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Selective Arterial Clamping Versus Hilar Clamping for Minimally Invasive Partial Nephrectomy
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  • 作者：Mona Yezdani ; Sue-Jean Yu ; David I. Lee
  • 关键词：Robotic partial nephrectomy ; Selective arterial clamping ; Hilar clamping ; Microvascular dissection ; Renal function
  • 刊名：Current Urology Reports
  • 出版年：2016
  • 出版时间：May 2016
  • 年：2016
  • 卷：17
  • 期：5
  • 全文大小：274 KB
  • 参考文献：1.Campbell SC, Novick AC, Belldegrun A, et al. Guideline for management of the clinical T1 renal mass. J Urol. 2009;182:1271–9.CrossRef PubMed
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    14.••
Ng CK, Gill IS, Patil MB, et al. Anatomic renal artery branch microdissection to facilitate zero-ischemia partial nephrectomy. European Urology. 2012;61:67–74. Hilar microdissection was performed in medial to lateral orientation using preoperative 3D imaging for guidance and extended intrarenally for selective arterial clamping using neurovascular aneurysm microsurgical bulldog clamp. Compared to off clamp, those undergoing SAC had larger tumors, were more hilar, and more complex. No significant difference in renal function between SAC and off-clamp procedure up to 2 months post-operatively.CrossRef PubMed
15.••
Desai MM, Abreu ALDC, Leslie S, et al. Robotic partial nephrectomy with superselective versus main artery clamping: a retrospective comparison. Eur Urol. 2014;66:713–9. SAC compared to hilar clamping. SAC group composed of patients with larger, more complex, more hilar tumors with longer operative time and higher transfusion rates. SAC group had better preserved eGFR at 4–6 months post-operatively.CrossRef PubMed
16.••
Martin GL, Warner JN, Nateras RN, et al. Comparison of total, selective, and nonarterial clamping techniques during laparoscopic and robotic-assisted partial nephrectomy. Journal of Endourology 2012;26(2):152–156. No difference seen in post-operative eGFR between SAC, off clamp, and hilar clamp groups at mean follow-up of 411 days. Off clamping group was older, had smaller tumors, and lower preoperative eGFR.
17.McClintock TR, Bjurlin MA, Wysock JS, et al. Can selective arterial clamping with fluorescence imaging preserve kidney function during robotic partial nephrectomy? J Urol. 2014;84(2):327–34.CrossRef
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24.Mir MC, Ercole C, Takagi T, et al. Decline in renal function after partial nephrectomy: etiology and prevention. J Urol. 2015;193:1889–98.CrossRef PubMed
25.••
Komninos C, Shin TY, Tuliao P, et al. Renal function is the same 6 months after robot-assisted partial nephrectomy regardless of clamp technique: analysis of outcomes for off-clamp, selective arterial clamp and main artery clamp techniques, with a minimum follow-up of 1 year. BJU Int. 2015;115:921–8. Significant difference seen at 3 months in eGFR reduction in hilar clamping group compared to SAC and off clamp groups, however this difference was not present at 6 months or at 1 year. After 7 days from surgery, only low RENAL score, preoperative eGFR, and type of clamp procedure were predictive of normal renal function. At 1 year follow-up, only age and preoperative eGFR correlated with normal eGFR.CrossRef PubMed
26.Shah PH, George AK, Moreira DM, et al. To clamp or not to clamp? Long-term functional outcomes for elective off-clamp laparoscopic partial nephrectomy. BJU Int. 2015;117:293–9.CrossRef PubMed
27.Kallingal GJS, Weinberg JM, Reis IM, et al. Long-term response to renal ischaemia in the human kidney after partial nephrectomy: results from a prospective clinical trial. BJU Int. 2015. doi:10.​1111/​bju.​13192 .PubMed
28.•Zhang Z, et al. Acute kidney injury after partial nephrectomy: role of parenchymal mass reduction and ischemia and impact on subsequent functional recovery. Eur Urol 2015. Median recovery in eGFR from ischemia from partial nephrectomy in solitary kidney was 99% in those without preoperative AKI, 95% for those with grade 1 AKI, 90% for those with grade 2 AKI, and 88% for those with grade 3 AKI up to 12 months after surgery.
  • 作者单位：Mona Yezdani (1)
    Sue-Jean Yu (1)
    David I. Lee (1)

    1. University of Pennsylvania, 51 N. 39th St, MOB 300, Philadelphia, PA, 19104, USA
  • 刊物主题：Urology/Andrology; Nephrology;
  • 出版者：Springer US
  • ISSN：1534-6285
    • 文摘
    Partial nephrectomy has become an accepted treatment of cT1 renal masses as it provides improved long-term renal function compared to radical nephrectomy (Campbell et al. J Urol. 182:1271–9, 2009). Hilar clamping is utilized to help reduce bleeding and improve visibility during tumor resection. However, concern over risk of kidney injury with hilar clamping has led to new techniques to reduce length of warm ischemia time (WIT) during partial nephrectomy. These techniques have progressed over the years starting with early hilar unclamping, controlled hypotension during tumor resection, selective arterial clamping, minimal margin techniques, and off-clamp procedures. Selective arterial clamping has progressed significantly over the years. The main question is what are the exact short- and long-term renal effects from increasing clamp time. Moreover, does it make sense to perform these more time-consuming or more complex procedures if there is no long-term preservation of kidney function? More recent studies have shown no difference in renal function 6 months from surgery when selective arterial clamping or even hilar clamping is employed, although there is short-term improved decline in estimated glomerular filtration rate (eGFR) with selective clamping and off-clamp techniques (Komninos et al. BJU Int. 115:921-8, 2015; Shah et al. 117:293-9, 2015; Kallingal et al. BJU Int. doi:10.​1111/​bju.​13192, 2015). This paper reviews the progression of total hilar clamping to selective arterial clamping (SAC) and the possible difference its use makes on long-term renal function. SAC may be attempted based on surgeon’s decision-making, but may be best used for more complex, larger, more central or hilar tumors and in patients who have renal insufficiency at baseline or a solitary kidney.

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