Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Zero ischaemia partial nephrectomy: a call for standardized nomenclature and functional outcomes

Nature Reviews Urology volume 13, pages 674–683 (2016)Cite this article

Subjects

Key Points

  • Warm ischaemia time (WIT) is seemingly the sole variable that surgeons strive to address in minimizing loss of renal function after partial nephrectomy

  • The term 'zero ischaemia' partial nephrectomy has been inconsistently, if not arbitrarily, applied by researchers and surgeons alike

  • The development of various novel partial nephrectomy techniques has been accompanied by even more substantial diversity in the methods of reporting postoperative renal functional outcomes

  • The diversity in the methods of reporting functional outcomes stems from the lack of evidence to support the adoption of a particular parameter for measurement of postoperative renal functional outcomes

  • The absence of a consensus on the measurement of postoperative functional outcomes hampers the effective evaluation of the various novel techniques that aim to reduce WIT in nephron-sparing surgery

  • An unmet need exists to establish standard and reproducible classifications or guidelines to accurately describe technical terms and quantify renal functional outcome to match the continuously evolving field of nephron-sparing surgery

Abstract

Nephron-sparing surgery for the removal of small renal masses delivers equivalent oncological outcomes and better functional outcomes compared with those associated with radical nephrectomy. All contemporary partial nephrectomy techniques including open, laparoscopic and robotic approaches involve the use of hilar clamping in order to facilitate haemostasis, and to enable accurate tumour excision and parenchymal reconstruction. Zero ischaemia was subsequently introduced as a technique to eliminate the renal ischaemia induced by hilar clamping. Following the introduction of zero ischaemia techniques, researchers have arbitrarily applied this term to techniques ranging from no use of clamping to selective clamping of renal arteries and/or veins, or their branches. Substantial variations exist in the way that zero ischaemia and other renal preservation techniques are described in the literature. Similarly, further diversity exists in the measurement and reporting of functional outcomes after surgery. The introduction of standard and reproducible classifications or guidelines will ensure consistency and uniformity. Establishing consensus on the terminology used to describe techniques and functional outcomes will not only facilitate improved communication and surgical practice, but will also enable critical appraisal of surgical techniques.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1: Arterial supply to the kidneys.
Figure 2: Renal ischaemia during partial nephrectomy.

Similar content being viewed by others

References

  1. Guideline for management of the clinical stage 1 renal mass, https://www.auanet.org/common/pdf/education/clinical-guidance/Renal-Mass.pdf (American Urological Association Education and Research, Inc., 2009).

  2. Jordan, G. H. & Winslow, B. H. Laparoendoscopic upper pole partial nephrectomy with ureterectomy. J. Urol. 150, 940–943 (1993).

    Article  CAS  Google Scholar 

  3. Winfield, H. N., Donovan, J. F., Godet, A. S. & Clayman, R. V. Laparoscopic partial nephrectomy: initial case report for benign disease. J. Endourol. 7, 521–526 (1993).

    Article  CAS  Google Scholar 

  4. Leslie, S., Goh, A. & Gill, I. Partial nephrectomy—contemporary indications, techniques and outcomes. Nat. Rev. Urol. 10, 275–283 (2013).

    Article  Google Scholar 

  5. Ficarra, V., Rossanese, M., Gnech, M., Novara, G. & Mottrie, A. Outcomes and limitations of laparoscopic and robotic partial nephrectomy. Curr. Opin. Urol. 24, 441–447 (2014).

    Article  Google Scholar 

  6. Nguyen, M. & Gill, I. Halving ischemia time during laparoscopic partial nephrectomy. J. Urol. 179, 627–632 (2008).

    Article  Google Scholar 

  7. Simmons, M. N., Fergany, A. F. & Campbell, S. C. Effect of parenchymal volume preservation on kidney function after partial nephrectomy. J. Urol. 186, 405–410 (2011).

    Article  Google Scholar 

  8. Thompson, R. H. et al. Renal function after partial nephrectomy: effect of warm ischemia relative to quantity and quality of preserved kidney. Urology 79, 356–360 (2012).

    Article  Google Scholar 

  9. Gill, I. S. et al. “Zero ischemia” partial nephrectomy: novel laparoscopic and robotic technique. Eur. Urol. 59, 128–134 (2011).

    Article  Google Scholar 

  10. Thompson, R. et al. Every minute counts when the renal hilum is clamped during partial nephrectomy. Eur. Urol. 58, 340–345 (2010).

    Article  Google Scholar 

  11. Zargar, H. et al. The impact of extended warm ischemia time on late renal function after robotic partial nephrectomy. J. Endourol. 29, 444–448 (2015).

    Article  Google Scholar 

  12. Lane, B. R., Gill, I. S., Fergany, A. F., Larson, B. T. & Campbell, S. C. Limited warm ischemia during elective partial nephrectomy has only a marginal impact on renal functional outcomes. J. Urol. 185, 1598–1603 (2011).

    Article  Google Scholar 

  13. Porpiglia, F. et al. Evaluation of functional outcomes after laparoscopic partial nephrectomy using renal scintigraphy: clamped versus clampless technique. BJU Int. 115, 606–612 (2015).

    Article  Google Scholar 

  14. Wiener, S. et al. Predictors of postoperative decline in estimated glomerular filtration rate in patients undergoing robotic partial nephrectomy. J. Endourol. 28, 807–813 (2014).

    Article  Google Scholar 

  15. Abreu, A., Gill, I. & Desai, M. Zero-ischaemia robotic partial nephrectomy (RPN) for hilar tumours. BJU Int. 108, 948–954 (2011).

    Article  Google Scholar 

  16. Gill, I. S. et al. Zero ischemia anatomical partial nephrectomy: a novel approach. J. Urol. 187, 807–815 (2012).

    Article  Google Scholar 

  17. Satkunasivam, R. et al. Robotic unclamped “minimal-margin” partial nephrectomy: ongoing refinement of the anatomic zero-ischemia concept. Eur. Urol. 68, 705–712 (2015).

    Article  Google Scholar 

  18. Shin, T. et al. Simplified zero ischemia in robot assisted partial nephrectomy: initial yonsei experience. Korean J. Urol. 54, 78–84 (2013).

    Article  Google Scholar 

  19. Papalia, R. et al. Laparoscopic and robotic partial nephrectomy without renal ischaemia for tumours larger than 4 cm: perioperative and functional outcomes. World J. Urol. 30, 671–676 (2012).

    Article  Google Scholar 

  20. Ng, C. et al. Anatomic renal artery branch microdissection to facilitate zero-ischemia partial nephrectomy. Eur. Urol. 61, 67–74 (2012).

    Article  Google Scholar 

  21. Peña, J. et al. The road to real zero ischemia for partial nephrectomy. J. Endourol. 27, 936–942 (2013).

    Article  Google Scholar 

  22. Rizkala, E. et al. Zero ischemia robotic partial nephrectomy: sequential preplaced suture renorrhaphy technique. Urology 82, 100–104 (2013).

    Article  Google Scholar 

  23. D'Urso, L. et al. Benefits and shortcomings of superselective transarterial embolization of renal tumors before zero ischemia laparoscopic partial nephrectomy. Eur. J. Surg. Oncol. 40, 1731–1737 (2014).

    Article  CAS  Google Scholar 

  24. Imkamp, F. et al. Initial experiences with the Hemopatch® as a hemostatic agent in zero-ischemia partial nephrectomy. World J. Urol. 33, 1527–1534 (2014).

    Article  Google Scholar 

  25. Engel, J. D. & Williams, S. B. Unclamped hand-assisted laparoscopic partial nephrectomy for predominantly endophytic renal tumors. Urol. J. 10, 767–773 (2013).

    PubMed  Google Scholar 

  26. Simone, G., Papalia, R., Guaglianone, S., Carpanese, L. & Gallucci, M. Zero ischemia laparoscopic partial nephrectomy after superselective transarterial tumor embolization for tumors with moderate nephrometry score: long-term results of a single-center experience. J. Endourol. 25, 1443–1446 (2011).

    Article  Google Scholar 

  27. Simone, G., Papalia, R., Guaglianone, S. & Gallucci, M. ''Zero ischaemia'' sutureless laparoscopic partial nephrectomy for renal tumours with a low nephrometry score. BJU Int. 110, 124–130 (2011).

    Article  Google Scholar 

  28. Liu, W. et al. Off-clamp versus complete hilar control partial nephrectomy for renal cell carcinoma: a systematic review and meta-analysis. J. Endourol. 28, 567–576 (2014).

    Article  CAS  Google Scholar 

  29. Smith, G. L., Kenney, P. A., Lee, Y. & Libertino, J. A. Non-clamped partial nephrectomy: techniques and surgical outcomes. BJU Int. 107, 1054–1058 (2011).

    Article  Google Scholar 

  30. Kopp, R. P. et al. Factors affecting renal function after open partial nephrectomy—a comparison of clampless and clamped warm ischemic technique. Urology 80, 865–870 (2012).

    Article  Google Scholar 

  31. Papalia, R. et al. Laparoscopic and robotic partial nephrectomy with controlled hypotensive anesthesia to avoid hilar clamping: feasibility, safety and perioperative functional outcomes. J. Urol. 187, 1190–1194 (2012).

    Article  Google Scholar 

  32. Kim, T. S., Oh, J. H. & Rhew, H. Y. ''Off-clamp, non-renorrhaphy'' laparoscopic partial nephrectomy with perirenal fat and Gerota's fascia reapproximation: initial experience and perioperative outcomes. J. Laparoendosc. Adv. Surg. Tech. A 24, 339–344 (2014).

    Article  Google Scholar 

  33. Rais-Bahrami, S. et al. Off-clamp versus complete hilar control laparoscopic partial nephrectomy: comparison by clinical stage. BJU Int. 109, 1376–1381 (2011).

    Article  Google Scholar 

  34. George, A. K. et al. Perioperative outcomes of off-clamp versus complete hilar control laparoscopic partial nephrectomy. BJU Int. 111, E235–E241 (2013).

    Article  Google Scholar 

  35. Springer, C. et al. Clampless laparoendoscopic single-site partial nephrectomy for renal cancer with low PADUA score: technique and surgical outcomes. BJU Int. 111, 1091–1098 (2013).

    Article  Google Scholar 

  36. Salami, S. S. et al. Off-clamp laparoscopic partial nephrectomy for hilar tumors: oncologic and renal functional outcomes. J. Endourol. 28, 191–195 (2014).

    Article  Google Scholar 

  37. Kaczmarek, B. F. et al. Off-clamp robot-assisted partial nephrectomy preserves renal function: a multi-institutional propensity score analysis. Eur. Urol. 64, 988–993 (2013).

    Article  Google Scholar 

  38. Peyronnet, B. et al. Early unclamping technique during robotic partial nephrectomy can minimize warm ischemia without increasing morbidity. BJU Int. 114, 741–747 (2014).

    Article  Google Scholar 

  39. Imbeault, A., Pouliot, F. & Dujardin, T. Prospective study comparing two techniques of clamping in laparosocpic partial nephrectomy: impact on perioperative parameters. J. Urol. 181, 473–474 (2009).

    Article  Google Scholar 

  40. Simone, G., Papalia, R., Guaglianone, S., Forestiere, E. & Gallucci, M. Preoperative superselective transarterial embolization in laparoscopic partial nephrectomy: technique, oncologic, and functional outcomes. J. Endourol. 23, 1473–1478 (2009).

    Article  Google Scholar 

  41. Shao, P. et al. Precise segmental renal artery clamping under the guidance of dual-source computed tomography angiography during laparoscopic partial nephrectomy. Eur. Urol. 62, 1001–1008 (2012).

    Article  Google Scholar 

  42. Shao, P. et al. Laparoscopic partial nephrectomy with segmental renal artery clamping: technique and clinical outcomes. Eur. Urol. 59, 849–855 (2011).

    Article  Google Scholar 

  43. McClintock, T. R. et al. Can selective arterial clamping with fluorescence imaging preserve kidney function during robotic partial nephrectomy? Urology 84, 327–332 (2014).

    Article  Google Scholar 

  44. Simon, J. et al. Laparoscopic partial nephrectomy with selective control of the renal parenchyma: initial experience with a novel laparoscopic clamp. BJU Int. 103, 805–808 (2009).

    Article  Google Scholar 

  45. Viprakasit, D. P. et al. Selective renal parenchymal clamping in robot-assisted laparoscopic partial nephrectomy: a multi-institutional experience. J. Endourol. 25, 1487–1491 (2011).

    Article  Google Scholar 

  46. Simone, G. et al. Indications, techniques, outcomes, and limitations for minimally ischemic and off-clamp partial nephrectomy: a systematic review of the literature. Eur. Urol. 68, 632–640 (2015).

    Article  Google Scholar 

  47. Hew, M. N. et al. Critical appraisal of the PADUA classification and assessment of the R.E.N.A.L. nephrometry score in patients undergoing partial nephrectomy. J. Urol. 186, 42–46 (2011).

    Article  CAS  Google Scholar 

  48. Waldert, M. et al. External validation of the preoperative anatomical classification for prediction of complications related to nephron-sparing surgery. World J. Urol. 28, 531–535 (2010).

    Article  Google Scholar 

  49. Mottrie, A. et al. Validation of the preoperative aspects and dimensions used for an anatomical (PADUA) score in a robot-assisted partial nephrectomy series. World J. Urol. 31, 799–804 (2013).

    Article  Google Scholar 

  50. Wen, K. et al. Application of a standardized anatomical classification in a Chinese partial nephrectomy series. Int. J. Urol. 19, 551–558 (2012).

    Article  Google Scholar 

  51. Papalia, R. et al. Novel kidney segmentation system to describe tumour location for nephron-sparing surgery. World J. Urol. 33, 865–871 (2015).

    Article  Google Scholar 

  52. Levey, A. S. et al. A new equation to estimate glomerular filtration rate. Ann. Intern. Med. 150, 604–612 (2009).

    Article  Google Scholar 

  53. Hougardy, J. M., Delanaye, P., Le Moine, A. & Nortier, J. [Estimation of the glomerular filtration rate in 2014 by tests and equations: strengths and weaknesses]. Rev. Med. Brux. 35, 250–257 (in French) (2014).

    CAS  PubMed  Google Scholar 

  54. Tachikake, T. et al. Decrease of renal function due to warm ischemia after laparoscopic partial nephrectomy: evaluation using 99mTc-DMSA renal scintigraphy. Urol. Int. 82, 162–165 (2009).

    Article  Google Scholar 

  55. Sankin, A. et al. Assessing renal function following partial neprectomy using renal nuclear scintigraphy and eGFR. Urology 80, 343–346 (2012).

    Article  Google Scholar 

  56. Thomas, A. A. et al. Acute kidney injury: novel biomarkers and potential utility for patient care in urology. Urology 77, 5–11 (2011).

    Article  Google Scholar 

  57. http://web.squ.edu.om/medLib/MED_CD/E_CDs/anesthesia/site/content/v02/020586r00.htm

Download references

Author information

Authors and Affiliations

  1. Urology Department, Mubarak Al Kabeer Hospital & Sabah Al Ahmad Urology Centre, PO Box 43787, State of Kuwait

    Ahmad Alenezi

  2. Department of Surgery – Urology Clinic, University of Padua, Via Giustiniani 35100, Padua, Italy

    Giacomo Novara

  3. OLV Vattikuti Robotic Surgery Institute, Campus Aalst, Moorselbaan 164, 9300, Aalst, Belgium

    Alexander Mottrie

  4. Bristol Urological Institute, Southmead Hospital, BS10 5NB, Bristol, UK

    Salah Al-Buheissi

  5. Department of Urology, Queen Alexandra Hospital, PO6 3LY, Portsmouth, UK

    Omer Karim

Authors
  1. Ahmad Alenezi
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Giacomo Novara
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Alexander Mottrie
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Salah Al-Buheissi
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Omer Karim
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

A.A. researched data for this article, A.A., A.M., and O.K. made a substantial contribution to discussions of content, A.A. wrote the manuscript and all authors edited and/or reviewed the manuscript before submission.

Corresponding author

Correspondence to Ahmad Alenezi.

Ethics declarations

Competing interests

The authors declare no competing financial interests.

PowerPoint slides

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Alenezi, A., Novara, G., Mottrie, A. et al. Zero ischaemia partial nephrectomy: a call for standardized nomenclature and functional outcomes. Nat Rev Urol 13, 674–683 (2016). https://doi.org/10.1038/nrurol.2016.185

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrurol.2016.185

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing