Comparison of Off-Clamp and On-Clamp Partial Nephrectomy and Its Impact on the Renal Functional Outcome: A Single Institute Experience in South Indian Patients

Sivakumar Mahalingam, Anand Raja, Kathiresan Narayanaswamy, Krishna Kumar Rathinam

Department of Surgical Oncology, Cancer Institute (WIA), Adyar, Chennai, India
Cancer Institute (WIA), Dr. S.Krishnamurthy Campus, Apollo Speciality Hospitals, Chennai, India
Department of Nuclear medicine, Cancer Institute (WIA), Adyar, Chennai, India

^*Correspondance to: Anand Raja 

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Abstract:

Introduction: Partial nephrectomy (PN) or nephron sparing surgery is the standard of care for all feasible renal tumors < 4cm. Multiple partial nephrectomy techniques have evolved to reduce the ischemic injury to the renal parenchyma with variable effects on renal function. Off clamp technique avoid ischemic injury to the renal parenchymal altogether and better preserves the long term renal function, delaying or avoiding the development of chronic kidney disease. The aim of the study is to compare off-clamp and on-clamp techniques of partial nephrectomy and its impact on the renal functional outcome.Methods: Patient who underwent partial nephrectomy from January 2007 to December 2016 were analyzed retrospectively. The partial nephrectomy renal units were grouped into off-clamp and on-clamp (warm and cold ischemia) group. The demographic data, clinico-pathological factors, pre-operative and post-operative glomerular filtration rate (GFR) as measured by radioisotope renography Tc99m-DTPA (diethylenetriaminepentacetate) scan, surgical margin, complications (Clavien Dindo classification), hospital stay, blood loss and blood transfusion rate were compared and analyzed between the two group.Results: Twenty three eligible rental units who underwent partial nephrectomy between January 2007 and December 2016 were included for analysis. The mean age was 46 years. One was a pediatric patient with bilateral wilms tumor aged 2 years and he underwent staged bilateral partial nephrectomy. Majority had clear cell histology 78% (18/23), papillary histology 13% (3/23) and two wilms tumor. All had open partial nephrectomy except two had laparoscopic assisted procedure. Ten (43%) underwent on-clamp technique out of which one had warm ischemic and nine had cold ischemic clamping technique. The mean clamping time was 35 minutes for the available six rental units in the on-clamp group. Thirteen (57%) patients underwent off-clamp technique. There is no difference in the age, sex, tumor site, size, grade, margins, histology type, overall complications, blood loss, blood transfusion and hospital stay among the two groups. All surgical margins were negative in both groups. The preoperative mean GFR (Tc99m-DTPA scan) was comparable 70.13 and 67.78 ml/min/1.73m2 (p=0.765) between the on-clamp and off-clamp group. The percentage GFR decrease in the postoperative period (>3 months) was 0.28 % in the off-clamp group compared to 8 % in the on-clamp group.
Conclusion: Off-clamp partial nephrectomy is a feasible and oncologically safe technique. It is a promising technique which avoids the ischemic renal parenchymal injury after partial nephrectomy. The renal functional outcome is better with off-clamp technique compared to on-clamp partial nephrectomy. The limitation is the non-availability of standardization of techniques and prospective randomized trials.

Keywords:

Nephrectomy; Chronic kidney disease; Glomerular filtration rate; Radioisotope renography

Cite the Article:

Navarro-Martin A, de Luna CJ, Fuentes R, Fernández MDA, Jové J. Extracranial Oligometastasis in Non- Small Cell Lung Cancer. Clin Oncol. 2018; 3: 1397.