Differences in pentafecta outcome between on-clamp and off-clamp robotic partial nephrectomy

Robotic partial nephrectomy (RAPN) can be considered the gold standard for the treatment of localized renal tumors (cT1-T2a). The on-clamp approach is considered safer for complex tumors, but the off-clamp approach is constantly growing, offering advantages for renal function.

We enrolled 517 patients underwent RAPN between 1/2020 and 12/2023 and we divided in two groups: A (on-clamp) and B (off-clamp). We analyzed the individual parameters of the pentafecta outcomes, so absence of complications, negative surgical margins (PSMs), and warm ischemia period shorter than 25' or zero ischemia, >90% preservation of estimated glomerular filtration rate (eGFR) and no stage progression of chronic kidney disease (CKD) at 1-year follow-up, and finally the overall results.

The duration of surgery was significantly longer in group A (120' vs 90') (p <0.001). The median value for duration of warm ischemia was 16 minutes. Postoperative complications occurred in 22 cases (4.2%). Although the frequency of anemia was higher in Group B, in relation to the total number of procedures, no statistically significant difference was found (p = 0.36), neither for PSMs rate (p = 0.73). The achievement of pentafecta outcomes in group A and B was 79.7% and 91.2%, respectively (p ≤0.001). In patients who have undergone ischemia, the duration of clamping is correlated with the increase in postoperative creatinine (p <0.001).

Off-clamp approaches show better results in pentafecta outcomes and to reduce the risk of increased creatinine in the post-operative course, although they require greater surgical skill but offer shorter execution times.