Collaborative Review – Kidney CancerAssessing the Impact of Ischaemia Time During Partial Nephrectomy☆
Introduction
Open partial nephrectomy (OPN) has become the standard procedure for management of small renal tumours, especially since publication of the current European Urological Association Guidelines on Treatment of Renal Cancer in 2007 [1]. In addition, the incidence of small renal masses fulfilling the prerequisites for nephron-sparing surgery (NSS) has been steadily rising [2], [3].
For larger tumours >4 cm in diameter, however, the same guidelines recommend laparoscopic radical nephrectomy [1], despite recent studies on NSS demonstrating improved renal function and life expectancy resulting from the preservation of healthy parenchyma [4], [5], [6], [7]. Furthermore, elective OPN for these larger tumours has shown oncologic results equivalent to radical nephrectomy (RN) in experienced centres [8], [9], [10]. Although these data support the concept of organ-sparing surgery in localised renal masses independent of tumour diameter, whenever possible and feasible, partial nephrectomy (PN) still appears to be underutilised [11], [12].
Whether laparoscopic PN (LPN) can combine preservation of renal function by NSS with the minimal invasiveness of laparoscopy remains to be seen. During LPN, cooling is more complex, and mean ischaemia time seems to be longer than in OPN. In the latter, cooling is being increasingly omitted because ischaemia times within 20 min can be achieved in general. In most instances, the mean diameter of tumours treated by LPN is somewhat smaller compared with OPN (2.7 vs 3.5 cm [13] and 2.8 vs 3.3 cm [14], respectively).
Thus, the maximum tolerable ischaemia time in PN is essential in the quest for the optimal approach. This review of all organ-sparing procedures with appropriate experimental data and clinical history of renal ischaemia attempts to answer this question. Furthermore, data on a new technique, robotic PN (RPN), are analysed because RPN appears to combine a minimally invasive approach with the quality, speed, and dexterity of OPN [15], [16]. Warm ischaemia (WI) and cold ischaemia (CI), renal tolerance time, medical preservation of the clamped kidney, and the pathophysiology of reperfusion injury following ischaemia are highlighted.
Section snippets
Evidence acquisition
Literature research included Medline queries on the keywords nephron-sparing surgery, partial nephrectomy, and ischaemia. Links to related articles and cross-reading of citations in related articles were surveyed, as were reviews, letters to editors, and information collected from urologic textbooks. These references formed the basis of this review article, with selection and deletion based on the relevance and importance of the content. A literature list with 79 references remained. In a final
Evidence synthesis
In general, it has to be stated that only few well-designed, scientifically performed studies in the realm of renal ischaemia during PN are available that prove an optimal approach. Every paper has to be analysed critically in terms of methodology and content that could be driven by the personal preferences of the author.
Conclusions
In addition to oncologic and surgical outcome, postoperative renal function is the central issue in NSS. Profound expertise of the surgeon is indispensable to determine the optimal intraoperative technique even before approaching the tumour. If ischaemia is required, the tumour should be removed within the minimum possible duration, preferably with <20 min in WI, which is currently recommended, regardless of surgical approach. Efforts should be made to start immediately with CI if the
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