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中华腔镜泌尿外科杂志(电子版) ›› 2026, Vol. 20 ›› Issue (05) : 527 -533. doi: 10.3877/cma.j.issn.1674-3253.2026.05.006

临床研究

Off-clamp与On-clamp机器人辅助腹腔镜肾部分切除术治疗cT1期肾癌的疗效对比
张国灵, 薛岳, 张皓寻, 王久亮, 焦治兴, 贾光, 齐奥, 于逸鹏, 王渤文, 熊枫, 王春阳†()   
  1. 150001　黑龙江，哈尔滨医科大学附属第一医院泌尿外科
  • 收稿日期:2025-07-21 出版日期:2026-10-01
  • 通信作者: 王春阳

Comparison of safety and clinical outcomes between Off-clamp and On-clamp robot-assisted partial nephrectomy for cT1 renal cell carcinoma

Guoling Zhang, Yue Xue, Haoxun Zhang, Jiuliang Wang, Zhixing Jiao, Guang Jia, Ao Qi, Yipeng Yu, Bowen Wang, Feng Xiong, Chunyang Wang†()   

  1. Department of Urology, First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
  • Received:2025-07-21 Published:2026-10-01
  • Corresponding author: Chunyang Wang
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引用本文：

张国灵, 薛岳, 张皓寻, 王久亮, 焦治兴, 贾光, 齐奥, 于逸鹏, 王渤文, 熊枫, 王春阳. Off-clamp与On-clamp机器人辅助腹腔镜肾部分切除术治疗cT1期肾癌的疗效对比[J/OL]. 中华腔镜泌尿外科杂志(电子版), 2026, 20(05): 527-533.

Guoling Zhang, Yue Xue, Haoxun Zhang, Jiuliang Wang, Zhixing Jiao, Guang Jia, Ao Qi, Yipeng Yu, Bowen Wang, Feng Xiong, Chunyang Wang. Comparison of safety and clinical outcomes between Off-clamp and On-clamp robot-assisted partial nephrectomy for cT1 renal cell carcinoma[J/OL]. Chinese Journal of Endourology(Electronic Edition), 2026, 20(05): 527-533.

目的

比较Off-clamp机器人辅助腹腔镜肾部分切除术（Off-clamp RAPN）与On-clamp机器人辅助腹腔镜肾部分切除术（On-clamp RAPN）在治疗cT1期肾癌中的安全性及临床疗效。

方法

回顾性分析2021年4月至2024年9月哈尔滨医科大学附属第一医院122例行RAPN的cT1期肾癌患者的临床资料，其中66例采用Off-clamp RAPN，56例采用On-clamp RAPN。两组患者在年龄、性别、体重指数（BMI）、肿瘤最大径、R.E.N.A.L.评分、术前血肌酐（Scr）、术前估算肾小球滤过率（eGFR）等基线特征上差异无统计学意义（P>0.05）。比较两组手术时间、术后肾功能指标、术中出血量、术后恢复情况及并发症等临床结局。

结果

122例手术均顺利完成，无中转开放手术，肾根治性切除术，无中转肾动脉阻断及切缘阳性病例。Off-clamp组[122.50（100.75，150.00）min]与On-clamp组[140.00（115.00，162.75）min]手术时间差异有统计学意义（P=0.034）。两组术中出血量、术后住院时间及术后血红蛋白下降量差异均无统计学意义（P>0.05）。Off-clamp组在术后急性肾损伤发生率（7.58% vs 25.00%）、术后3天Scr上升率[8.38%（3.10%，17.54%）vs 21.42%（12.80%，34.67%）]、术后3天eGFR下降率[2.76%（1.04%，5.75%) vs 6.88%（4.11%，11.40%）]、术后3个月Scr上升率[6.72%（5.62%，8.22%） vs 8.79%（6.69%，12.82%）]、术后3个月eGFR下降率[2.23%（1.83%，3.15%） vs 2.92%（2.26%，4.65%）]等方面均优于On-clamp组（P<0.05）。两组"三连胜"达成率分别为80.30%与60.71%，差异有统计学意义（P=0.029）。

结论

在严格适应证的前提下，Off-clamp RAPN是cT1期肾癌的一种安全、可行且有效的治疗方式。该技术可缩短手术时间、改善术后肾功能保护效果并提高"三连胜"达成率，并达到与On-clamp RAPN相当的肿瘤学效果，但其远期疗效和肾功能变化仍需进一步随访验证。

关键词: 免游离, 肾功能保护, 肾癌, 肾部分切除术, 机器人辅助，腹腔镜
Objective

To compare the safety and clinical outcomes of off-clamp robot-assisted partial nephrectomy (Off-clamp RAPN) versus on-clamp robot-assisted partial nephrectomy (On-clamp RAPN) in the treatment of cT1 renal cell carcinoma (RCC).

Methods

The clinical data of 122 patients with cT1 RCC who underwent RAPN at the First Affiliated Hospital of Harbin Medical University from April 2021 to September 2024 were retrospectively analyzed. Among these, 66 patients underwent Off-clamp RAPN and 56 underwent On-clamp RAPN. There were no statistically significant differences between the two groups in terms of age, gender, body mass index (BMI), maximum tumor diameter, R.E.N.A.L. score, preoperative serum creatinine (Scr), preoperative estimated glomerular filtration rate (eGFR), and other baseline characteristics (P>0.05). The clinical outcomes compared between the two groups included operation time, postoperative renal function indicators, intraoperative blood loss, postoperative recovery, and complications.

Results

All 122 surgeries were successfully completed, with no conversions to open surgery, radical nephrectomy, renal artery clamping, or positive surgical margin. The operation time for the Off-clamp group was [122.50 (100.75, 150.00) min], compared to [140.00 (115.00, 162.75) min] for the On-clamp group, which was statistically significant (P=0.034). There were no significant differences in intraoperative blood loss, postoperative hospital stay, and postoperative hemoglobin drop between the two groups (P>0.05). The Off-clamp group demonstrated a lower incidence of postoperative acute kidney injury (7.58% vs 25.00%), a lower three-day Scr rise rate [8.38% (3.10%, 17.54%) vs 21.42% (12.80%, 34.67%)], a lower three-day eGFR decline rate [2.76% (1.04%, 5.75%) vs 6.88% (4.11%, 11.40%)], a lower three-month Scr rise rate [6.72% (5.62%, 8.22%) vs 8.79% (6.69%, 12.82%)], and a lower three-month eGFR decline rate [2.23% (1.83%, 3.15%) vs 2.92% (2.26%, 4.65%)] compared to the On-clamp group, all of which were statistically significant (P<0.05). The "trifecta" achievement rates were 80.30% and 60.71% for the Off-clamp and On-clamp groups, respectively (P=0.029).

Conclusion

Off-clamp RAPN is a safe, feasible, and effective alternative to On-clamp RAPN for the treatment of cT1 RCC when applied to appropriately selected patients. It offers superior renal function preservation, shorter operative time, and higher trifecta achievement rates, while maintaining comparable oncological outcomes and complication rates. However, long-term efficacy and renal functional changes require further investigation.

Key words: Off-clamp, Renal function preservation, Renal cell carcinoma, Partial nephrectomy, Robot-assisted laparoscopy
表1 Off-clamp RAPN组与On-clamp RAPN组肾癌患者术前一般资料比较
组别 例数 性别[例（%）] 年龄[岁，M(Q)] ASA分级[例（%）] BMI[kg/m2，M(Q)] 手术入路[例（%）]
女 男 1 2 3 经腹膜后 经腹腔
Off-clamp RAPN组 66 29 (43.94) 37 (56.06) 60.00 (51.25，65.00) 5 (7.58) 25 (37.88) 36 (54.55) 26.08 (24.05，28.06) 58 (87.88) 8 (12.12)
On-clamp RAPN组 56 27 (48.21) 29 (51.79) 56.00 (48.75，63.00) 3 (5.36) 26 (46.43) 27 (48.21) 25.74 (23.14，27.82) 47 (83.93) 9 (16.07)
统计值   χ2=0.080 Z=1.633 χ2=1.145 Z=0.345 χ2=0.130
P值   0.772 0.104 0.650 0.733 0.715
组别 肿瘤侧别[例（%）] 肿瘤最大径[cm，M(Q)] R.E.N.A.L.评分[M(Q)] 术前Scr[μmol/L，(±s)] 术前eGFR[mL/(min·1.73m2)，M(Q)] 术前血红蛋白[g/L，M(Q)]
左 右
Off-clamp RAPN组 33 (50.00) 33 (50.00) 2.92 (2.33，3.51) 6.00 (5.00，7.00) 72.50±15.56 90.08 (85.74，99.84) 146.00 (131.25，155.00)
On-clamp RAPN组 24 (42.86) 32 (57.14) 3.30 (2.55，4.06) 6.00 (5.00，7.00) 67.84±17.95 94.03 (87.35，104.25) 144.00 (134.00，154.00)
统计值 χ2=0.370 Z=-1.870 Z=0.298 t=1.540 Z=-1.653 Z=-0.001
P值 0.545 0.061 0.762 0.132 0.099 0.999
图1 机器人辅助肾部分切除术（RAPN）术前行肾脏CT血管造影与三维重建术注：a为肾脏CT血管造影提示右肾肿瘤基底存在肿瘤滋养动脉；b为三维重建技术评估肿瘤形态、位置及肾周血供分布情况；c为术中充分解剖并显露右肾肿瘤及其周围组织；d为三维重建成像与右肾肿瘤周围重要血管的重叠图像
图2 Off-clamp RAPN手术关键步骤注：a为距肿瘤周围2～5 mm左右做环形切除标记；b为吸引器辅助为创面提供张力，沿肿瘤假包膜切除肿瘤；c为检查创面基底并电凝止血；d为2-0 V-Loc倒刺缝线缝合创面基底；e为创面外层缝合后沿缝线滑动Hem-o-lok夹调整吻合口张力；f为降低气腹压，观察创面有无活动性出血，必要时收紧缝线或补针加固
表2 Off-clamp RAPN组与On-clamp RAPN组肾癌患者围手术期相关结果比较
组别 例数 手术时间[min，M（Q）] 热缺血时间[min，M（Q）] 术后血红蛋白[g/dL，(±s)] 术后血红蛋白下降量[g/dL，(±s)]
Off-clamp RAPN组 66 122.50 (100.75，150.00) 0 128.53±19.65 14.09±10.07
On-clamp RAPN组 56 140.00 (115.00，162.75) 27.00 (23.00，30.00) 129.59±18.11 13.34±9.76
统计值   Z=-2.117 Z=-10.478 t=-0.310 t=-0.420
P值   0.034 <0.001 0.758 0.677
组别 术中估计失血量[mL，M（Q）] 术后住院时间[d，M（Q）] 输血[例（%）] 切缘阳性[例（%）] 三连胜[例（%）]
Off-clamp RAPN组 75.00 (50.00，100.00) 5.00 (4.00，6.00) 8 (12.12) 0 53 (80.30)
On-clamp RAPN组 50.00 (50.00，100.00) 6.00 (5.00，6.00) 6 (10.71) 0 34 (60.71)
统计值 Z=-1.701 Z=-1.792 χ2=0 - χ2=4.770
P值 0.089 0.073 >0.999 - 0.029
表3 Off-clamp RAPN组与On-clamp RAPN组肾癌患者术后肾功能相关结果比较
组别 例数 术后AKI[例（%）] 术后3天Scr[μmol/L，M（Q）] 术后3天Scr上升率[%，M（Q）] 术后3天eGFR[ml/（min·1.73m2），M（Q）] 术后3天eGFR下降率[%，M（Q）]
Off-clamp RAPN组 66 5 (7.58) 77.20 (65.65，91.30) 8.38 (3.10，17.54) 87.05 (83.50，94.98) 2.76 (1.04，5.75)
On-clamp RAPN组 56 14 (25.00) 81.45 (65.78，106.50) 21.42 (12.80，34.67) 86.93 (78.02，98.24) 6.88 (4.11, 11.40)
统计值   χ2=5.730 Z=-0.764 Z=-4.499 Z=-0.141 Z=-5.425
P值   0.017 0.445 <0.001 0.888 <0.001
组别 术后3个月Scr[μmol/L，M（Q）] 术后3个月Scr上升率[%，M（Q）] 术后3个月eGFR[mL/（min·1.73m2），M（Q）] 术后3个月eGFR下降率[%，M（Q）]
Off-clamp RAPN组 77.85 (65.93，88.45) 6.72 (5.62，8.22) 88.70 (83.98，97.75) 2.23 (1.83，3.15)
On-clamp RAPN组 73.13 (61.88，83.03) 8.79 (6.69，12.82) 90.46 (83.28，102.98) 2.92 (2.26，4.65)
统计值 Z=-0.796 Z=-4.855 Z=-0.901 Z=-5.019
P值 0.426 <0.001 0.367 <0.001
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