Impact of different renal artery clamping strategies on postoperative renal function in patients with pre-existing renal insufficiency in robotic partial nephrectomy

Abstract

Objective‍ ‍To compare the effects of main artery clamping (MAC) and selective artery clamping (SAC) strategies on postoperative renal function in patients with chronic renal insufficiency undergoing robot-assisted partial nephrectomy. Methods‍ ‍A retrospective cohort study was conducted on 231 patients with preoperative chronic renal insufficiency [eGFR <90 mL/(min·1.73 m²) with renal injury markers or eGFR <60 mL/(min·1.73 m²)] who underwent robot-assisted partial nephrectomy in the Department of Urology of the First Affiliated Hospital of Army Medical University from February 2018 to February 2024. According to intraoperative renal artery clamping strategy, they were divided into a MAC group (n=129) and a SAC group (n=102). Preoperatively, individualized renal artery clamping strategies were developed using a machine learning-based multimodal holographic 3-D reconstruction technique. Serum creatinine (Scr) level was measured at 3 d and 3 months after surgery, and estimated glomerular filtration rate (eGFR) was calculated using the chronic kidney disease epidemiology collaboration equation (CKD-EPI) formula. Renal dynamic imaging with 99mTc-DTPA or 99mTc-MAG3 was used to assess the GFR of the affected kidney. Results‍ ‍At 3 d after surgery, the decrease in GFR of the affected kidney was significantly lower [(8.3±7.7) vs (16.0±10.2) mL/(min·1.73 m²), 95%CI: -10.2~-5.2, P<0.001] in the SAC group than the MAC group. Scr increment analysis showed that the SAC group exhibited notably lower Scr increase [8.2 (2.5, 18.7) vs 15.5 (5.8, 28.3) μmol/L, 95%CI: -12.3~-1.8, P=0.027], and milder eGFR decline [3.0 (0.5, 7.8) vs 7.5 (2.0, 14.3) mL/(min·1.73 m²), 95%CI: -6.2~-0.8, P=0.015]. And, in 3 months after surgery, the SAC group had lower Scr level [(89.2±23.1) vs (95.3±22.1) μmol/L, 95%CI: -11.9~-0.3, P=0.042], and higher GFR of the affected kidney [(33.5±10.5) vs (26.1±10.9) mL/(min·1.73 m²), 95%CI: 4.6~10.2, P<0.001]. Conclusion‍ ‍For patients with chronic renal insufficiency undergoing robot-assisted partial nephrectomy, SAC strategy is superior to MAC strategy in protecting postoperative renal function without increasing surgical risk.

Keywords

• kidney neoplasms
• renal insufficiency
• partial nephrectomy
• robotic surgical procedures
• vascular occlusion