Exploring the evidence for early unclamping during robot-assisted partial nephrectomy: is it worth the time and effort?

摘要

There is level 1 evidence that impaired renal function has adverse effects on cardiovascular mortality, and baseline chronic kidney disease grade III is present in up to 30% of patients presenting with a small renal mass. Accordingly, there is an increasing drive towards nephron-sparing surgery in the treatment of renal cancer. The attrition of renal function after partial nephrectomy remains a complex interplay of preoperative, intra-operative and postoperative factors, including: age and pre-existing renal/vascular disease (a kidney's inherent 'fragility'); extent of parenchymal defect created by tumour excision (particularly the amount of normal parenchyma removed); intra-operative fluid shifts/blood loss; method of reconstruction; and warm ischaemia time (WIT). Of these factors, WIT has received considerable attention because of its modifiable nature, and there has been considerable focus on reducing WIT by numerous methods, including early unclamping.