BACKGROUND: Acute kidney injury (AKI) after robot-assisted partial nephrectomy (RAPN) is a robust surrogate for chronic kidney disease. The objective of this study was to evaluate the association of ischemia type and duration during RAPN with postoperative AKI. MATERIALS AND METHODS: We reviewed all patients who underwent RAPN at our institution since 2011. The ischemia types were warm ischemia (WI), selective artery clamping (SAC), and zero ischemia (ZI). AKI was defined according to the Risk Injury Failure Loss End-Stage (RIFLE) criteria. We calculated ischemia time thresholds for WI and SAC using the Youden and Liu indices. Logistic regression and decision curve analyses were assessed to examine the association with AKI. RESULTS: Overall, 154 patients met the inclusion criteria. Among all RAPNs, 90 (58.4%), 43 (28.0%), and 21 (13.6%) were performed with WI, SAC, and ZI, respectively. Thirty-three (21.4%) patients experienced postoperative AKI. We extrapolated ischemia time thresholds of 17 min for WI and 29 min for SAC associated with the occurrence of postoperative AKI. Multivariable logistic regression analyses revealed that WIT ≤ 17 min (odds ratio [OR] 0.1, p < 0.001), SAC ≤ 29 min (OR 0.12, p = 0.002), and ZI (OR 0.1, p = 0.035) significantly reduced the risk of postoperative AKI. CONCLUSIONS: Our results confirm the commonly accepted 20 min threshold for WI time, suggest less than 30 min ischemia time when using SAC, and support a ZI approach if safely performable to reduce the risk of postoperative AKI. Selecting an appropriate ischemia type for patients undergoing RAPN can improve short- and long-term functional kidney outcomes.

Department of Radiology and Nuclear Medicine Kantonsspital Winterthur 8401 Winterthur Switzerland

Department of Urology 2nd Faculty of Medicine Charles University 15006 Prague Czech Republic

Department of Urology Kantonsspital Winterthur 8401 Winterthur Switzerland

Department of Urology Medical University of Vienna 1090 Vienna Austria

Department of Urology University of Texas Southwestern Medical Center Dallas TX 75390 USA

Departments of Urology Weill Cornell Medical College New York NY 10065 USA

Division of Urology Department of Special Surgery Jordan University Hospital The University of Jordan Amman 19328 Jordan

Institute for Urology and Reproductive Health 1 M Sechenov 1st Moscow State Medical University 119435 Moscow Russia

Karl Landsteiner Institute of Urology and Andrology 1090 Vienna Austria

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Ljungberg B., Bensalah K., Canfield S., Dabestani S., Hofmann F., Hora M., Kuczyk M.A., Lam T., Marconi L., Merseburger A.S., et al. EAU guidelines on renal cell carcinoma: 2014 update. Eur. Urol. 2015;67:913–924. doi: 10.1016/j.eururo.2015.01.005. PubMed DOI

Mir M.C., Derweesh I., Porpiglia F., Zargar H., Mottrie A., Autorino R. Partial Nephrectomy Versus Radical Nephrectomy for Clinical T1b and T2 Renal Tumors: A Systematic Review and Meta-analysis of Comparative Studies. Eur. Urol. 2017;71:606–617. doi: 10.1016/j.eururo.2016.08.060. PubMed DOI

Thompson R.H., Boorjian S.A., Lohse C.M., Leibovich B.C., Kwon E.D., Cheville J.C., Blute M.L. Radical nephrectomy for pT1a renal masses may be associated with decreased overall survival compared with partial nephrectomy. J. Urol. 2008;179:468–471; discussion 472–463. doi: 10.1016/j.juro.2007.09.077. PubMed DOI

Larcher A., Capitanio U., Terrone C., Volpe A., De Angelis P., Dehó F., Fossati N., Dell’Oglio P., Antonelli A., Furlan M., et al. Elective Nephron Sparing Surgery Decreases Other Cause Mortality Relative to Radical Nephrectomy Only in Specific Subgroups of Patients with Renal Cell Carcinoma. J. Urol. 2016;196:1008–1013. doi: 10.1016/j.juro.2016.04.093. PubMed DOI

Simhan J., Smaldone M.C., Tsai K.J., Li T., Reyes J.M., Canter D., Kutikov A., Chen D.Y., Greenberg R.E., Uzzo R.G., et al. Perioperative outcomes of robotic and open partial nephrectomy for moderately and highly complex renal lesions. J. Urol. 2012;187:2000–2004. doi: 10.1016/j.juro.2012.01.064. PubMed DOI

Hennessey D.B., Wei G., Moon D., Kinnear N., Bolton D.M., Lawrentschuk N., Chan Y.K. Strategies for success: A multi-institutional study on robot-assisted partial nephrectomy for complex renal lesions. BJU Int. 2018;121((Suppl. S3)):40–47. doi: 10.1111/bju.14059. PubMed DOI

Shekarriz B., Shah G., Upadhyay J. Impact of temporary hilar clamping during laparoscopic partial nephrectomy on postoperative renal function: A prospective study. J. Urol. 2004;172:54–57. doi: 10.1097/01.ju.0000132125.78189.93. PubMed DOI

Lane B.R., Gill I.S., Fergany A.F., Larson B.T., Campbell S.C. Limited warm ischemia during elective partial nephrectomy has only a marginal impact on renal functional outcomes. J. Urol. 2011;185:1598–1603. doi: 10.1016/j.juro.2010.12.046. PubMed DOI

Nohara T., Fujita H., Yamamoto K., Kitagawa Y., Gabata T., Namiki M. Modified anatrophic partial nephrectomy with selective renal segmental artery clamping to preserve renal function: A preliminary report. Int. J. Urol. 2008;15:961–966. doi: 10.1111/j.1442-2042.2008.02141.x. PubMed DOI

Tanagho Y.S., Bhayani S.B., Kim E.H., Sandhu G.S., Vaughn N.P., Figenshau R.S. Off-clamp robot-assisted partial nephrectomy: Initial Washington University experience. J. Endourol. 2012;26:1284–1289. doi: 10.1089/end.2012.0094. PubMed DOI

Chawla L.S., Eggers P.W., Star R.A., Kimmel P.L. Acute kidney injury and chronic kidney disease as interconnected syndromes. N. Engl. J. Med. 2014;371:58–66. doi: 10.1056/NEJMra1214243. PubMed DOI PMC

Martini A., Cumarasamy S., Beksac A.T., Abaza R., Eun D.D., Bhandari A., Hemal A.K., Porter J.R., Badani K.K. A Nomogram to Predict Significant Estimated Glomerular Filtration Rate Reduction After Robotic Partial Nephrectomy. Eur. Urol. 2018;74:833–839. doi: 10.1016/j.eururo.2018.08.037. PubMed DOI

Schmid M., Abd-El-Barr A.E., Gandaglia G., Sood A., Olugbade K., Ruhotina N., Sammon J.D., Varda B., Chang S.L., Kibel A.S., et al. Predictors of 30-day acute kidney injury following radical and partial nephrectomy for renal cell carcinoma. Urol. Oncol. 2014;32:1259–1266. doi: 10.1016/j.urolonc.2014.05.002. PubMed DOI

Kim C.S., Bae E.H., Ma S.K., Kweon S.S., Kim S.W. Impact of partial nephrectomy on kidney function in patients with renal cell carcinoma. BMC Nephrol. 2014;15:181. doi: 10.1186/1471-2369-15-181. PubMed DOI PMC

Martini A., Sfakianos J.P., Paulucci D.J., Abaza R., Eun D.D., Bhandari A., Hemal A.K., Badani K.K. Predicting acute kidney injury after robot-assisted partial nephrectomy: Implications for patient selection and postoperative management. Urol. Oncol. 2019;37:445–451. doi: 10.1016/j.urolonc.2019.04.018. PubMed DOI

Rajan S., Babazade R., Govindarajan S.R., Pal R., You J., Mascha E.J., Khanna A., Yang M., Marcano F.D., Singh A.K., et al. Perioperative factors associated with acute kidney injury after partial nephrectomy. Br. J. Anaesth. 2016;116:70–76. doi: 10.1093/bja/aev416. PubMed DOI

Paulucci D.J., Rosen D.C., Sfakianos J.P., Whalen M.J., Abaza R., Eun D.D., Krane L.S., Hemal A.K., Badani K.K. Selective arterial clamping does not improve outcomes in robot-assisted partial nephrectomy: A propensity-score analysis of patients without impaired renal function. BJU Int. 2017;119:430–435. doi: 10.1111/bju.13614. PubMed DOI

Von Elm E., Altman D.G., Egger M., Pocock S.J., Gøtzsche P.C., Vandenbroucke J.P., Initiative S. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for reporting observational studies. Int. J. Surg. 2014;12:1495–1499. doi: 10.1016/j.ijsu.2014.07.013. PubMed DOI

Levey A.S., Stevens L.A., Schmid C.H., Zhang Y.L., Castro A.F., Feldman H.I., Kusek J.W., Eggers P., Van Lente F., Greene T., et al. A new equation to estimate glomerular filtration rate. Ann. Intern. Med. 2009;150:604–612. doi: 10.7326/0003-4819-150-9-200905050-00006. PubMed DOI PMC

Bellomo R., Ronco C., Kellum J.A., Mehta R.L., Palevsky P., Acute Dialysis Quality Initiative (ADQI) Workgroup Acute renal failure—definition, outcome measures, animal models, fluid therapy and information technology needs: The Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit. Care. 2004;8:R204–R212. doi: 10.1186/cc2872. PubMed DOI PMC

National Clinical Guideline Centre (UK) National Institute for Health and Care Excellence: Clinical Guidelines. National Institute for Health and Care Excellence (UK); London, UK: 2014. Chronic Kidney Disease (Partial Update): Early Identification and Management of Chronic Kidney Disease in Adults in Primary and Secondary Care. PubMed

Desai M.M., de Castro Abreu A.L., Leslie S., Cai J., Huang E.Y., Lewandowski P.M., Lee D., Dharmaraja A., Berger A.K., Goh A., et al. Robotic partial nephrectomy with superselective versus main artery clamping: A retrospective comparison. Eur. Urol. 2014;66:713–719. doi: 10.1016/j.eururo.2014.01.017. PubMed DOI

Kutikov A., Uzzo R.G. The R.E.N.A.L. nephrometry score: A comprehensive standardized system for quantitating renal tumor size, location and depth. J. Urol. 2009;182:844–853. doi: 10.1016/j.juro.2009.05.035. PubMed DOI

Rod X., Peyronnet B., Seisen T., Pradere B., Gomez F.D., Verhoest G., Vaessen C., De La Taille A., Bensalah K., Roupret M. Impact of ischaemia time on renal function after partial nephrectomy: A systematic review. BJU Int. 2016;118:692–705. doi: 10.1111/bju.13580. PubMed DOI

Funahashi Y., Hattori R., Yamamoto T., Kamihira O., Kato K., Gotoh M. Ischemic renal damage after nephron-sparing surgery in patients with normal contralateral kidney. Eur. Urol. 2009;55:209–215. doi: 10.1016/j.eururo.2008.07.048. PubMed DOI

Lane B.R., Babineau D.C., Poggio E.D., Weight C.J., Larson B.T., Gill I.S., Novick A.C. Factors predicting renal functional outcome after partial nephrectomy. J. Urol. 2008;18:2363–2368; discussion 2368–2369. doi: 10.1016/j.juro.2008.08.036. PubMed DOI

Rosen D.C., Kannappan M., Paulucci D.J., Beksac A.T., Attalla K., Abaza R., Eun D.D., Bhandari A., Hemal A.K., Porter J., et al. Reevaluating Warm Ischemia Time as a Predictor of Renal Function Outcomes After Robotic Partial Nephrectomy. Urology. 2018;120:156–161. doi: 10.1016/j.urology.2018.06.019. PubMed DOI

Rosen D.C., Paulucci D.J., Abaza R., Eun D.D., Bhandari A., Hemal A.K., Badani K.K. Is Off Clamp Always Beneficial During Robotic Partial Nephrectomy? A Propensity Score-Matched Comparison of Clamp Technique in Patients with Two Kidneys. J. Endourol. 2017;31:1176–1182. doi: 10.1089/end.2017.0450. PubMed DOI

Anderson B.G., Potretzke A.M., Du K., Vetter J.M., Bergeron K., Paradis A.G., Figenshau R.S. Comparing Off-clamp and On-clamp Robot-assisted Partial Nephrectomy: A Prospective Randomized Trial. Urology. 2019;126:102–109. doi: 10.1016/j.urology.2018.11.053. PubMed DOI

Kaczmarek B.F., Tanagho Y.S., Hillyer S.P., Mullins J.K., Diaz M., Trinh Q.D., Bhayani S.B., Allaf M.E., Stifelman M.D., Kaouk J.H., et al. Off-clamp robot-assisted partial nephrectomy preserves renal function: A multi-institutional propensity score analysis. Eur. Urol. 2013;64:988–993. doi: 10.1016/j.eururo.2012.10.009. PubMed DOI

Ratliff B.B., Rabadi M.M., Vasko R., Yasuda K., Goligorsky M.S. Messengers without borders: Mediators of systemic inflammatory response in AKI. J. Am. Soc. Nephrol. 2013;24:529–536. doi: 10.1681/ASN.2012060633. PubMed DOI

Deng W., Liu X., Hu J., Chen L., Fu B. Off-clamp partial nephrectomy has a positive impact on short- and long-term renal function: A systematic review and meta-analysis. BMC Nephrol. 2018;19:188. doi: 10.1186/s12882-018-0993-3. PubMed DOI PMC

Trehan A. Comparison of off-clamp partial nephrectomy and on-clamp partial nephrectomy: A systematic review and meta-analysis. Urol. Int. 2014;93:125–134. doi: 10.1159/000362799. PubMed DOI

Greco F., Autorino R., Altieri V., Campbell S., Ficarra V., Gill I., Kutikov A., Mottrie A., Mirone V., van Poppel H. Ischemia Techniques in Nephron-sparing Surgery: A Systematic Review and Meta-Analysis of Surgical, Oncological, and Functional Outcomes. Eur. Urol. 2019;75:477–491. doi: 10.1016/j.eururo.2018.10.005. PubMed DOI PMC

Badani K.K., Kothari P.D., Okhawere K.E., Eun D., Hemal A., Abaza R., Porter J., Lovallo G., Ahmed M., Munver R., et al. Selective clamping during robot-assisted partial nephrectomy in patients with a solitary kidney: Is it safe and does it help? BJU Int. 2020;125:893–897. doi: 10.1111/bju.15043. PubMed DOI

Guillonneau B., Bermúdez H., Gholami S., El Fettouh H., Gupta R., Adorno Rosa J., Baumert H., Cathelineau X., Fromont G., Vallancien G. Laparoscopic partial nephrectomy for renal tumor: Single center experience comparing clamping and no clamping techniques of the renal vasculature. J. Urol. 2003;169:483–486. doi: 10.1016/S0022-5347(05)63939-0. PubMed DOI

Tuderti G., Brassetti A., Mastroianni R., Misuraca L., Bove A., Anceschi U., Ferriero M., Guaglianone S., Gallucci M., Simone G. Expanding the limits of nephron-sparing surgery: Surgical technique and mid-term outcomes of purely off-clamp robotic partial nephrectomy for totally endophytic renal tumors. Int. J. Urol. 2022;29:282–288. doi: 10.1111/iju.14763. PubMed DOI

Brassetti A., Cacciamani G.E., Mari A., Garisto J.D., Bertolo R., Sundaram C.P., Derweesh I., Bindayi A., Dasgupta P., Porter J., et al. On-Clamp vs. Off-Clamp Robot-Assisted Partial Nephrectomy for cT2 Renal Tumors: Retrospective Propensity-Score-Matched Multicenter Outcome Analysis. Cancers. 2022;14:4431. doi: 10.3390/cancers14184431. PubMed DOI PMC

Brassetti A., Anceschi U., Bove A.M., Prata F., Costantini M., Ferriero M., Mastroianni R., Misuraca L., Tuderti G., Torregiani G., et al. Purely Off-Clamp Laparoscopic Partial Nephrectomy Stands the Test of Time: 15 Years Functional and Oncologic Outcomes from a Single Center Experience. Curr. Oncol. 2023;30:1196–1205. doi: 10.3390/curroncol30010092. PubMed DOI PMC

Rangaswamy D., Sud K. Acute kidney injury and disease: Long-term consequences and management. Nephrology. 2018;23:969–980. doi: 10.1111/nep.13408. PubMed DOI

Waikar S.S., Curhan G.C., Wald R., McCarthy E.P., Chertow G.M. Declining mortality in patients with acute renal failure, 1988 to 2002. J. Am. Soc. Nephrol. 2006;17:1143–1150. doi: 10.1681/ASN.2005091017. PubMed DOI

Goldstein S.L., Jaber B.L., Faubel S., Chawla L.S., Acute Kidney Injury Advisory Group of the American Society of Nephrology AKI transition of care: A potential opportunity to detect and prevent CKD. Clin. J. Am. Soc. Nephrol. 2013;8:476–483. doi: 10.2215/CJN.12101112. PubMed DOI