title: Anatomic partial nephrectomy: technique evolution.
abstract: OBJECTIVE
  Partial nephrectomy provides equivalent long-term oncologic and superior functional outcomes as radical nephrectomy for T1a renal masses. Herein, we review the various vascular clamping techniques employed during minimally invasive partial nephrectomy, describe the evolution of our partial nephrectomy technique and provide an update on contemporary thinking about the impact of ischemia on renal function.
  
  
  RESULTS
  Recently, partial nephrectomy surgical technique has shifted away from main artery clamping and towards minimizing/eliminating global renal ischemia during partial nephrectomy. Supported by high-fidelity three-dimensional imaging, novel anatomic-based partial nephrectomy techniques have recently been developed, wherein partial nephrectomy can now be performed with segmental, minimal or zero global ischemia to the renal remnant. Sequential innovations have included early unclamping, segmental clamping, super-selective clamping and now culminating in anatomic zero-ischemia surgery. By eliminating 'under-the-gun' time pressure of ischemia for the surgeon, these techniques allow an unhurried, tightly contoured tumour excision with point-specific sutured haemostasis. Recent data indicate that zero-ischemia partial nephrectomy may provide better functional outcomes by minimizing/eliminating global ischemia and preserving greater vascularized kidney volume.
  
  
  CONCLUSIONS
  Contemporary partial nephrectomy includes a spectrum of surgical techniques ranging from conventional-clamped to novel zero-ischemia approaches. Technique selection should be tailored to each individual case on the basis of tumour characteristics, surgical feasibility, surgeon experience, patient demographics and baseline renal function.
authors.affiliation: aUSC Institute of Urology, Catherine & Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA bUrology Department, King Abdulaziz University, Jeddah, Saudi Arabia.
authors.forename: Raed A
authors.initials: RA
authors.lastname: Azhar
authors.forename: Charles
authors.initials: C
authors.lastname: Metcalfe
authors.forename: Inderbir S
authors.initials: IS
authors.lastname: Gill
mesh_terms: D002292:Carcinoma, Renal Cell / Q000601:surgery*; D003250:Constriction; D006801:Humans; D021621:Imaging, Three-Dimensional; D007668:Kidney / Q000098:blood supply / Q000601:surgery*; D007680:Kidney Neoplasms / Q000601:surgery*; D009392:Nephrectomy / Q000379:methods*; D059351:Organ Sparing Treatments; D051437:Renal Insufficiency / Q000517:prevention & control*; D025321:Surgery, Computer-Assisted; D052096:Warm Ischemia