title: Partial nephrectomy with perfusion cooling for imperative indications: a 24-year experience.
abstract: OBJECTIVE
  To report our 24-year experience with open nephron-sparing surgery for renal tumours, using cold ischaemia achieved by renal artery perfusion, as partial nephrectomy for imperative indications is a surgical challenge.
  
  
  METHODS
  From 1980 to 2004, open partial nephrectomy was performed in 717 patients; of these, 65 (9.1%) with a solitary kidney, synchronous bilateral tumours or renal failure in the opposite kidney (imperative indication) had surgery under cold ischaemia, achieved by continuous perfusion of Ringer's lactate at 4 degrees C through the renal artery, which was clamped and cannulated. The tumour was resected in a bloodless field, with biopsies taken from the tumour bed. Focusing on patients with an imperative indication and cold perfusion, we report our perfusion technique, and the ischaemia time, complication rate and cancer-specific survival rate of these patients.
  
  
  RESULTS
  The mean (SD, range) operative duration was 132 (103, 91-252) min and ischaemia time 49 (37, 31-71) min. The most common complications were postoperative haemorrhage in 19%, urinary fistula in 8% and acute renal failure in 6% of patients. There were no specific complications related to the perfusion technique (renal artery stenosis, renal artery or vein thrombosis). The mean (SD, range) long-term follow-up of 95 (71, 4.3-231) months showed increased but constant creatinine values (95 micromol/L before, 182 micromol/L after surgery; P < 0.05) with no need for long-term dialysis. The tumour-specific survival rate was 94%, 76% and 76% after 1, 5 and 10 years, respectively.
  
  
  CONCLUSIONS
  Partial nephrectomy under cold ischaemia remains reserved for selected patients with renal tumours with an imperative indication. The technique provides excellent intraoperative visibility in an absolutely bloodless field, allows surgery with no pressure of time, and makes ex vivo workbench surgery with autotransplantation unnecessary. Perfusion cooling allows good tumour-specific long-term results, with stable residual kidney function sufficient to prevent dialysis.
authors.affiliation: Department of Urology and Paediatric Urology, St. Antonius-Hospital Eschweiler, Homburg/Saar, Germany. jsteffans.sah-eschweiler@clinet.de
authors.forename: Joachim
authors.initials: J
authors.lastname: Steffens
authors.forename: Ulrich
authors.initials: U
authors.lastname: Humke
authors.forename: Manfred
authors.initials: M
authors.lastname: Ziegler
authors.forename: Stefan
authors.initials: S
authors.lastname: Siemer
mesh_terms: D002292:Carcinoma, Renal Cell / Q000401:mortality / Q000601:surgery*; D003080:Cold Temperature; D003250:Constriction; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007511:Ischemia; D007668:Kidney / Q000002:abnormalities; D007680:Kidney Neoplasms / Q000401:mortality / Q000601:surgery*; D008297:Male; D009367:Neoplasm Staging; D009378:Neoplasms, Multiple Primary / Q000401:mortality / Q000601:surgery*; D009392:Nephrectomy / Q000379:methods* / Q000401:mortality; D010477:Perfusion; D011182:Postoperative Care; D012077:Renal Artery; D015996:Survival Rate