Robotic Partial Nephrectomy with Superselective Versus Main Artery Clamping: A Retrospective Comparison
Menée à partir des données médicales portant sur 121 patients atteints d'une tumeur rénale, cette étude rétrospective compare, du point de vue de données péri-opératoires (perte de sang, durée de l'opération), de la qualité des marges de résection, de la préservation des fonctions rénales et des événements indésirables, l'efficacité de deux techniques de néphrectomie partielle assistée par robot, l'une comportant le clampage de l'artère rénale principale, l'autre une dévascularisation tumorale spécifique avec perfusion artérielle continue de l'autre partie du rein
Background : Concerns have been raised regarding partial nephrectomy (PN) techniques that do not occlude the main renal artery. Objective : Compare the perioperative outcomes of superselective versus main renal artery control during robotic PN. Design, setting, and participants : A retrospective analysis of 121 consecutive patients undergoing robotic PN using superselective control (group 1, n=58) or main artery clamping (group 2, n=63). Intervention : Group 1 underwent tumor-specific devascularization, maintaining ongoing arterial perfusion to the renal remnant at all times. Group 2 underwent main renal artery clamping, creating global renal ischemia. Outcome measurements and statistical analysis : Perioperative and functional data were evaluated. The Pearson chi-square or Fisher exact and Wilcoxon rank sum tests were used. Results and limitations : All robotic procedures were successful, all surgical margins were negative, and no kidneys were lost. Compared with group 2 tumors, group 1 tumors were larger (3.4 vs 2.6cm, p=0.004), more commonly hilar (24% vs 6%, p=0.009), and more complex (PADUA 10 vs 8, p=0.009). Group 1 patients had longer median operative time (p<0.001) and transfusion rates (24% vs 6%, p<0.01) but similar estimated blood loss (200 vs 150ml), perioperative complications (15% vs 13%), and hospital stay. Group 1 patients had less decrease in estimated glomerular filtration rate at discharge (0% vs 11%, p=0.01) and at last follow-up (11% vs 17%, p=0.03). On computed tomography volumetrics, group 1 patients trended toward greater parenchymal preservation (95% vs 90%, p=0.07) despite larger tumor size and volume (19 vs 8ml, p=0.002). Main limitations are the retrospective study design, small cohort, and short follow-up. Conclusions : Robotic PN with superselective vascular control enables tumor excision without any global renal ischemia. Blood loss, complications, and positive margin rates were low and similar to main artery clamping. In this initial developmental phase, limitations included more perioperative transfusions and longer operative time. The advantage of superselective clamping for better renal function preservation requires validation by prospective randomized studies. Patient summary : Preserving global blood flow to the kidney during robotic partial nephrectomy (PN) does not lead to a higher complication rate and may lead to better postoperative renal function compared with clamped PN techniques. Take Home Message : To compare perioperative outcomes of superselective versus main renal artery control during robotic partial nephrectomy (PN), we collected data on 121 consecutive patients undergoing robotic PN using superselective control (n=58) or main artery clamping (n=63). Robotic PN with superselective vascular control enables tumor excision without the need for global renal ischemia. Blood loss, complications, and negative margin rates were low and similar to main artery clamping.