Off-clamp vs on-clamp robot-assisted partial nephrectomy: a systematic review and meta-analysis

OBJECTIVE

To compare intra- and postoperative outcomes between off-clamp and on-clamp robot-assisted partial nephrectomy (RAPN), using data from randomised controlled trials (RCTs) or covariate-matched studies (propensity score-matched or matched-pair analysis).

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant literature review was conducted on PubMed, EMBASE, Scopus and CENTRAL for relevant studies comparing off-clamp to on-clamp RAPN. Primary outcomes were estimated blood loss, postoperative percentage decrease in estimated glomerular filtration rate (eGFR), and margin positive rate. Secondary outcomes were operative time, postoperative eGFR, length of stay, all postoperative complications, major complications, and need for transfusion. Random-effects meta-analyses were performed to generate mean differences (MDs) or odds ratios (ORs).

RESULTS

A total of 10 studies (2307 patients) were shortlisted for analysis. There was no significant difference in estimated operative blood loss between off-clamp and on-clamp RAPN (MD 21.9 mL, 95% confidence interval [CI] -0.9 to 44.7 mL; P = 0.06, I2  = 58%). Off-clamp RAPN yielded a smaller postoperative eGFR deterioration (MD 3.10%, 95% CI 1.05-5.16%; P = 0.008, I2  = 13%) and lower odds of margin positivity (OR 0.62, 95% CI 0.40-0.94; P = 0.03, I2  = 0%). No significant differences were found for all secondary outcomes.

CONCLUSIONS

Off-clamp and on-clamp RAPN are similarly effective approaches for selected renal masses. Within the classic trifecta of PN outcomes, off-clamp RAPN yields similar rates of perioperative complications and may possibly offer better preservation of renal function and reduced margin-positive rates.

The role of anti-endothelial cell antibodies in venous insufficiency

It is a hypothesis that autoimmune factors directed against endothelial cells play a role in developing venous insufficiency. We investigated the association between anti-endothelial cell antibodies (AECA) and the development of venous insufficiency and varicose veins. Patients, methods: 44 patients were evaluated with clinical examination and duplex ultrasound for diagnosing chronic venous insufficiency and varicose veins and 120 healthy volunteers were assigned as the control group without evidence of chronic venous insufficiency and varicose veins. All sera samples were analysed by using slides, each containing biochips coated with frozen sections of HUVEC (human umblical vein endothelial cells) and capillary-rich tissue such as skeletal muscle (Euroimmun, FB 1960–1005–2, Germany). If a positive reaction is obtained, specific antibodies of class IgA, IgG, IgM attach to the antigens. In a second step, the bound antibodies are stained with fluorescein labeled antihuman antibodies and visualised by fluorescence microscopy. Results: AECA was positive in 24 out of 44 patients (54.54%) and in 30 out of 120 volunteers (25%). We detected that anti HUVEC antibody occurred significantly more frequent in patients with chronic venous insufficiency or varicose veins: p = 0.0007, OR: 3.60 (1.65 < 7.92). Discussion: The presence of antibodies directed against the endothelial structure causes inflammatory cells of the immune system to move towards the location by both forming antigen-antibody complex and activating the complement system. Tissue damage may occur due to inflammation. In our study we have found a statistically significant relationship between antiendothelial cell antibodies and chronic venous insufficiency. Conclusion: Early diagnosis or prediction of venous insufficiency and/or varicose veins before the occurrence of symptoms may prevent the damage or even help to establish a prophylactic treatment.

Fresh arterial homograft transplantation: a novel concept for critical limb ischaemia

INTRODUCTION

homografts have been used since the early days of vascular surgery, but have failed to provide long-term success. Arteries supplying organ transplants seldom show signs of biodegradation. We therefore introduced fresh arterial homograft repair with consecutive immunosuppression (ATX).

AIM

to assess feasibility and clinical usefulness of ATX.

SETTING

university teaching hospital.

MATERIAL AND METHOD

conduits were harvested during multi-organ procurement and stored in Custodiol. Implantation followed immediately. Viability of the transplant was documented in all cases. Patients received immunosuppression for the duration of bypass function.

RESULTS

thirteen patients received ATX for critical limb ischaemia (M/F: 11/2, age: 62yr, previous revascularisations: 4.5 (1-8), median run-off index 5, previous organ transplant: n=2. Most bypasses were anastomosed to single tibial or pedal vessels. There was no early failure. Within an average follow up of 12 months there were 6 graft thromboses in 5 patients, successfully revised in 4. Three limbs were lost after 2, 5 and 6 months due to graft failure. Graft rejection was shown in 1 out of 3 explanted grafts.

CONCLUSION

we report a concept, which may circumvent the problem of biologic graft degeneration. Limb salvage was possible in 75% at 12 months in otherwise difficult circumstances.

Midterm durability of abdominal aortic aneurysm endograft repair: a word of caution

PURPOSE

Endograft technology for abdominal aortic aneurysm (AAA) repair is being applied more liberally. There is little information about the midterm performance of these grafts. This study is focused on follow-up interventions after endograft repair for AAA.

METHODS

Prospective follow-up analysis of a consecutive patient series (n = 173 patients) at a single center who underwent endovascular AAA repair up to 50 months after operation. Seventeen percent of the patients were regarded unfit for open surgery. Four types of commercially available grafts were used. The Society for Vascular Surgery/International Society for Cardiovascular Surgery guidelines were applied for endograft implantation and data preparation.

RESULTS

In two patients, the procedure was converted to open surgery. In one procedure, emergency repair for iliac artery rupture was performed. The 30-day mortality rate was 2.8% (n = 5 patients). An early second procedure to correct type I endoleaks was necessary in 8 cases (4.6%; 3-10 days). The following midterm results were obtained: median follow-up of the 166 remaining patients was 18 months (range, 1-50 months); 50 additional procedures were necessary in 37 patients (22.3%) for the treatment of leaks (n = 45 interventions) or to maintain graft patency (n = 5 grafts; four patients with concomitant graft segment disconnection); and 46% of the reinterventions were performed within the first year of follow-up and 74% of the reinterventions were performed within the second year of follow-up. One patient died after emergency surgery for rupture as the result of a secondary endoleak at 1 year. Although seven interventions (14%) were performed for type II endoleak, no serious complications were related to patent sidebranches. There was no statistically significant difference between the need for maintenance in different graft configurations (tubular, bifurcated, aorto-uniiliac), or number of graft segments (1, 2, 3-4, > or = 5 segments). New generation grafts (after 1996) performed better than early generation grafts (P = 0.04, chi-squared test) with regard to endoleak development.

CONCLUSION

Endograft repair for AAA is safe but, with current technology, not as durable as open repair. Our data suggest that the use of endograft repair for AAA is becoming safer as endograft design improves. Nevertheless in 26.6% of the patients, there is need for reintervention within midterm follow-up. Close follow-up is crucial because late leaks may develop after more than 2 years after the initial procedure. Endoluminal repair should therefore be applied with caution, strict indication, and only if a tight follow-up is warranted. These findings may also affect health care reimbursement policies.