SURGICAL OUTCOMES AND PERIOPERATIVE MORBIDITY OF CLAMP vs OFF-CLAMP LAPAROSCOPIC PARTIAL NEPHRECTOMY
Objective
Nephron sparing surgery (NSS) is now reference standard for many T1 renal tumors. To reduce renal damage several technique have been proposed; cold ischemia, artery clamping, selective artery clamping, zero ischemia. We retrospectively compared perioperative results of clamp vs no clamp procedure in patients affected by T1 renal cancer.
Materials and Methods
From database of our institution we reviewed patients affected by single, clinical T1 tumor who underwent a laparoscopic partial nephrectomy (LPN). A transperitoneal approach was performed in all patients. In Clamp LPN group renal artery was clamped using laparoscopic Bull dog. In off-clamp group, a controlled hypotension, to carefully lower the mean arterial pressure (MAP) while maintaining excellent systemic perfusion, was maintened at approximately 60 mmHg. To induce hypotension, the doses of inhalational isoflurane was increased. The renal lesion was excised using cold endoshears. Parenchyma was repaired with Vicryl™ sutures arrested with absorbable clips and Hem-O-lok™. In clamp group bulld dog was removed while in the off –clamp group blood pressure was restored to preoperative levels. Biologic hemostatic agents and Surgicel™ were applied to the resection bed when appropriated.
Results
We identified 59 patients in the clamp group and 67 in off-clamp group; baseline characteristic of the two groups are described in table 1. Patients of off clamp group presented significant less operative time, blood loss and transfusion rate than clamp group. Hospitalization and suture time were shorter for off-clamp group, also [table 2]. No significant differences were observed in terms of histological evaluation [table 3]. Postoperative complication were rare [table 4].
Table 1. Baseline characteristics
Clamp group Off clamp group p value
pts n 59 67
Age (y) y 59.8 ± 13.6 58.4 ±12.4 0.57
BMI 28.5 ±4.6 27.8 ±5.3 0.56
cTumor size mm 40.5 11.7 42.7 ±15.4 0.41
pTumor size mm 44.7 ±16.4 41.3 ±16.0 0.40
ASA (%) I 6.1 5.9 0.56
II 39.4 47.1
III 51.5 45.1
IV 3.0 1.9
RENAL (%) Low 17.0 20,3
Medium 57.6 72,5
High 25.4 7,2
Table 2. operative outcomes
Clamp group Off clamp group p value
Operative time min. 214.5 ±56.6 147.6 ±54.7 0.001
Resection time min. 6.9 ± 2.9 8.5 ±4.6 0.46
Suture time min. 16.3 ±7.3 9.6 ±6.4 0.006
Blood loss min. 747.4 ±706.3 357.1 ±340.4 0.001
Hb drop gr/dl 2.3 ±1.7 2.1 ±1.1 0.51
Transfusion (n) 0 33 58 0.002
1 13 3
2 5 5
3 8 0
Hospitalization Days 10.2 7.4 0.03
Table 3. Histological outcomes
Clamp group Off clamp group p value
Type
RCC 38 34
Cromophobe 1 5
Papillary 6 12
unclassificable 1 1
Oncocytoma 6 9
aml 3 3
Benign 4 3
Stage
T1a 26 (56.5) 25 (48.1) 0.87
T1b 15 (32.6) 20 (38.5)
T2 1 (2.2) 2 (3.8)
T3a 4 (8.7) 5 (9.6)
+ve surgical margins 1 (1.7%) 0
Tab 4. Perioperative complications
Clamp group Off clamp group
haemorrage 2 (3.4%) 0
Diaphragmatic lesion 2 (3.4%) 1 (1.5%)
Urine leakage 3 (5.1%) 2 (3.0%)
Pnx 1 (1.7%) 0
fever 2 (3.4%) 5 (7.5%)
Conclusion
Clamp and off-clamp laparoscopic partial nephrectomy are equally safe and reproducible technique in terms of perioperative outcomes and complications. However the appropriate procedure should be selected taking into account tumor complexity, patient comorbidity and surgeon experience.
Argomenti: Cancro del rene