Eliminating global renal ischemia during partial nephrectomy

Patil, Mukul; Lee, Dennis J.; Gill, Inderbir S.

doi:10.1097/mou.0b013e32834ef70c

Cited by 13 publications

(9 citation statements)

References 18 publications

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“…More recently, minimally invasive PN has become a viable alternative to open PN (OPN) and is routinely performed at many centers worldwide [3]. Much effort has been made to integrate the anatomy of the renal mass and its vasculature into current concepts [4,5]. A detailed understanding of surgical anatomy is necessary to optimize preoperative planning and operative technique, thus providing a basis for maximizing oncologic and functional outcomes.…”

Section: Introductionmentioning

confidence: 99%

A Literature Review of Renal Surgical Anatomy and Surgical Strategies for Partial Nephrectomy

et al. 2015

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Context A detailed understanding of renal surgical anatomy is necessary to optimize preoperative planning and operative technique and provide a basis for improved outcomes. Objective To evaluate the literature regarding pertinent surgical anatomy of the kidney and related structures, nephrometry scoring systems, and current surgical strategies for partial nephrectomy (PN). Evidence acquisition A literature review was conducted. Evidence synthesis Surgical renal anatomy fundamentally impacts PN surgery. The renal artery divides into anterior and posterior divisions, from which approximately five segmental terminal arteries originate. The renal veins are not terminal. Variations in the vascular and lymphatic channels are common; thus, concurrent lymphadenectomy is not routinely indicated during PN for cT1 renal masses in the setting of clinically negative lymph nodes. Renal-protocol contrast-enhanced computed tomography or magnetic resonance imaging is used for standard imaging. Anatomy-based nephrometry scoring systems allow standardized academic reporting of tumor characteristics and predict PN outcomes (complications, remnant function, possibly histology). Anatomy-based novel surgical approaches may reduce ischemic time during PN; these include early unclamping, segmental clamping, tumor-specific clamping (zero ischemia), and unclamped PN. Cancer cure after PN relies on complete resection, which can be achieved by thin margins. Post-PN renal function is impacted by kidney quality, remnant quantity, and ischemia type and duration. Conclusions Surgical renal anatomy underpins imaging, nephrometry scoring systems, and vascular control techniques that reduce global renal ischemia and may impact post-PN function. A contemporary ideal PN excises the tumor with a thin negative margin, delicately secures the tumor bed to maximize vascularized remnant parenchyma, and minimizes global ischemia to the renal remnant with minimal complications. Patient summary In this report we review renal surgical anatomy. Renal mass imaging allows detailed delineation of the anatomy and vasculature and permits nephrometry scoring, and thus precise, patient-specific surgical planning. Novel off-clamp techniques have been developed that may lead to improved outcomes.

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Section: Introductionmentioning

confidence: 99%

A Literature Review of Renal Surgical Anatomy and Surgical Strategies for Partial Nephrectomy

et al. 2015

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“…These techniques achieve the same goal and replace global ischemia by regional ischemia during PN. However, regional ischemia can theoretically have higher complication rates compared to global ischemia, especially hemorrhage, due to the difficulty of the operation [12]. …”

Section: Introductionmentioning

confidence: 99%

Safety and Postoperative Outcomes of Regional versus Global Ischemia for Partial Nephrectomy: A Systematic Review and Meta-Analysis

Wang¹,

Zhang³

et al. 2014

Urol Int

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Objective: To analyze current evidence comparing the safety and outcomes of regional and global ischemia for partial nephrectomy (PN). Materials and Methods: A systematic search of the PubMed and Web of Science databases was conducted in May 2014 to identify studies comparing the safety and outcomes of regional and global ischemia for PN. A systematic review and meta-analysis was also performed. Results: Six retrospective observational studies were selected for the analysis, including 363 patients who underwent PN (162 regional ischemia and 201 global ischemia cases). Operation times were not statistically different [weighted mean difference (WMD) = 20.35 min, 95% CI: -0.28-40.97, p = 0.05], but estimated blood loss was significantly higher in the regional ischemia group (WMD = 52.04 ml, 95% CI: 14.30-89.78, p = 0.007) than in the global ischemia group. Complication rates [odds ratio (OR) = 1.16; 95% CI: 0.63-2.15, p = 0.63] and blood transfusion rates (OR = 1.85; 95% CI: 0.86-4.01, p = 0.12) of the two groups were not significantly different. The regional ischemia group showed better postoperative renal function (WMD = 4.23 ml/min, 95% CI: 2.61-5.85, p < 0.00001) than the global ischemia group, and all cases in the regional ischemia group showed negative margins. Conclusions: Regional ischemia is as safe to perform as global ischemia, and the former leads to better postoperative renal functions than the latter. These findings support the application of regional ischemia for PN.

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“…It was reported by multiple studies that up to 40 min of WIT is safe, sufficient for the resection of the tumor, and performing renorrhaphy. [ 11 12 ] There are multiple ways to assess the renal function, and each technique has some advantages and disadvantages. Serum creatinine measurement and radionuclide renal scans are the most commonly utilized tools to assess the renal function.…”

Section: Introductionmentioning

confidence: 99%

“…Serum creatinine measurement and radionuclide renal scans are the most commonly utilized tools to assess the renal function. [ 4 5 11 ] On the other hand, other studies used glomerular filtration rate (GFR) to measure the renal function. [ 2 3 ]…”

Section: Introductionmentioning

confidence: 99%

Off-clamp robotic partial nephrectomy: Technique and outcome

Lamoshi

Salkini

2015

Urol Ann

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Introduction:Robotic partial nephrectomy (RPN) is a technically challenging procedure. Advanced skills are needed to accomplish tumor resection, hemostasis, and renorrhaphy within short ischemia time in RPN. Off-clamp RPN with zero ischemia may decrease the risk of ischemic reperfusion injury to the kidney. However, the off-clamp technique has been associated with an increased risk of blood loss. The purpose of this study was to evaluate the outcome of our modified off-clamp technique utilized in certain RPN cases.Patients and Methods:A total of 81 patients underwent RPN between September 2009 and July 2013 for renal masses. We studied a subgroup of patients who underwent off-clamp RPN with zero ischemia time. The off-clamp technique was utilized for exophytic, nonhilar tumors that have a base of 2 cm or less. We developed a novel technique to avoid ischemia reperfusion renal injury while minimizing blood loss in certain cases of RPN.Results:Of the 81 cases of RPN, we reviewed and adopted the off-clamp technique in 34 patients (41.98%). Utilizing off-clamp RPN resulted in an average blood loss of 96.29 ml and 1.56 days (range: 1-3 days) of hospital stay and minimal change in serum creatinine.Conclusions:Off-clamp RPN is safe and feasible approach to excise certain kidney tumors. It carries the benefits of RPN and prevents ischemia reperfusion renal injury.

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Eliminating global renal ischemia during partial nephrectomy

Cited by 13 publications

References 18 publications

A Literature Review of Renal Surgical Anatomy and Surgical Strategies for Partial Nephrectomy

A Literature Review of Renal Surgical Anatomy and Surgical Strategies for Partial Nephrectomy

Safety and Postoperative Outcomes of Regional versus Global Ischemia for Partial Nephrectomy: A Systematic Review and Meta-Analysis

Off-clamp robotic partial nephrectomy: Technique and outcome

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