EURURO-6205; No. of Pages 2 EUROPEAN UROLOGY XXX (2015) XXX–XXX
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Priority – Editorial Referring to the article published on pp. x–y of this issue
To Clamp or Not To Clamp During Partial Nephrectomy R. Houston Thompson * Department of Urology, Mayo Clinic, Rochester, MN, USA
Simply put, the benefit of partial nephrectomy (PN) in renal mass patients, compared with radical nephrectomy (RN), is preservation of renal function. This advantage is paramount in patients with imperative situations (bilateral renal tumors, solitary kidney, or impaired baseline renal function) but can also be a decided advantage in elective situations for those who subsequently develop either chronic kidney disease or a contralateral tumor. Within the past decade, multiple observations suggested that PN was associated with improved overall survival compared with RN, with the hypothesis that protection of renal function was responsible for apparently improved outcomes. An overall survival benefit for PN was additionally supported by meta-analyses and multiple institutional series comparing PN and RN for patients with benign renal masses [1–3]. Nevertheless, a randomized controlled trial comparing PN and RN did not observe a survival benefit, and although this trial had its own set of limitations, it represents the only level 1 evidence comparing the surgical approaches [4]. Thus, we are left with the relative certainty that PN protects renal function compared with RN [5], whereas the potential impact on survival remains controversial. Renal functional outcomes after PN are related to a host of modifiable and nonmodifiable factors. Lane et al, for example, reported that the nonmodifiable features of kidney quality (as measured by preoperative glomerular filtration rate [GFR]) and quantity (as measured by estimated amount of preserved renal parenchyma) were the strongest features associated with long-term renal function after PN when short warm ischemic intervals and judicious application of hypothermia were used [6]. In addition, we observed that prolonged periods of warm ischemia (>25 min) represent an important modifiable
feature associated with long-term renal function [7]— a notion that was recently supported by an updated collaborative review [8]. More recently, the applicability of off-clamp PN has been reported to hold promise for appropriately selected patients. In this month’s issue of European Urology, Simone and colleagues provided a systematic review of the literature on this subject [9]. Among 52 papers reviewed, the authors noted that the frequency of publications on offclamp and minimally ischemic PN is rapidly increasing, that most observations suggested excellent renal preservation, and that off-clamp PN is an established procedure particularly suitable for patients with imperative situations [9]. Importantly, oncologic success (as measured by negative margins) appears satisfactory for these selected patients. However, the authors also reported that off-clamp and minimally ischemic techniques are technically demanding, are associated with increased risk of blood loss and perioperative transfusions, and require considerable experience with PN [9]. Furthermore, the lack of randomized trials and the relatively small sample sizes and short follow-up in published retrospective studies limit the ability to generate firm conclusions. Going forward, the authors recommended that future assessment of ischemia and renorrhaphy techniques should be accomplished with renal scintigraphy [9], which is particularly germane to patients with contralateral healthy kidneys. To study the impact of ischemia, or the lack thereof, the solitary kidney setting is an ideal model and represents a situation in which renal scintigraphy is not needed. We previously combined data from the Mayo Clinic and the Cleveland Clinic and compared renal functional outcomes between patients treated with warm ischemia and those treated with off-clamp PN in the setting of a solitary
DOI of original article: http://dx.doi.org/10.1016/j.eururo.2015.04.020. * Department of Urology, Mayo Clinic, 200 1st Street SW, Rochester, MN, USA. Tel. +1 507 266 9968; Fax: +1 507 284 2511. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.eururo.2015.05.003 0302-2838/# 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Thompson RH. To Clamp or Not To Clamp During Partial Nephrectomy. Eur Urol (2015), http:// dx.doi.org/10.1016/j.eururo.2015.05.003
EURURO-6205; No. of Pages 2 2
EUROPEAN UROLOGY XXX (2015) XXX–XXX
kidney [10]. As mentioned by Simone and colleagues [9], 362 warm ischemia patients and 96 off-clamp patients were evaluated. Patients treated with warm ischemia were nearly 6 times more likely to develop acute renal failure (GFR 2.5 times more likely to develop stage IV chronic kidney disease during long-term follow-up compared with offclamp patients in a multivariable analysis [10]. Although selection bias was clearly a limitation, these data support the use of off-clamp PN for appropriately selected patients, especially in imperative situations. The ultimate goal of PN is to preserve renal function without compromising oncologic control. This is why we entertain certain risks with PN, such as urinary fistula or pseudoaneurysm, which should be nonexistent following RN. Does off-clamp PN better preserve renal function compared with warm ischemia? For appropriately selected patients, the answer is probably yes; however, just like PN compared with RN, it comes with increased risks.
[2] Kim SP, Murad MH, Thompson RH, et al. Comparative effectiveness for survival and renal function of partial and radical nephrectomy for localized renal tumors: a systematic review and meta-analysis. J Urol 2012;188:51–7. [3] Weight CJ, Lieser G, Larson BT, et al. Partial nephrectomy is associated with improved overall survival compared to radical nephrectomy in patients with unanticipated benign renal tumours. Eur Urol 2010;58:293–8. [4] Van Poppel H, Da Pozzo L, Albrecht W, et al. A prospective, randomised EORTC intergroup phase 3 study comparing the oncologic outcome of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma. Eur Urol 2011;59:543–52. [5] Scosyrev E, Messing EM, Sylvester R, Campbell S, Van Poppel H. Renal function after nephron-sparing surgery versus radical nephrectomy: results from EORTC randomized trial 30904. Eur Urol 2014;65:372–7. [6] Lane BR, Russo P, Uzzo RG, et al. Comparison of cold and warm ischemia during partial nephrectomy in 660 solitary kidneys reveals predominant role of nonmodifiable factors in determining ultimate renal function. J Urol 2011;185:421–7. [7] Thompson RH, Lane BR, Lohse CM, et al. Renal function after partial nephrectomy: effect of warm ischemia relative to quantity and quality of preserved kidney. Urology 2012;79:356–60. [8] Volpe A, Blute ML, Ficarra V, et al. Renal ischemia and function after partial nephrectomy: a collaborative review of the literature. Eur
Conflicts of interest: The author has nothing to disclose.
Urol. In press. http://dx.doi.org/10.1016/j.eururo.2015.01.025 [9] Simone G, Gill IS, Mottrie A, et al. Indications, techniques, outcomes,
References
and limitations for minimally ischemic and off-clamp partial nephrectomy: a systematic review of the literature. Eur Urol. In press.
[1] Kaushik D, Kim SP, Childs MA, et al. Overall survival and develop-
http://dx.doi.org/10.1016/j.eururo.2015.04.020
ment of stage IV chronic kidney disease in patients undergoing
[10] Thompson RH, Lane BR, Lohse CM, et al. Comparison of warm
partial and radical nephrectomy for benign renal tumors. Eur Urol
ischemia versus no ischemia during partial nephrectomy on a
2013;64:600–6.
solitary kidney. Eur Urol 2010;58:331–6.
Please cite this article in press as: Thompson RH. To Clamp or Not To Clamp During Partial Nephrectomy. Eur Urol (2015), http:// dx.doi.org/10.1016/j.eururo.2015.05.003
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Priority – Editorial Referring to the article published on pp. x–y of this issue
To Clamp or Not To Clamp During Partial Nephrectomy R. Houston Thompson * Department of Urology, Mayo Clinic, Rochester, MN, USA
Simply put, the benefit of partial nephrectomy (PN) in renal mass patients, compared with radical nephrectomy (RN), is preservation of renal function. This advantage is paramount in patients with imperative situations (bilateral renal tumors, solitary kidney, or impaired baseline renal function) but can also be a decided advantage in elective situations for those who subsequently develop either chronic kidney disease or a contralateral tumor. Within the past decade, multiple observations suggested that PN was associated with improved overall survival compared with RN, with the hypothesis that protection of renal function was responsible for apparently improved outcomes. An overall survival benefit for PN was additionally supported by meta-analyses and multiple institutional series comparing PN and RN for patients with benign renal masses [1–3]. Nevertheless, a randomized controlled trial comparing PN and RN did not observe a survival benefit, and although this trial had its own set of limitations, it represents the only level 1 evidence comparing the surgical approaches [4]. Thus, we are left with the relative certainty that PN protects renal function compared with RN [5], whereas the potential impact on survival remains controversial. Renal functional outcomes after PN are related to a host of modifiable and nonmodifiable factors. Lane et al, for example, reported that the nonmodifiable features of kidney quality (as measured by preoperative glomerular filtration rate [GFR]) and quantity (as measured by estimated amount of preserved renal parenchyma) were the strongest features associated with long-term renal function after PN when short warm ischemic intervals and judicious application of hypothermia were used [6]. In addition, we observed that prolonged periods of warm ischemia (>25 min) represent an important modifiable
feature associated with long-term renal function [7]— a notion that was recently supported by an updated collaborative review [8]. More recently, the applicability of off-clamp PN has been reported to hold promise for appropriately selected patients. In this month’s issue of European Urology, Simone and colleagues provided a systematic review of the literature on this subject [9]. Among 52 papers reviewed, the authors noted that the frequency of publications on offclamp and minimally ischemic PN is rapidly increasing, that most observations suggested excellent renal preservation, and that off-clamp PN is an established procedure particularly suitable for patients with imperative situations [9]. Importantly, oncologic success (as measured by negative margins) appears satisfactory for these selected patients. However, the authors also reported that off-clamp and minimally ischemic techniques are technically demanding, are associated with increased risk of blood loss and perioperative transfusions, and require considerable experience with PN [9]. Furthermore, the lack of randomized trials and the relatively small sample sizes and short follow-up in published retrospective studies limit the ability to generate firm conclusions. Going forward, the authors recommended that future assessment of ischemia and renorrhaphy techniques should be accomplished with renal scintigraphy [9], which is particularly germane to patients with contralateral healthy kidneys. To study the impact of ischemia, or the lack thereof, the solitary kidney setting is an ideal model and represents a situation in which renal scintigraphy is not needed. We previously combined data from the Mayo Clinic and the Cleveland Clinic and compared renal functional outcomes between patients treated with warm ischemia and those treated with off-clamp PN in the setting of a solitary
DOI of original article: http://dx.doi.org/10.1016/j.eururo.2015.04.020. * Department of Urology, Mayo Clinic, 200 1st Street SW, Rochester, MN, USA. Tel. +1 507 266 9968; Fax: +1 507 284 2511. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.eururo.2015.05.003 0302-2838/# 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Thompson RH. To Clamp or Not To Clamp During Partial Nephrectomy. Eur Urol (2015), http:// dx.doi.org/10.1016/j.eururo.2015.05.003
EURURO-6205; No. of Pages 2 2
EUROPEAN UROLOGY XXX (2015) XXX–XXX
kidney [10]. As mentioned by Simone and colleagues [9], 362 warm ischemia patients and 96 off-clamp patients were evaluated. Patients treated with warm ischemia were nearly 6 times more likely to develop acute renal failure (GFR 2.5 times more likely to develop stage IV chronic kidney disease during long-term follow-up compared with offclamp patients in a multivariable analysis [10]. Although selection bias was clearly a limitation, these data support the use of off-clamp PN for appropriately selected patients, especially in imperative situations. The ultimate goal of PN is to preserve renal function without compromising oncologic control. This is why we entertain certain risks with PN, such as urinary fistula or pseudoaneurysm, which should be nonexistent following RN. Does off-clamp PN better preserve renal function compared with warm ischemia? For appropriately selected patients, the answer is probably yes; however, just like PN compared with RN, it comes with increased risks.
[2] Kim SP, Murad MH, Thompson RH, et al. Comparative effectiveness for survival and renal function of partial and radical nephrectomy for localized renal tumors: a systematic review and meta-analysis. J Urol 2012;188:51–7. [3] Weight CJ, Lieser G, Larson BT, et al. Partial nephrectomy is associated with improved overall survival compared to radical nephrectomy in patients with unanticipated benign renal tumours. Eur Urol 2010;58:293–8. [4] Van Poppel H, Da Pozzo L, Albrecht W, et al. A prospective, randomised EORTC intergroup phase 3 study comparing the oncologic outcome of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma. Eur Urol 2011;59:543–52. [5] Scosyrev E, Messing EM, Sylvester R, Campbell S, Van Poppel H. Renal function after nephron-sparing surgery versus radical nephrectomy: results from EORTC randomized trial 30904. Eur Urol 2014;65:372–7. [6] Lane BR, Russo P, Uzzo RG, et al. Comparison of cold and warm ischemia during partial nephrectomy in 660 solitary kidneys reveals predominant role of nonmodifiable factors in determining ultimate renal function. J Urol 2011;185:421–7. [7] Thompson RH, Lane BR, Lohse CM, et al. Renal function after partial nephrectomy: effect of warm ischemia relative to quantity and quality of preserved kidney. Urology 2012;79:356–60. [8] Volpe A, Blute ML, Ficarra V, et al. Renal ischemia and function after partial nephrectomy: a collaborative review of the literature. Eur
Conflicts of interest: The author has nothing to disclose.
Urol. In press. http://dx.doi.org/10.1016/j.eururo.2015.01.025 [9] Simone G, Gill IS, Mottrie A, et al. Indications, techniques, outcomes,
References
and limitations for minimally ischemic and off-clamp partial nephrectomy: a systematic review of the literature. Eur Urol. In press.
[1] Kaushik D, Kim SP, Childs MA, et al. Overall survival and develop-
http://dx.doi.org/10.1016/j.eururo.2015.04.020
ment of stage IV chronic kidney disease in patients undergoing
[10] Thompson RH, Lane BR, Lohse CM, et al. Comparison of warm
partial and radical nephrectomy for benign renal tumors. Eur Urol
ischemia versus no ischemia during partial nephrectomy on a
2013;64:600–6.
solitary kidney. Eur Urol 2010;58:331–6.
Please cite this article in press as: Thompson RH. To Clamp or Not To Clamp During Partial Nephrectomy. Eur Urol (2015), http:// dx.doi.org/10.1016/j.eururo.2015.05.003
