• Raj Satkunasivam, Sheaumei Tsai, Sumeet Syan, Jean-Christophe Bernhard, Andre Luis de Castro Abreu, Sameer Chopra, Andre K Berger, Dennis Lee, Andrew J Hung, Jie Cai, Mihir M Desai, and Inderbir S Gill.
• USC Institute of Urology, Catherine and Joseph Aresty Department of Urology, University of Southern California, Los Angeles, CA, USA.
• Eur. Urol. 2015 Oct 1; 68 (4): 705-12.

BackgroundAnatomic partial nephrectomy (PN) techniques aim to decrease or eliminate global renal ischemia.ObjectiveTo report the technical feasibility of completely unclamped "minimal-margin" robotic PN. We also illustrate the stepwise evolution of anatomic PN surgery with related outcomes data.Design, Setting, And ParticipantsThis study was a retrospective analysis of 179 contemporary patients undergoing anatomic PN at a tertiary academic institution between October 2009 and February 2013. Consecutive consented patients were grouped into three cohorts: group 1, with superselective clamping and developmental-curve experience (n = 70); group 2, with superselective clamping and mature experience (n = 60); and group 3, which had completely unclamped, minimal-margin PN (n = 49).Surgical ProcedurePatients in groups 1 and 2 underwent superselective tumor-specific devascularization, whereas patients in group 3 underwent completely unclamped minimal-margin PN adjacent to the tumor edge, a technique that takes advantage of the radially oriented intrarenal architecture and anatomy.Outcome Measurements And Statistical AnalysisPrimary outcomes assessed the technical feasibility of robotic, completely unclamped, minimal-margin PN; short-term changes in estimated glomerular filtration rate (eGFR); and development of new-onset chronic kidney disease (CKD) stage >3. Secondary outcome measures included perioperative variables, 30-d complications, and histopathologic outcomes.Results And LimitationsDemographic data were similar among groups. For similarly sized tumors (p = 0.13), percentage of kidney preserved was greater (p = 0.047) and margin width was narrower (p = 0.0004) in group 3. In addition, group 3 had less blood loss (200, 225, and 150ml; p = 0.04), lower transfusion rates (21%, 23%, and 4%; p = 0.008), and shorter hospital stay (p = 0.006), whereas operative time and 30-d complication rates were similar. At 1-mo postoperatively, median percentage reduction in eGFR was similar (7.6%, 0%, and 3.0%; p = 0.53); however, new-onset CKD stage >3 occurred less frequently in group 3 (23%, 10%, and 2%; p = 0.003). Study limitations included retrospective analysis, small sample size, and short follow-up.ConclusionsWe developed an anatomically based technique of robotic, unclamped, minimal-margin PN. This evolution from selective clamped to unclamped PN may further optimize functional outcomes but requires external validation and longer follow-up.Patient SummaryThe technical evolution of partial nephrectomy surgery is aimed at eliminating global renal damage from the cessation of blood flow. An unclamped minimal-margin technique is described and may offer renal functional advantage but requires long-term follow-up and validation at other institutions.Copyright © 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.

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