Eliminating global renal ischemia during partial nephrectomy:  an anatomical approach.
OBJECTIVE
Partial nephrectomy surgery typically requires clamping the main renal artery. This creates the bloodless field necessary for precise tumor excision and reconstruction. However, hilar clamping also renders the entire kidney ischemic, an undesirable albeit unavoidable consequence. We recently developed a novel, anatomical zero-ischemia technique that eliminates global renal ischemia. Herein, we critically evaluate the outcomes of unclamped and zero-ischemia partial nephrectomy techniques.


RESULTS
Our anatomical zero-ischemia technique takes advantage of renal segmental and end-arterial anatomy to allow even substantial partial nephrectomy surgery without clamping the main renal artery/vein. Anatomic vascular microdissection is performed to super-selectively devascularize the tumor, while maintaining uninterrupted arterial blood flow to the uninvolved kidney. Global renal ischemia is thus eliminated.


CONCLUSIONS
Partial nephrectomy can now be safely performed without global renal ischemia, even for complex tumors. Initial perioperative and renal functional outcomes of anatomical zero-ischemia surgery are encouraging. Going forward, clamping the main renal artery appears unnecessary during most partial nephrectomy surgery.
USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA. mpatil@usc.edu
Mukul B
MB
Patil
Dennis J
DJ
Lee
Inderbir S
IS
Gill
D016063:Blood Loss, Surgical / Q000517:prevention & control; D003250:Constriction; D006801:Humans; D007511:Ischemia / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D007668:Kidney / Q000098:blood supply / Q000601:surgery*; D042282:Microdissection; D009392:Nephrectomy / Q000009:adverse effects / Q000379:methods*; D012077:Renal Artery / Q000503:physiopathology / Q000601:surgery*; D012079:Renal Circulation; D012082:Renal Veins / Q000503:physiopathology / Q000601:surgery*; D018570:Risk Assessment; D012307:Risk Factors; D016896:Treatment Outcome