The role of warm ischemia time on functional outcomes after robotic partial nephrectomy: a radionuclide renal scan study from the clock randomized trial

Purpose To evaluate the relationship between warm ischemia time (WIT) duration and renal function after robot-assisted partial nephrectomy (RAPN).

Methods The CLOCK trial is a phase 3 randomized controlled trial comparing on- vs off-clamp RAPN.

All patients underwent pre- and postoperative renal scintigraphy.

Six-month absolute variation of eGFR (AV-GFR), rate of relative variation in eGFR over 25% (RV-GFR > 25), absolute variation of split renal function (SRF) at scintigraphy (AV-SRF).

The relationships WIT/outcomes were assessed by correlation graphs and then modeled by uni- and multivariable regression.

Results 324 patients were included (206 on-clamp, 118 off-clamp RAPN).

Correlation graphs showed a threshold on WIT equal to 10 min.

The differences in outcome measures between cases with WIT < vs ≥ 10 min were: AV-GFR − 3.7 vs − 7.5 ml/min ( p  < 0.001); AV-SRF − 1% vs − 3.6% ( p  < 0.001); RV-GFR > 25 9.3% vs 17.8% ( p  = 0.008).

Multivariable models found that AV-GFR was related to WIT ≥ 10 min (regression coefficient [RC] − 0.52, p  = 0.019), age (RC − 0.35, p = 0.001) and baseline eGFR (RC − 0.30, p < 0.001); RV-GFR > 25 to WIT ≥ 10 min (odds ratio [OR] 1.11, p  = 0.007) and acute kidney injury defined as > 50% increase in serum creatinine (OR 19.7, p  = 0.009); AV-SRF to WIT ≥ 10 min (RC − 0.30, p  = 0.018), baseline SRF (RC − 0.76, p  < 0.001) and RENAL score (RC − 0.60.

p  = 0.028).

The main limitation was that the CLOCK trial was designed on a different endpoint and therefore the present analysis could be underpowered.

Conclusions Up to 10 min WIT had no consequences on functional outcomes.

Above the 10-min threshold, a statistically significant, but clinically negligible impact was found.