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

Area of Science:

• Urology
• Surgical Oncology
• Robotic Surgery

Background:

• Robotic partial nephrectomy (RAPN) is the standard for localized renal tumors (cT1-T2a).
• The on-clamp technique is favored for complex cases, while the off-clamp approach is gaining traction due to potential renal function benefits.

Purpose of the Study:

• To compare the outcomes of on-clamp versus off-clamp robotic partial nephrectomy.
• To evaluate the achievement of pentafecta outcomes and postoperative renal function in both approaches.

Main Methods:

• A retrospective analysis of 517 patients undergoing RAPN between January 2020 and December 2023.
• Patients were divided into two groups: on-clamp (Group A) and off-clamp (Group B).
• Outcomes assessed included complications, positive surgical margins (PSMs), warm ischemia time, preservation of estimated glomerular filtration rate (eGFR), and chronic kidney disease (CKD) stage progression.

Main Results:

• The off-clamp group (B) demonstrated a significantly higher pentafecta success rate (91.2%) compared to the on-clamp group (A) (79.7%) (p ≤0.001).
• While surgery duration was longer in the on-clamp group (120' vs 90'), the off-clamp approach showed a trend towards higher anemia rates (p=0.36) but no significant difference in PSMs (p=0.73).
• Increased warm ischemia time correlated with higher postoperative creatinine levels (p <0.001).

Conclusions:

• The off-clamp RAPN approach yields superior pentafecta outcomes and better postoperative renal function compared to the on-clamp method.
• Despite requiring advanced surgical skills, the off-clamp technique offers shorter operative times and reduced risk of creatinine elevation.
• The study highlights the growing efficacy and benefits of the off-clamp approach in partial nephrectomy.