Does eliminating global renal ischemia during partial nephrectomy improve functional outcomes?

Abstract

Presently, there is debate over what drives ultimate postoperative function after partial nephrectomy. Some argue that volume of preserved parenchyma and baseline renal function virtually exclusively drive functional outcomes. Others contend that global renal ischemic injury also matters. Herein, we critically review recent literature, with particular focus on emerging data of functional outcomes after ischemia-free partial nephrectomy. Recent retrospective reports suggest the primacy of renal volume preservation and baseline renal function over ischemia time in impacting post-partial nephrectomy function. These studies rely on historical series when the technique of selective clamping was not available. Data from more contemporary series indicate superior functional outcomes when partial nephrectomy is performed without global ischemia, even after correcting for volume loss. Elimination of global ischemia is made possible through novel technical refinements, such as anatomical partial nephrectomy surgery. Amount of kidney excised and ischemia time are inseparably interlinked; the larger/deeper the tumor, the longer the ischemia time. Post-partial nephrectomy kidney quantity and quality are surgically nonmodifiable; however, ischemia time is. Anatomical tumor-specific devascularization opens the door to more sophisticated partial nephrectomy surgery, wherein we can now tailor the technique to the individual tumor and patient.