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Robot-Assisted Partial Nephrectomy: Early Unclamping Technique
Andrew G. Percy, M.A., Peter Chang, M.D., Joshua R. Kaplan, M.D., Andrew A. Wagner, M.D..
Beth Israel Deaconess Medical Center, Boston, MA, USA.

BACKGROUND: Robot-assisted partial nephrectomy(RAPN) using an early unclamping(EU) technique can reduce warm ischemia time(WIT) compared to traditional laparoscopic renorrhaphy. We present outcomes for the largest-reported cohort study of patients who underwent RAPN using the EU technique. METHODS: From January 2010 to March 2012, 77 consecutive RAPNs were performed by a single surgeon using the EU technique. Tumor resection and one running barbed suture at the resection base were performed “on-clamp,” while the remaining renorrhaphy was performed “off clamp.” Data were prospectively collected and analyzed from a database approved by our hospital's institutional review board. Complications were recorded using the Clavien classification system. The Chronic Kidney Disease Epidemiology Collaboration(CKD-EPI) formula was used to estimate pre- and postoperative glomerular filtration rate(GFR). RESULTS: Table 1 displays demographic and perioperative outcomes. There were no conversions to open surgery or radical nephrectomy. There were two intraoperative complications of recognized cautery burn to bowel, oversewn without sequellae. The majority of postoperative complications(94%) were Clavien grade 1-2. One patient required angiography for delayed postop bleeding(Clavien IIIa). Mean percent change in GFR at 1 month and 1 year postoperative were -8.3% and -10.0%, respectively. CONCLUSIONS: RAPN using EU is safe with few serious complications in this single surgeon series. The technique does not appear to be more technically difficult than standard laparoscopic reconstruction “on-clamp,” yet may offer more reliably short WIT.
Table 1 Demographics characteristics and perioperative outcomes
Pt demographics
N77
Gender
Male (N, %)
Female (N, %)
46, 60%
31, 40%
Mean age (range)55.6 (19-88)
Mean kg/m2 body mass index (range)27.7 (20.1-40.1)
Mean ASA score (range)2.27 (1-3)
Mean Charlson comorbidity index (range)3.08 (0-9)
Mean cm preoperative tumor size (range)2.8 (1.1-5.5)
Side
Left (N, %)
Right (N, %)
43, 56%
34, 44%
Mean total nephrometry score
Percent Low (4-6)
Percent Medium (7-9)
Percent High (10-12)
6.97
34
58
8
Mean ml/min per 1.73m2 preoperative eGFR (range)86.8 (32.7-132.6)
Mean operative minutes (range)211.1 (122-353)
Mean mL EBL (range)250.0 (50-1000)
Mean minutes WIT (range)15.6 (8-30)
Mean days LOS (range)2.5 (2-7)
Intraoperative Complications (N, %)2, 2.6%
Complications (N, %)16, 20.8%
Clavien Grade:
1: 8
II: 7
IIIa: 1
IIIb: 0
IV: 0
V: 0
Transfusion (N) Postoperative eGFR change (%) Mean cm postoperative tumor size (range)1
≤ 3 months: -8.3%
1 year: -10.0%
2.8 (1-6.5)
Mean nuclear Fuhrman grade (range)2.15 (1-4)
Pathology
Clear Cell (N, %)
Papillary (N, %)
Oncocytoma (N, %)
AML (N, %)
Chromophobe (N, %)
Other benign (N, %)
Other malignant (N, %)
31, 40%
16, 21%
11, 14%
9, 12%
6, 8%
4, 5%
0
PSM (N, %)3, 3.9%
AML angiomyolipoma, ASA American Society of Anesthesia eGFR estimated glomerular filtration rate, EBL estimated blood loss, LOS length of stay, PSM positive surgical margin, WIT warm ischemia time


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