Clamped or Unclamped Surgery in Treating Patients With Kidney Cancer

PRIMARY OBJECTIVES: I. To compare the changes in renal function (post-operative compared to
pre-operative) in patients undergoing unclamped partial nephrectomy with or without
controlled hypotension (Arm A) vs. those undergoing partial nephrectomy with hilar clamping
(Arm B), as measured by change in estimated glomerular filtration rate (eGFR). SECONDARY
OBJECTIVES: I. To compare the changes in renal function (post-operative compared to
pre-operative) in patients undergoing unclamped partial nephrectomy with or without
controlled hypotension (Arm A) vs. those undergoing partial nephrectomy with hilar clamping
(Arm B), as measured by change in MAG3 (% of function attributed to affected kidney) and
change in serum creatinine. II. To evaluate the safety of the unclamped procedure by
estimating the differences in complication rates in patients undergoing unclamped partial
nephrectomy with or without controlled hypotension (Arm A) vs. patients undergoing partial
nephrectomy with hilar clamping (Arm B) in terms of intra-operative complications and
post-operative complications. III. To evaluate the surgical effectiveness of the unclamped
procedure by estimating the differences between patients undergoing unclamped partial
nephrectomy with or without controlled hypotension (Arm A) vs. patients undergoing partial
nephrectomy with hilar clamping (Arm B) in terms of surgical margin status, estimated blood
loss, and transfusion rate (intraoperative and post-operative). TERTIARY OBJECTIVES: I.
To record and compare the intrarenal blood flow and resistive index measurements in order to
determine if a relationship exists between intraoperative findings and postoperative renal
function. II. To quantify the amount of acute kidney injury (AKI) and compare the
differences between patients undergoing unclamped partial nephrectomy with or without
controlled hypotension (Arm A) vs. patients undergoing partial nephrectomy with hilar
clamping (Arm B) as measured by urinary and serum biomarkers. III. To compare the effects
of the unclamped procedure (Arm A) to the clamped procedure (Arm B) in patients with
baseline eGFR < 60, and in patients with age >= 75 (exploratory subset analyses).
OUTLINE: Patients are randomized to 1 of 2 treatment arms. ARM A: Patients undergo
unclamped partial nephrectomy. Some patients may undergo unclamped partial nephrectomy with
controlled hypotension. ARM B: Patients undergo clamped partial nephrectomy. After
completion of study treatment, patients are followed up at 1 week and then at 1, 3, 6, and
12 months.

Inclusion Criteria:

- Solitary renal mass

- Clinical stage T1a, T1b

- Body Mass Index (BMI) < 40

- Surgical candidate (preoperative cardiac and anesthesia clearance obtained)

- Able to give informed consent

Exclusion Criteria:

- Pregnancy

- Multiple renal masses

- Previous renal surgery on the ipsilateral kidney

- Clinical Stage T2 or greater

- BMI > 40

- Contraindication to systemic hypotension:

- Left Main Coronary Arterial Disease

- Severe cardiac decompensation (ejection fraction [EF] < 40%)

- Prior history of cerebrovascular accident

- Unable to consent

- Unwilling or unable to potentially receive blood transfusion