Vol. 43 (x): 2017 November 11.[Ahead of print]
Cecilia Lanchon 1, 2, Valentin Arnoux 1, Gaëlle Fiard 1, 2, Jean-Luc Descotes 1, 2, Jean-Jacques Rambeaud 1, Jean-Benjamin Lefrancq 1, Delphine Poncet 1, Nicolas Terrier 1, Camille Overs 1, Quentin Franquet 1, Jean-Alexandre Long 1, 2
1 Department of Urology, Grenoble University Hospital, Grenoble, France; 2 UJF-Grenoble 1, CNRS, INSERM, TIMC-IMAG UMR 5525, 38041 Grenoble, France
Introduction: Super-selective clamping of tumor-specific segmental arteries was developed to eliminate ischemia of the remnant kidney while limiting hemorrhage during partial nephrectomy. The objective is to evaluate the benefice of super-selective clamping on renal functional outcome, compared to early-unclamping of the renal artery.
Materials and Methods: From March 2015 to July 2016, data from 30 patients undergoing super-selective robot-assisted PN (RAPN) for a solitary tumor by a single surgeon were prospectively collected. Tumor devascularization was assessed using indocyanine green near-infrared fluorescence. A matched-pair analysis with a retrospective cohort undergoing early-unclamping was conducted, adjusting on tumor complexity and preoperative eGFR. Perioperative, oncologic and functional outcomes using DMSA-renal scintigraphy were assessed. Multivariate analysis was performed to identify predictors of postoperative renal function and de novo chronic kidney disease (CKD).
Results: Super-selective RAPN was successful in 23/30 patients (76.7%), 5 requiring secondary main artery clamping due to persistent tumor fluorescence. Matched-pair analysis showed similar operating time, blood loss, positives margins and complication rates. Super-selective clamping was associated with an improved eGFR variation at discharge (p=0.002), 1-month (p=0.01) and 6-month post-op (-2%vs-16% p=0.001).
It also led to a better relative function on scintigraphy (46%vs40% p=0.04) and homolateral eGFR (p=0.04), and fewer upstaging to CKD stage ≥3 (p=0.03). On multivariate analysis, super-selective clamping was a predictor of postoperative renal function.
Conclusion: Super-selective RAPN leads to an improved preservation of renal function and a reduced risk of de novo CKD stage≥3, while keeping the benefit of main artery clamping on perioperative outcomes.
Keywords: Nephrectomy; Kidney; Ischemia