Non-clamped, Non-ischemic Partial Nephrectomy: The New Gold Standard

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Background: In nephron sparing surgery (NSS), the safe duration for clamping the renal hilum and subjecting the kidney to either warm or cold ischemia remains controversial. Therefore, we describe our extensive experience with performing non-clamped, non-ischemic partial nephrectomy.
Methods: We recorded the preoperative, operative, and postoperative parameters for all patients undergoing NSS at the Lahey Clinic Medical Center. Patients undergoing bench surgery and autotransplantation were excluded, and patients with Von-Hippel Lindau (VHL) were included.
Results: From 1980 through 2007, data were available on 711 patients undergoing NSS. A minimally invasive procedure was performed in 138 patients (19.4%), and an open procedure was performed in 573 (80.6%) patients. In total, 440 (62%) patients underwent a non-clamped, non-ischemic partial nephrectomy, and the renal hilum was clamped in only 197(27.7%) patients. Average clamp time was 24.4 minutes. The pathology demonstrated benign disease in 132 (18.9%), T1a in 449 (63.2%), T1b in 71 (10%), T2 in 17 (2.4%), and T3a in 39 (5.5%), T3b in 5 (0.7%). Margins were positive in 49 (7.6%) patients. The average tumor size was 3.2 cm and 177 (24.9%) patients had a tumor size greater than or equal to 4 cm. NSS was performed in 134 (18.9%) patients with a solitary kidney, and 96 (13.6%) patients had more than one lesion removed at the time of their surgery. The tumors were located at the hilum or mid-portion of the kidney in 224 (31.5%) patients. A preoperative and postoperative creatinine clearance was available in 220 (31%) patients. The mean preoperative creatinine clearance was 87.3 ml/min and mean postoperative creatinine clearance was 83.1 ml/min. When comparing preoperative and postoperative creatinine clearance, 129 (58.6%) had no change, 66 (30%) had a minimal change (greater than a 0% change and less than or equal to a 25% change), and 23 (10.5%) had a minor change (greater than 25% change and less than 50% change), and 2 (1%) had a major change in creatinine clearance (greater than a 50% change). The mean blood loss was 790cc. When stratifying the blood loss, 406 (57.1%) had less than or equal to 500 cc of blood loss, 145 (20.4%) had between 501 and 1000cc of blood loss, and 142 (19.9%) had greater than 1000cc of blood loss.

Conclusions:
Non-clamped, non-ischemic partial nephrectomy is feasible and can be safely performed in a majority of nephron sparing surgical procedures. Almost 90% of patients have no change or only a minor change in their creatinine clearance.

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