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.

  • Opinion
  • Published:

Nonclamping partial nephrectomy: towards improved nephron sparing

Nature Reviews Urology volume 8, pages 523–527 (2011)Cite this article

Subjects

Abstract

Ischemia–reperfusion injury caused by vascular clamping contributes to the decline in glomerular filtration rate following partial nephrectomy. Ischemia is the main modifiable factor that determines postoperative kidney function, and it is likely that a harmless duration of ischemia does not exist. Each additional minute of warm ischemia increases the odds of acute renal failure, severe chronic kidney disease (CKD) and end-stage renal disease. Our experience comparing partial nephrectomy with and without clamping in solitary kidneys suggests that renovascular clamping is the only statistically significant determinant of postoperative renal dysfunction. Studies comparing partial nephrectomy with and without clamping demonstrate that ischemia is associated with a risk of acute renal failure, advanced CKD, and renal replacement therapy. Oncologic outcomes and complications in partial nephrectomy without clamping are similar to those with clamping. Even in complex lesions, partial nephrectomy without vascular clamping is preferable when feasible.

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: A 65-year-old man with a solitary kidney presented with hematuria.
Figure 2: An incidentally discovered centrally located renal tumor in a 62-year-old woman who underwent a successful nonclamping partial nephrectomy.

Similar content being viewed by others

References

  1. Jemal, A., Siegel, R., Xu, J. & Ward, E. Cancer statistics, 2010. CA Cancer J. Clin. 60, 277–300 (2010).

    Article  PubMed  Google Scholar 

  2. Lee, C. T. et al. Surgical management of renal tumors 4 cm. or less in a contemporary cohort. J. Urol. 163, 730–736 (2000).

    Article  CAS  PubMed  Google Scholar 

  3. Leibovich, B. C. et al. Nephron sparing surgery for appropriately selected renal cell carcinoma between 4 and 7 cm results in outcome similar to radical nephrectomy. J. Urol. 171, 1066–1070 (2004).

    Article  PubMed  Google Scholar 

  4. Dash, A. et al. Comparison of outcomes in elective partial vs radical nephrectomy for clear cell renal cell carcinoma of 4–7 cm. BJU Int. 97, 939–945 (2006).

    Article  PubMed  Google Scholar 

  5. Huang, W. C. et al. Chronic kidney disease after nephrectomy in patients with renal cortical tumours: a retrospective cohort study. Lancet Oncol. 7, 735–740 (2006).

    Article  PubMed  PubMed Central  Google Scholar 

  6. La Rochelle, J. et al. Functional and oncological outcomes of partial nephrectomy of solitary kidneys. J. Urol. 181, 2037–2043 (2009).

    Article  PubMed  Google Scholar 

  7. Wszolek, M. F., Kenney, P. A., Lee, Y. & Libertino, J. A. Comparison of hilar clamping and non-hilar clamping partial nephrectomy for tumours involving a solitary kidney. BJU Int. 107, 1886–1892 (2011).

    Article  PubMed  Google Scholar 

  8. Go, A. S., Chertow, G. M., Fan, D., McCulloch, C. E. & Hsu, C. Y. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N. Engl. J. Med. 351, 1296–1305 (2004).

    Article  CAS  PubMed  Google Scholar 

  9. Huang, W. C., Elkin, E. B., Levey, A. S., Jang, T. L. & Russo, P. Partial nephrectomy versus radical nephrectomy in patients with small renal tumors—is there a difference in mortality and cardiovascular outcomes? J. Urol. 181, 55–62 (2009).

    Article  PubMed  Google Scholar 

  10. Weight, C. J. et al. Elective partial nephrectomy in patients with clinical T1b renal tumors is associated with improved overall survival. Urology 76, 631–637 (2010).

    Article  PubMed  Google Scholar 

  11. Clark, M. A. et al. Chronic kidney disease before and after partial nephrectomy. J. Urol. 185, 43–48 (2011).

    Article  PubMed  Google Scholar 

  12. Lane, B. R. et al. Factors predicting renal functional outcome after partial nephrectomy. J. Urol. 180, 2363–2369 (2008).

    Article  PubMed  Google Scholar 

  13. Lane, B. R. et al. Comparison of cold and warm ischemia during partial nephrectomy in 660 solitary kidneys reveals predominant role of nonmodifiable factors in determining ultimate renal function. J. Urol. 185, 421–427 (2011).

    Article  PubMed  Google Scholar 

  14. Russo, P. Partial nephrectomy for renal cancer (part II): the impact of renal ischaemia, patient preparation, surgical approaches, management of complications and utilization. BJU Int. 105, 1494–1507 (2010).

    Article  PubMed  Google Scholar 

  15. Simmons, M. N., Schreiber, M. J. & Gill, I. S. Surgical renal ischemia: a contemporary overview. J. Urol. 180, 19–30 (2008).

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  17. Becker, F. et al. Assessing the impact of ischaemia time during partial nephrectomy. Eur. Urol. 56, 625–634 (2009).

    Article  PubMed  Google Scholar 

  18. Silva, P. Energy and fuel substrate metabolism in the kidney. Semin. Nephrol. 10, 432–444 (1990).

    CAS  PubMed  Google Scholar 

  19. Novick, A. C. Renal hypothermia: in vivo and ex vivo. Urol. Clin. North Am. 10, 637–644 (1983).

    CAS  PubMed  Google Scholar 

  20. Song, C., Bang, J. K., Park, H. K. & Ahn, H. Factors influencing renal function reduction after partial nephrectomy. J. Urol. 181, 48–54 (2009).

    Article  PubMed  Google Scholar 

  21. Thompson, R. H. et al. The impact of ischemia time during open nephron sparing surgery on solitary kidneys: a multi-institutional study. J. Urol. 177, 471–476 (2007).

    Article  PubMed  Google Scholar 

  22. Gong, E. M. et al. Artery-only occlusion may provide superior renal preservation during laparoscopic partial nephrectomy. Urology 72, 843–846 (2008).

    Article  PubMed  Google Scholar 

  23. Tracy, C. R. et al. Characterization of renal ischemia using DLP hyperspectral imaging: a pilot study comparing artery-only occlusion versus artery and vein occlusion. J. Endourol. 24, 321–325 (2010).

    Article  PubMed  Google Scholar 

  24. Marberger, M. Renal ischaemia: not a problem in laparoscopic partial nephrectomy? BJU Int. 99, 3–4 (2007).

    Article  PubMed  Google Scholar 

  25. Turner Warwick, R. T. The supracostal approach to the renal area. Br. J. Urol. 37, 671–672 (1965).

    Article  CAS  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  27. Moinzadeh, A. et al. Temporary segmental renal artery occlusion using reverse phase polymer for bloodless robotic partial nephrectomy. J. Urol. 182, 1582–1587 (2009).

    Article  PubMed  PubMed Central  Google Scholar 

  28. Thompson, R. H. et al. Comparison of warm ischemia versus no ischemia during partial nephrectomy on a solitary kidney. Eur. Urol. 58, 331–336 (2010).

    Article  PubMed  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  PubMed  Google Scholar 

  30. Fergany, A. F., Saad, I. R., Woo, L. & Novick, A. C. Open partial nephrectomy for tumor in a solitary kidney: experience with 400 cases. J. Urol. 175, 1630–1633 (2006).

    Article  PubMed  Google Scholar 

  31. Ghavamian, R. et al. Renal cell carcinoma in the solitary kidney: an analysis of complications and outcome after nephron sparing surgery. J. Urol. 168, 454–459 (2002).

    Article  PubMed  Google Scholar 

  32. Levey, A. S. et al. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann. Intern. Med. 139, 137–147 (2003).

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Lahey Clinic Medical Center, 41 Mall Road, Burlington, 01805, MA, USA

    Matthew F. Wszolek, Patrick A. Kenney & John A. Libertino

Authors
  1. Matthew F. Wszolek
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Patrick A. Kenney
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. John A. Libertino
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

M. F. Wszolek and P. A Kenney contributed equally to writing the manuscript. They also researched data for the article, made a substantial contribution to discussions of content and reviewed and edited the article before submission. J. A. Libertino made a substantial contribution to discussions of content and reviewed and edited the article before submission.

Corresponding author

Correspondence to John A. Libertino.

Ethics declarations

Competing interests

The authors declare no competing financial interests.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Wszolek, M., Kenney, P. & Libertino, J. Nonclamping partial nephrectomy: towards improved nephron sparing. Nat Rev Urol 8, 523–527 (2011). https://doi.org/10.1038/nrurol.2011.103

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrurol.2011.103

This article is cited by

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