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Partial nephrectomy—contemporary indications, techniques and outcomes

Abstract

Increased detection of the small renal mass over the last two decades has led to greater utilization of partial nephrectomy techniques. Appreciation of the negative impact of chronic renal impairment has resulted in partial nephrectomy surpassing radical nephrectomy as the preferred treatment for technically feasible lesions. Indeed the management of localized renal tumours has become focused on techniques that maximally preserve nephron quantity and quality, and therefore maximize renal function after surgery. Postoperative renal function is determined primarily by three factors: preoperative renal function, volume of renal mass preserved and surgical renal ischaemia. Minimization of surgical ischaemia is achieved by early unclamping and unclamped (zero ischaemia) techniques. In addition, laparoscopic and robotic approaches to nephron-sparing surgery have significantly reduced the morbidity of the partial nephrectomy procedure compared with the traditional open approach. The contemporary techniques used for partial nephrectomy demonstrate excellent renal functional and oncological outcomes and minimize perioperative complications.

Key Points

  • Partial nephrectomy for the management of the small renal mass is associated with superior renal function outcomes compared with radical nephrectomy

  • Chronic renal impairment has been associated with increased cardiovascular morbidity and overall mortality

  • Renal function after partial nephrectomy is determined primarily by three factors: preoperative renal function, volume of renal mass preserved and surgical renal ischaemia

  • Minimization of surgical ischaemia is achieved by early unclamping and unclamped (zero ischaemia) techniques

  • Robotic and laparoscopic partial nephrectomy series have demonstrated excellent perioperative, functional and oncological outcomes, as well as eliminated the morbidity associated with a large open incision

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Figure 1: Intraoperative TILEPro display ultrasonography.
Figure 2: Superselective occlusion of tertiary arterial branches supplying the tumour and surrounding parenchyma to avoid global renal ischaemia.
Figure 3: 3D reconstruction of the relationship between tumour and arterial vasculature.
Figure 4: Indocyanine green dye and near infrared fluorescence imaging during robotic partial nephrectomy for a kidney tumour (asterisk).
Figure 5: The use of a bolster and haemostatic matrix to maximize haemostasis during partial nephrectomy.
Figure 6: Closure of the collecting system after partial nephrectomy.

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S. Leslie and A. C. Goh researched data for the article. S. Leslie, A. C. Goh and I. S. Gill contributed to discussion of content, wrote the article and reviewed the manuscript before submission.

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Correspondence to Scott Leslie.

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Leslie, S., Goh, A. & Gill, I. Partial nephrectomy—contemporary indications, techniques and outcomes. Nat Rev Urol 10, 275–283 (2013). https://doi.org/10.1038/nrurol.2013.69

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