Hilar Dissection with Various Clamping Techniques

An advantage of robotic surgery is the precision that can facilitate the delicate vascular dissection of the renal hilum. Consequently, to minimize the time of warm ischemia, several hilar control techniques have been described. However, there is a lack of consensus on which method of hilar management is optimal. In fact, with robotic partial nephrectomy (RPN) the pedicle can be managed in different ways: off-clamp approach, on-clamp approach (hilar clamp, selective clamp, superselective clamp) and early unclamping approach. In particular, for on-clamp RPN in addition to hilar clamping, it is possible to perform selective-clamping, which has been defined as clamping a secondary/tertiary renal arterial branch to create regional ischemia; or a superselective clamp can be performed, which has been defined as clamping only the specific arterial branch supplying the tumor. Regarding early unclamping technique, is defined as unclamping the renal hilum immediately after completion of the initial central hemostatic suture, prior to completion of the renal parenchymal repair. Obviously, the clamping technique cannot be standardized due to the individual anatomical variability of the arterial tree. For this purpose, reconstruction techniques are used in pre-operative planning nowadays that help in the choice and type of clamping: Hyper Accuracy 3D (HA3D), Indocyanine (ICG) and Augmented Reality (AR). All these new technologies are still in the experimental phase and to date the debate on clamping (hilar, selective, superselective) or non-clamping for the preservation of renal function remains debated.