Original Article: Clinical Investigation
Purely off-clamp robotic partial nephrectomy: Preliminary 3-year
oncological and functional outcomes
Samer F Al-Rawashdah,
and Michele Gallucci
Department of Urology, “Regina Elena” National Cancer Institute, Rome, Italy, and
Urology Unit, Department of Special Surgery,
Mutah University, Karak, Jordan
Abbreviations & Acronyms
ASA = American Society of
CKD = chronic kidney
cT = clinical tumor
eGFR = estimated
glomerular ﬁltration rate
Off-C = off-clamp
Off-RPN = off-clamp robotic
On-C = on-clamp
PN = partial nephrectomy
POD = postoperative day
RCC = renal cell carcinoma
RF = renal function
RN = radical nephrectomy
Simone Ph.D., F.E.B.U.,
Department of Urology, “Regina
Elena” National Cancer Institute,
Via Elio Chianesi 53, 00144
Rome, Italy. Email:
Received 30 November 2017;
accepted 12 March 2018.
Online publication 16 April
This article is already included
in Abstracts of the Conference
of the Society.
Objectives: To describe our surgical technique and to report perioperative, 3-year
oncological and functional outcomes of a single-center series of purely off-clamp robotic
Methods: A prospective renal cancer institutional database was queried, and data of
consecutive patients treated with purely off-clamp robotic partial nephrectomy between
2010 and 2015 in a high-volume center were collected. Perioperative complications, and
3-year oncological and functional outcomes were assessed. Univariable and multivariable
analyses were carried out to identify independent predictors of renal function deterioration.
Results: Out of 308 patients treated, 41 (13.3%) experienced perioperative
complications, 2.9% of which were Clavien grade ≥3. The 3-year local recurrence-free
survival and renal cell carcinoma-speciﬁc survival rates were 99.5% and 97.9%,
respectively. No patient with preoperative chronic kidney disease stage ≤3B developed
severe renal function deterioration (chronic kidney disease stage 4) at 1-year follow up.
At multivariable analysis, preoperative estimated glomerular ﬁltration rate (P = 0.005)
was the only independent predictor of a new-onset chronic kidney disease stage ≥3in
patients with preoperative chronic kidney disease stages 1 or 2.
Conclusions: Off-clamp robotic partial nephrectomy is a safe surgical approach in
tertiary referral centers, with adequate oncological outcomes and negligible impact on
off-clamp, oncological outcomes, partial nephrectomy, renal function,
PN is the standard of care for cT1a renal tumors
and, if technically feasible, has been pro-
ven to be oncologically safe for T1b neoplasms.
With on-C PN being the standard of care,
off-C PN remains a questionable option, because of the potential increased risk of intraopera-
tive bleeding and consequently increased risk of positive surgical margins. In contrast, the
main goal of nephron-sparing techniques is maximal preservation of RF. In the past decade,
several attempts were made to minimize ischemia time, the only surgeon-modiﬁable factor
affecting RF. This has led to the development of different surgical techniques.
Notwithstanding, minimally ischemic or purely off-C PN are challenging surgical tech-
niques, requiring advanced surgical skills.
The primary aim of the present study was to show the safety of purely off-RPN, and to
show the oncological and functional outcomes of a single-center series enumerating 308 con-
secutive robot-assisted procedures.
From August 2010 to December 2015, a total of 308 patients with a renal mass underwent
off-RPN. Preoperative work-up included clinical and laboratory evaluation, and cross-
© 2018 The Japanese Urological Association
International Journal of Urology (2018) 25, 606--614 doi: 10.1111/iju.13580