles by this author , Stanley WengStanley Weng More articles by this author , Lennert EismannLennert Eismann More articles by this author , Katiana Vasquez-RiveraKatiana Vasquez-Rivera More articles by this author , Jonathan ColemanJonathan Coleman More articles by this author , A. Ari HakimiA. Ari Hakimi More articles by this author , and Paul RussoPaul Russo More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003345.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: In patients undergoing surgery for a renal mass in a solitary kidney, it remains unknown the extent of acute kidney injury (AKI), post-operative renal recovery, and role for large renal tumors (>T2b) in patients undergoing surgery for renal masses in a solitary kidney. Thus, we explored the clinical outcomes and post-operative renal function in a cohort of patients undergoing renal-sparing surgery. METHODS: This study was a single-center retrospective analysis of patients undergoing renal sparing surgery in a solitary kidney at a high-volume academic institution. Descriptive statistics were captured and compared using a Chi-squared test and Wilcoxon Rank Test for categorical and continuous variables, respectively. Multivariable regression was performed using a least-square estimates linear regression model. Survival analysis was performed using the Kaplan-Meier method. RESULTS: In total, 148 patients underwent a partial nephrectomy in a solitary kidney. Most patients were male [110 (74.3%)], 20 (13.5%) had diabetes and 96 (64.9%) had hypertension. The cause of a solitary kidney was a prior history of nephrectomy for carcinoma (n=137, 92.6%). The time from prior nephrectomy to secondary nephrectomy was 77.9 mo (IQR: 14.1-157.2) and median pre-operative eGFR was 52.1 (IQR: 43.7 – 64.7). Most patients had a complex renal mass with 77 (52.0%) having a RENAL score greater than 7. Most patients were clinical stage T1/2 (n=119, 80.4%), however 27 (18.2%) had a T3 tumor. Most patients underwent an open procedure (n=132, 89.2%), had an on-clamp partial (n=92, 62.2%) and had cold ischemia (n=68, 73.9%). The median clamp time was 36 min (IQR: 26-47). eGFR was measured in the 12 months after surgery and after an initial decline in eGFR, there was noted to be recovery of renal function. In our multi-variable model, there was no differences in change from baseline eGFR at 12 months, including starting eGFR, cold vs. warm ischemia time and on-clamp vs. off-clamp partial nephrectomy. Dialysis was required in 14 (9.5%) patients and of those who required dialysis, 8 (57.1%) only had temporary dialysis, while in 6 (42.9%) dialysis was permanent. Median OS was 118.3 mo (95% CI: 138.8 -106.2). At the end of follow-up, 69 (46.6%) had died and of those 27 (39.1%) died of kidney cancer. Of those who died of kidney cancer, 7 (25.9%) had clinical stage T3 at time of surgery. CONCLUSIONS: In this selected cohort of renal masses in solitary kidneys, nephron-sparing surgery was feasible with most patients recovering to baseline GFR regardless of approach. Source of Funding: MSK P30 grant © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1053 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Arnold Oparanozie More articles by this author Stephen W. Reese More articles by this author Stanley Weng More articles by this author Lennert Eismann More articles by this author Katiana Vasquez-Rivera More articles by this author Jonathan Coleman More articles by this author A. Ari Hakimi More articles by this author Paul Russo More articles by this author Expand All Advertisement PDF downloadLoading ...

Robotic Off-Clamp Simple Enucleation Single-Layer Renorrhaphy Partial Nephrectomy (ROSS): Surgical Insights after an Initial Experience

Robotic technology allows the beginner surgeon to approach minimally-invasive partial nephrectomy (PN) avoiding the otherwise long learning curve of pure laparoscopy. The present video-article reported the surgical technique and the outcomes of the first 11 cases performed by a young surgeon starting with the experience of robotic PN. Transperitoneal robotic PN, with an off-clamp approach, a simple enucleation technique, and a single-layer medullar renorrhaphy was performed uneventfully in all cases but one, with comparable outcomes to the available literature. With the present experience, we are trying to give the reader a different point of view of the current knowledge. In our series, off-clamp robotic PN was not chosen while looking for a better functional outcome, but rather as a "forced" choice within the specific "in training" setting the interventions were performed in. We underline how the off-clamp approach was the way to cut out the potential for vascular complications derived from the application/removal of the clamp itself on the renal artery. Indeed, when Scanlan bulldogs are not available, one of the limits of robotic PN is that the first surgeon is not autonomous in placing/removing the clamp. We found that tumour enucleation resection technique had the perfect synergistic effect in maximizing the perioperative vision, and thus the safety, notwithstanding the clampless approach.

Purely Off-Clamp Partial Nephrectomy: Robotic Approach Better than Open Using a Pentafecta Outcome with Propensity Score Matching.

Partial nephrectomy (PN) is the gold standard treatment for localized renal masses. Robot-assisted PN (RAPN) has overcome laparoscopy's technical limitations, greatly expanding the indications of minimally invasive PN, which is dominated by renal artery clamping in almost all published series. We compared off-clamp RAPN (OFFC-RAPN) with the open approach (OFFC-OPN) using propensity score (PS) matching. A favourable pentafecta outcome was defined as a combination of no positive surgical margins (PSM), no complications of Clavien-Dindo (CD) grade ≥ 3, post-operative eGFR loss &lt;10%, length of hospital stay (LOS) ≤ 5 days and estimated blood loss (EBL) &lt; 200 mL. A total of 340 consecutive patients were included. The PS-matched cohort included 142 patients: 71 matched pairs well-balanced for all covariates. The OFFC-RAPN group showed significantly shorter operative time (149.8 vs. 173.9 min, p = 0.003), lower EBL (182.1 vs. 329.3 mL, p = 0.001), and shorter LOS (5.8 vs. 6.9 days, p = 0.02), with a higher proportion of patients with LOS ≤ 5 days (57.7% vs. 23.9%, p &lt; 0.001). No significant differences were found for PSM rate (2.8% vs. 8.4%, p = 0.27), CD &gt; 2 complication rate (4.2% vs. 2.8%, p = 1.00) and mean ± SD eGFR change (-0.06 ± 0.3 vs. -0.8 ± 0.3, p = 0.5). Pentafecta was achieved in 56.3% and 21.1% in the OFFC-RAPN and OFFC-OPN series, respectively (p &lt; 0.0001). On multivariable analysis, surgical approach and BMI proved to be independent predictors of achieving pentafecta. After adjusting for potential treatment selection bias, OFFC-RAPN outperformed OFFC-OPN for important peri-operative outcomes, without compromising oncological and functional safety.

Every decade counts: a narrative review of functional recovery after partial nephrectomy.

To provide a narrative review of the major advances regarding ischaemia and functional recovery after partial nephrectomy (PN), along with the ongoing controversies. Key articles reflecting major advances regarding ischaemia and functional recovery after PN were identified. Special emphasis was placed on contributions that changed perspectives about surgical management. Priority was also placed on randomized trials of off-clamp vs on-clamp cohorts. A decade ago, 'Every minute counts' was published, showing strong correlations between duration of ischaemia and development of acute kidney injury (AKI) and chronic kidney disease after clamped PN. This reinforced perspectives that ischaemia was the main modifiable factor that could be addressed to improve functional outcomes and helped spur efforts towards reduced or zero ischaemia PN. These approaches were associated with strong functional recovery and some peri-operative risk, although they were generally safe in experienced hands. Further research demonstrated that, when parenchymal volume changes were incorporated into the analyses, ischaemia lost statistical significance, and percent parenchymal volume saved proved to be the main determinant. Cold ischaemia was confirmed to be highly protective, and limited warm ischaemia also proved to be safe. The reconstructive phase of PN, with avoidance of parenchymal devascularization, appears to be most important for functional outcomes. Randomized trials of on-clamp vs off-clamp PN have shown minimal impact of ischaemia on functional recovery. The past decade has witnessed great progress regarding functional recovery after PN, with many lessons learned. However, there are still unanswered questions, including: What is the threshold of warm ischaemia at which irreversible ischaemic injury begins to develop? Are some cohorts at increased risk for AKI or irreversible ischaemic injury? and Which patients should be prioritized for zero-ischaemia PN?

3D virtual clipping: A personalized planning and rehearsal tool for off-clamp partial nephrectomy

Kidney cancer treatments result in a loss of nephron mass. Nephron sparing surgery can reduce such loss through application of on- and off-clamp techniques. The on-clamp technique is widely used but resulting warm ischemia has a negative impact on long-term patient outcomes. The alternative off-clamp technique mitigates negative effects on renal function but is often considered a technique for expert hands in select cases only.

IJU this issue

This issue of International Journal of Urology contains 11 Original Articles, two Urological Notes, two Letters to the Editor, two Author’s reply, and three Editorial Comments. Partial nephrectomy for totally endophytic renal tumor is a surgical challenge and even if under robotic assistance, off-clamp partial nephrectomy is considered a risky procedure. Tuderti et al. (Rome, Italy) reported 56 consecutive patients with totally endophytic renal masses treated with off-clamp robotic partial nephrectomy (RAPN) in their institution. Preoperative super-selective delivery of a lipiodol-indocyanine green mixture into arterial branches feeding the renal mass provides a quick guide to identify tumor location without intraoperative ultrasound. Furthermore, it gives us a straight access to surgical area with minimal opening of Gerota’s capsule. Trifecta achievement was 91% in their patients with low operative complication rates. As Pandolfo et al. (Viriginia, USA) described in the Editorial Comment, the Editor also thinks that this procedure sacrifices visibility due to increased bleeding during the procedure. Moreover, it needs an extra step (preoperative super-selective delivery of a lipiodol-indocyanine green mixture) before surgery, which makes the procedure more complicated. With the technical advancement and accumulation of experience, the debate “on-clamp versus off-clamp” RAPN for completely endophytic renal masses will be settled in the near future. Gleason pattern 5 has been considered an independent unfavorable prognostic factor in localized and advanced prostate cancer. Morozumi et al. (Miyagi, Japan) retrospectively conducted multicenter analysis of outcomes of metastatic hormone-sensitive prostate cancer (mHSPC) with a Gleason score (GS) ≥8. They revealed that in high metastatic volume groups, hemoglobin and lactate dehydrogenase were significant factors for predicting overall survival (OS), while both Gleason pattern 5 and primary Gleason pattern 5 were not significant predictive factors after multivariate analysis. On the contrary, in the low-volume (LV) metastatic groups, only Gleason pattern 5 was an independent unfavorable predictive factor for OS after the analysis. Although there are several limitations, such as a lack of central pathology, they concluded that only in LV mHSPC patients with GS ≥8, primary Gleason pattern 5 should be considered as an unfavorable factor for the treatment strategy. As a homeostatic system, bladder storage function keeps the micturition interval constant by increasing bladder capacity during the diuretic phase, which is known as vesical adaptation response to diuresis (VARD). Matsuoka et al. (Fukushima, Japan) analyzed 94 male patients older than 65 years with lower urinary tract symptoms (LUTS). They found that 48 patients (51%) had VARD but in 46 patients (49%), VARD was lacking. Interestingly, absence of VARD was significantly associated with overactive bladder and benign prostate enlargement after adjusting for confounders. Although there are several limitations in their study, understanding of the pathophysiology underlying VARD might contribute a novel strategy for the treatment of bladder storage dysfunction in patients with LUTS. Immune checkpoint inhibitors (ICIs) therapy has become a key therapy against advanced urothelial carcinoma (UC), but there are no definitive data available for the association of the oncological outcome to first-line chemotherapy to subsequent ICIs therapy. Ozaki et al. (Hirosaki, Japan) reported their retrospective analysis of 218 patients with advanced UC who received systematic, platinum-based first-line chemotherapy. Focusing upon OS between patients treated with or without second-line ICIs therapy who had no progressive disease (PD) within four or few cycles of first-line chemotherapy (the non-PD ≤4 group), there was significant difference in the median survival (63 vs 26 months). On the contrary, in patients who had PD within four or few cycles of first-line chemotherapy (the PD ≤4 group), there was no significant difference in OS whether they were treated with ICI or not. These results suggest that the favorable response to the first-line chemotherapy was significantly associated with longer survival in patients with subsequent ICIs therapy than those without. Although we do not know the precise mechanisms of the results of the article, Miyake (Nara, Japan) commented in this issue that platinum derivatives could induce immunogenic cell death, which might enhance the antitumor activity of dendritic cells and T cells, which results in modulation of the expression of immune checkpoint molecules. Moreover, we still do not have the answer to how many first-line chemotherapy cycles will be appropriate before ICIs therapy. Consideration of introduction of antibody-drug conjugate, enfortumab vedotin for advanced UC treatment, we should accumulate more data about appropriate timing of changing armaments against this difficult disease. Unfortunately, the limited space restricts me to introduce the other excellent articles in this issue. I hope that the articles in this issue will help you in daily clinical practice. None declared.

Cross-analysis of two randomized controlled trials to compare pure versus robot-assisted laparoscopic approach during off-clamp partial nephrectomy.

article: Cross-analysis of two randomized controlled trials to compare pure versus robot-assisted laparoscopic approach during off-clamp partial nephrectomy - Minerva Urology and Nephrology 2022 February;74(1):5-10 - Minerva Medica - Journals

Comparison of the Effect of On-Clamp vs. Off-Clamp Partial Nephrectomy on Renal Function: A Retrospective Analysis

Comparison of the Effect of On-Clamp vs. Off-Clamp Partial Nephrectomy on Renal Function: A Retrospective Analysis

MP59-14 LONG TERM ONCOLOGIC OUTCOMES OF PARTIAL NEPHRECTOMY FOR CYSTIC RENAL TUMORS: A PROPENSITY SCORE MATCHED-PAIR COMPARISON OF CYSTIC VERSUS CLEAR CELL CARCINOMA FROM A SINGLE CENTER EXPERIENCE

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy V (MP59)1 Sep 2021MP59-14 LONG TERM ONCOLOGIC OUTCOMES OF PARTIAL NEPHRECTOMY FOR CYSTIC RENAL TUMORS: A PROPENSITY SCORE MATCHED-PAIR COMPARISON OF CYSTIC VERSUS CLEAR CELL CARCINOMA FROM A SINGLE CENTER EXPERIENCE Mariaconsiglia Ferriero, Riccardo Mastroianni, Gabriele Tuderti, Manuela Costantini, Umberto Anceschi, Leonardo Misuraca, Aldo Brassetti, Salvatore Guaglianone, Alfredo Maria Bove, Michele Gallucci, and Giuseppe Simone Mariaconsiglia FerrieroMariaconsiglia Ferriero More articles by this author , Riccardo MastroianniRiccardo Mastroianni More articles by this author , Gabriele TudertiGabriele Tuderti More articles by this author , Manuela CostantiniManuela Costantini More articles by this author , Umberto AnceschiUmberto Anceschi More articles by this author , Leonardo MisuracaLeonardo Misuraca More articles by this author , Aldo BrassettiAldo Brassetti More articles by this author , Salvatore GuaglianoneSalvatore Guaglianone More articles by this author , Alfredo Maria BoveAlfredo Maria Bove More articles by this author , Michele GallucciMichele Gallucci More articles by this author , and Giuseppe SimoneGiuseppe Simone More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002094.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Few data are available on survival outcomes of partial nephrectomy performed for cystic renal tumors. We present long term oncological outcomes of cystic (cystRCC) versus clear cell cell carcinoma (ccRCC) in a propensity score matched (PSM) analysis. METHODS: Our prospectively maintained “renal cancer “database was queried for off-clamp partial nephrectomy and cystic or clear cell variant histology at pathologic examination. The two groups were compared for the main clinical features. A 1:3 PSM analysis was employed to reduce covariate imbalance to <10% and generated two population homogeneous for age, gender, tumour size, pT stage and Fuhrman Grade. Student-t and Chi-Square test were used for continuous and categorical variables, respectively. Five-yr disease free survival (DFS) and cancer specific survival (CSS) were compared between the two study cohorts using log rank test. Age, gender, grade, pT stage, tumor size, necrosis and variant histology were included in a univariable Cox regression analysis to identify predictors of disease progression after partial nephrectomy. RESULTS: Clinical and pathological features of the study cohorts were reported in Table 1. Overall, 85 cases were cystRCC and 774 were ccRCC at pathologic examination. After applying the PSM analysis, two cohorts were selected, including 64 cystRCC and 170 ccRCC. (Table 1) Five-yr DFS and CSS were 84.1%, 97.2% versus 90.1% and 100 % for ccRCC and cystRCC, respectively. (log rank p=0.035 and p=0.146, respectively. (Fig. 1) At univariable regression analysis ccRCC histology was the only independent predictor of DFS (HR 2.96 95%CI 21.031-8.478, p=0.044). CONCLUSIONS: At 5-yr evaluation cystRCC showed favorable oncological outcomes after partial nephrectomy. Clear cell variant histology predicts less favorable progression probability than cystic tumors. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1035-e1036 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mariaconsiglia Ferriero More articles by this author Riccardo Mastroianni More articles by this author Gabriele Tuderti More articles by this author Manuela Costantini More articles by this author Umberto Anceschi More articles by this author Leonardo Misuraca More articles by this author Aldo Brassetti More articles by this author Salvatore Guaglianone More articles by this author Alfredo Maria Bove More articles by this author Michele Gallucci More articles by this author Giuseppe Simone More articles by this author Expand All Advertisement Loading ...

Off-Clamp Robot-Assisted Partial Nephrectomy: Is There Something More to Achieve Optimal Trifecta Outcomes?

Objectives: To report trifecta outcomes of our "off-clamp" partial nephrectomy (PN) patients operated without main renal artery and/or any selective/superselective clamping. Materials and Methods: Between April 2008 and March 2020, 52 patients received "off-clamp" robot-assisted partial nephrectomy. Postoperative sixth month estimated glomerular filtration rate (eGFR) and eGFR decrease were considered for renal function evaluation. Patients with negative surgical margins, <15% postoperative eGFR decrease and absence of grade ≥2 Clavien-Dindo complications were reported to achieve trifecta outcomes. Results: Mean age and body mass index of the patients were 57.51 ± 12.99 years and 27.23 ± 4.35 kg/m2, respectively. Mean preoperative hematocrit, serum creatinine, and eGFR were 42.01 ± 3.86%, 0.92 ± 0.28 mg/dL, and 85.26 ± 21.27 mL/min/1.73 m2, respectively. Mean tumor size was 30.32 ± 13.64 mm. Mean PADUA and RENAL scores were 7.63 ± 1.46 and 6.21 ± 1.63, respectively. One patient had focal surgical margin positivity. Mean console time and estimated blood loss was 82.11 ± 38.51 minutes and 280.76 ± 278.98 mL, respectively. Complications were observed in two (4%) patients (one Clavien I, one Clavien IIIB). At postoperative sixth month, serum creatinine and eGFR were 0.95 ± 0.32 mg/dL and 83.65 ± 22.44 mL/min/1.73 m2, respectively. Eventually seven patients had ≥15% postoperative eGFR decrease, one patient had grade ≥2 complication and one patient had positive surgical margin. Forty-three (83%) patients fulfilled trifecta outcomes. Conclusion: Off-clamp PN is important for optimal renal function preservation. Patient selection and additional operative measures along with experience in robotic procedure can contribute achievement of optimal trifecta outcomes.

Comparative Study Assessing Postoperative Renal Loss Using Two Different Partial Nephrectomy Techniques: Off-Clamp versus Standard On-Clamp Surgery

Objectives: To evaluate a case-matched study comparing postoperative renal function using two surgical techniques: an off-clamp partial nephrectomy (PN) with the aid of the Altrus® device and a standard on-clamp laparoscopic PN. Material and Methods: A total of 36 patients underwent PN. Eighteen had the off-clamp technique and 18 had the standard laparoscopic on-clamp PN. Demographic, clinical, radiological, and perioperative data were collected for analysis. An emphasis on renal function was made by analyzing both the perioperative and follow-up with estimated glomerular filtration rate and MAG3. Results: The median values did not signifcantly differ for age, Charlson Comorbidity Index, and hospital stay in the off-clamp versus on-clamp PN [62.5 (interquartile range, IQR 11) vs. 60 (IQR 16) years, 4 (IQR 2) vs. 5 (IQR 2) and 5 (IQR 1) vs. 4 (IQR 2) days], respectively. The median diameter of the tumors was 33 (IQR 23) versus 41 (IQR 28) mm (p = 0.63), with median R.E.N.A.L. nephrometry scores of 7 (IQR 2) versus 7 (IQR 2) (p = 0.33). There was greater blood loss in the Altrus® (375 vs. 200 ml, p = 0.037). The clamp time in the on-clamp group was 30 (IQR 6) minutes (range 22-68 minutes) compared to 0 minutes in the off-clamp group. There was no difference in hemoglobin or creatinine levels between the groups. However, the on-clamp group had a significant loss in ipsilateral renal function on the MAG3 scan (49 vs. 42%, p = 0.0001), whereas the off-clamp group had no difference (48 vs. 46%, p = 0.72). Conclusions: The off-clamp method for PN is a feasible and safe option with better preservation of ipsilateral renal function when compared with on-clamp PN in the treatment of small renal masses.

Single-port robotic partial and radical nephrectomies for renal cortical tumors: initial clinical experience.

To describe our institution's initial experience with radical (RN) and partial nephrectomy (PN) using the SP robotic system. The recent FDA approval of the da Vinci® SP robotic platform has led to its use in minimally invasive approaches to urologic malignancies. There are little data on its feasibility and safety after implementation for radical and partial nephrectomy. All patients who underwent PN or RN using the SP system at our institution were reviewed. All PNs were performed off-clamp. Patient demographics, preoperative imaging, operative approaches, and perioperative outcomes were collected and analyzed. Sixteen patients underwent PN (n = 13) or RN (n = 3) utilizing the SP robotic system between January 2019 and June 2019. Average age was 58.6 ± 13.9 and 61.0 ± 1.7years in each group, respectively. A retroperitoneal approach was performed in 7 (53.8%) PN patients and 1 (33.3%) RN patient. A transperitoneal approach was performed in 6 (46.1%) PNs and 2 (66.7%) RNs. Mean operative time and median estimated blood loss for PN was 176.9 ± 64.0min and 200 (50-800) ml compared to 176.3 ± 73.8min and 50 (50-400) ml for RN. There was one operative conversion (7.7%) to an open approach in the PN group. Length of hospital stay postoperatively averaged 1.9 ± 1.3days and 3.3 ± 1.2days for patients undergoing partial and radical nephrectomy, respectively. SP partial and radical nephrectomies through transperitoneal and retroperitoneal approaches appear to be feasible surgical techniques in the management of cortical renal masses. Off-clamp PN is also a feasible approach using the SP system. However, further study is needed to establish its safety and use in renalsurgeryacross multiple institutions and larger patient cohorts.

Nephron sparing surgery for renal tumors-comparison of off-clamp partial nephrectomy with hilar clamping.

Background and Objective:Open partial nephrectomy (PN) is still considered gold standard procedure for T1 localized renal tumors. Conventional technique involves clamping of the renal artery with or without vein however, renal ischemia produces a certain level of damage to the kidneys. This study aims to investigate potential effect of off-clamp vs. hilar clamping PN on renal function.Methods:This is a retrospective cohort study of patients who underwent unilateral, open partial nephrectomy for renal tumors b/w January 2009 December 2016 at our institution. A total of 90 partial nephrectomies were performed of which 65 cases were eligible for analysis. Non clamping technique was used in 43 while clamp was applied in 22 patients. Variables studied were patients’ demographics, clinical variables, the laterality, tumors size and location, R.E.N.A.L nephrometry score, blood loss, tumor histology and surgical margins. Patients’ renal function (serum creatinine and eGFR) were determined pre-operatively, at 3 and 12 months follow up. Data was analyzed on SPSS v. 22.Results:Both the groups were comparable with regards to pre-operative renal function. Mean radiological size of tumor was 4.71±1.31 and 3.81±1.0 (0.003) in two groups respectively. Mean R.E.N.A.L nephrometry score was 6.1±1.5 in off-clamp group compared to 7.05 ± 1.7 in clamp group (p=0.04). No statistically significant difference was found in operative duration, blood loss, positive surgical margins and intra/ peri-operative complications. At three months and one year, renal function was better preserved in non-clamp group compared to clamp group (p=0.001 and 0.007 respectively).Conclusion:Off clamp open partial nephrectomy is safe and feasible option leading to less decline in renal function.

IJU this issue

This issue contains three Review Articles, four Original Articles and four Urological Notes. Huge differences in the incidence and mortality rate of prostate cancer were detected between the USA and Japan. Such differences, however, have been decreasing over time, and were only twofold in 2017. Ito et al. (Takasaki, Japan) describe the important issue of screening for prostate cancer. They propose their screening strategies based on baseline prostate-specific antigen with a reasonable incremental cost-effectiveness ratio. In their perspectives, prostate cancer management might not only be aimed at decreasing the mortality of prostate cancer, but also aimed at achieving a significant increase in the quality-adjusted life year with an acceptable incremental cost-effectiveness ratio. The cancer-specific mortality among patients with localized prostate cancer has been reported to be very low irrespective of the treatment modalities. Nakamura et al. (Hamamatsu, Japan) focus on the patients’ quality of life after external beam radiotherapy using X-ray for prostate cancer, compared with other modalities, including radical prostatectomy and brachytherapy. In conclusion, the patients’ quality of life after external beam radiotherapy is strongly related to the total dose, fractionation regimens, dose parameters of the critical organs, beam delivery techniques and treatment plan quality, with a trade-off between the radicality of external beam radiotherapy and potentially increased toxicity. Particle beam radiotherapy (RT) for prostate cancer in Japan has changed considerably, and it is eligible for insurance coverage as of April 2018. Ishikawa et al. (Tsukuba, Japan) review the results of previous particle beam RT studies compared with photon beam RT, and introduce ongoing studies and prospects to establish high-quality evidence for particle beam RT for prostate cancer. Androgen deprivation therapy (ADT), a standard treatment for metastatic and locally advanced prostate cancer, is known to increase the risks of osteoporosis and fractures. Kimura et al. (Tokyo, Japan) prospectively investigated changes in bone quality, turnover markers and bone mineral density before and after ADT in castration-sensitive prostate cancer. They found that bone quality markers did not change significantly after ADT, whereas bone mineral density decreased significantly after ADT. Bone turnover markers might play an important role in monitoring bone health during ADT. Simone et al. (Rome, Italy) carried out propensity score-matched analysis to compare long-term renal functional outcomes after either off-clamp partial nephrectomy (PN) or on-clamp PN in patients with cT1–2/N0 M0 renal tumors. This study shows that off-clamp PN is associated with a significantly higher probability of maintaining 100% estimated glomerular filtration rate after surgery compared with on-clamp PN in patients with good baseline renal function. It also showed that patients treated with on-clamp PN had a 7.3-fold increased risk of developing a severe chronic kidney disease during long-term follow up. Molecular-targeted therapies have been generally used for treatment of metastatic renal cell carcinoma (mRCC), resulting in improvement in prognoses of mRCC. Konishi et al. (Hirosaki, Japan) retrospectively investigated the impact of C-reactive protein/albumin ratio (CAR) on prognosis, and the effect of adding CAR in the International Metastatic Renal Cell Carcinoma Database Consortium model for prognosis discrimination in Japanese patients who were treated with first-line tyrosine kinase inhibitor for mRCC. They concluded that CAR is an independent predictor of prognosis in patients with mRCC. Predictive activity was significantly improved in the International Metastatic Renal Cell Carcinoma Database Consortium-CAR model compared with the International Metastatic Renal Cell Carcinoma Database Consortium model. Kam et al. (Sydney, Australia) compared the operative performance of two single-use digital flexible ureteroscopes (fURS) with a reusable video fURS in order to show that single-use fURS would have a similar performance to reusable fURS with a lower scope failure rate. In conclusion, these single-use scopes offer a feasible alternative to reusable fURS, especially in complex stone cases where the risk of scope damage is high. None declared.