Recently published preliminary 3-year results of purely off-clamp robotic partial nephrectomy among 308 patients showed that 3-year local recurrence-free survival and disease specific survival rates 99.5% and 97.9%, respectively [1]. Importantly, no patient with preoperative CKD stage ≤3B developed severe renal function deterioration (CKD stage 4) at 1-year follow-up. Other studies have compared 120 on-clamp to 120 off-clamp patients undergoing robotic enucleation of the kidney tumor, finding that the off-clamp group had a significantly lower eGFR drop compared to the on-clamp group at the third post-operative day (1% vs 7%) and at 30th post-operative day (2.5% vs 9%) from baseline [2].
Dr. Rha is a proponent of off-clamp robotic partial nephrectomy and routinely performs these procedures. The remainder of his talk summarized 11 tips and tricks for performing these procedures:
It is important to mobilize the kidney and prepare the “angle of attack” for the eventual resection. According to Dr. Rha, this involves potentially full mobilization of the kidney prior to any resection
Preparation before tumor excision. This includes having a 3-O vicryl sutures on an SH needle, opening of an endocatch bag, and having Surgicel bolsters in the abdomen.
- Be mentally prepared to lose blood. Dr. Rha notes that he often loses 300-400cc of blood when he performs off clamp partial nephrectomies.
- Control bleeding with parenchymal compression, which Dr. Rha highlights the importance of having a capable bed-side assistant for these procedures.
- Use a simplified intrarenal suturing technique, including a deep stitch for “first suture traction”. Dr. Rha’s suture is a 3-O vicryl (25 cm) on an SH needle, with a Weck, metal clip and lapra-ty
- For renal capsule closure, Dr. Rha cautions that you should take as much as you need. His suture for capsule closure is a 2-O vicryl (25 cm) on a SH needle, with a Weck, metal clip and Hem-0-Lok
- Dr. Rha notes that the use of hemostatic agents, such as Floseal, Surgicel bolsters and fibrin glue. However, he does not routinely use hemostatic agents and feels that their use is optional
- If the surgeon is not completely comfortable doing an off-clamp resection, a selective clamping can be performed. Specifically, this may be pertinent for polar and/or larger masses. When selectively clamping, Dr. Rha using short curved or short straight Bulldog clamps
- Consider off-clamp robotic partial nephrectomy in solitary kidneys
- Consider off-clamp robotic partial nephrectomy in multiple tumors
- Consider off-clamp robotic partial nephrectomy in bilateral tumors. Dr. Rha cautions that this may not be standard of care, however he feels that in highly selected patients, particularly if the more difficult (first) side procedure is performed without complication
- Off-clamp robotic partial nephrectomy is feasible in selected small renal mass patients
- Off-clamp robotic partial nephrectomy may not be entirely necessary for those with two normal renal units, and may be better served for those with solitary kidneys, CKD, or those with risk factors for CKD
- Consider selective clamping for larger, more difficult tumors
- Importantly – is the patient benefit outweighing complication, anxiety and tension?
References:
1. Simone G, Misuraca L, Tuderti G, et al. Purely off-clamp robotic partial nephrectomy: Preliminary 3-year oncological and functional outcomes. Int J Urol 2018 [Epub ahead of print].
2. Mari A, Morselli S, Sessa F, et al. Impact of the off-clamp endoscopic robot-assisted simple enucleation (ERASE) of clinical T1 renal tumors on the postoperative renal function: Results from a matched-pair comparison. Eur J Surg Oncol 2018 [Epub ahead of print].
Written by: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre Twitter: @zklaassen_md at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA