Warm ischemia less than 30 minutes is not necessarily safe during partial nephrectomy: every minute matters.
ABSTRACT At the 11th Annual Meeting of the Society of Urologic Oncology (SUO), an expert panel discussed the importance of warm ischemia time on renal function during partial nephrectomy. The position of this manuscript is that every minute of warm ischemia time has a deleterious effect on renal function outcomes following partial nephrectomy.
The presentation was derived from a review of the published urologic, nephrology, and transplant literature related to warm ischemia time and renal function outcomes.
There exist numerous clinical models to study the effects of warm ischemia on renal function. These include the bilateral kidney, unilateral partial nephrectomy, solitary kidney partial nephrectomy, and transplant kidney model. Each of these models provides evidence for minimizing warm ischemia time to prevent acute renal failure, chronic kidney disease, and end stage renal failure. In the best available model, solitary kidney partial nephrectomy, each minute of warm ischemia was found to be associated with a 6% increased risk of acute renal failure, 7% increased risk of acute-onset end stage renal disease (ESRD), and 4% increased risk of new-onset ESRD while controlling for preoperative renal function, tumor size, and surgical approach.
There is ample evidence, consistent across multiple human kidney models, supporting the potentially deleterious renal effects of warm ischemia during partial nephrectomy. There does not appear to be a known safe threshold of warm ischemia since each minute sequentially contributes to the risk of developing acute kidney injury and renal function decline. Ultimate renal function following PN is dependent on the "3 Qs": quality (renal function prior to surgery), quantity (renal parenchyma preserved during surgery), and quickness (ischemia time).
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ABSTRACT: BACKGROUND: Most studies have found cold ischemic time to be an important predictor of delayed graft function in kidney transplantation. Relatively less is known about the warm time associated with vascular anastomosis and early outcomes. METHODS: A retrospective cohort of 298 consecutive solitary deceased donor kidney recipients from January 2006 to August 2012 was analyzed to examine the association between anastomosis time and delayed graft function (need for dialysis) and length of hospital stay. RESULTS: Delayed graft function (DGF) was observed in 56 patients (18.5%). The median anastomosis time was 30 minutes (interquartile range 24, 45 minutes). Anastomosis time was independently associated with DGF in a multivariable, binary logistic regression analysis (odds Ratio (OR) 1.037 per minute, 95% CI 1.016, 1.057, P = 0.001). An anastomosis time >29 minutes was also associated with a 3.5 fold higher (OR 3.5, 95% CI 1.6, 7.3, P = 0.001) risk of DGF. Median days in hospital was 9 (interquartile range 7, 14 days). Every 5 minutes of longer anastomosis time (0.20 days per minute, 95% CI 0.13, 0.27, P <0.001) was associated with 1 extra day in hospital in a multivariable linear regression model. An anastomosis time >29 minutes was associated with 3.8 (95% CI 1.6, 6.0, P <0.001) more days in hospital. CONCLUSION: Anastomosis time may be an underappreciated but modifiable variable in dictating use of hospital resources. The impact of anastomosis time on longer term outcomes deserves further study.Transplantation research. 05/2013; 2(1):8.
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ABSTRACT: To describe a robotic partial nephrectomy (PN) technique that eliminates renal global ischemia while decreasing parenchymal bleeding. Before tumor resection, a suture is placed through the parenchyma adjacent to the tumor and deep to the planned edge of resection. The tumor resection is begun between the tumor edge and the preplaced suture and continued along the excision margin until some bleeding is encountered. A second suture is placed into the already excised parenchyma. This is repeated until the mass is completely excised, while suturing the parenchyma simultaneously. Fourteen patients underwent this technique between April 2008 and January 2013 by a single surgeon. Median age was 66 years and 64.3% (N = 9) were men. Median body mass index (BMI) was 27.5 Kg/m(2). Median radius, endophytic, nearness to collecting system, anterior/posterior, and location (RENAL) nephrometry score was 6.5. Median tumor size excised off clamp was 2.2 cm. Three patients had multiple tumors; 2 having a warm ischemia time (WIT) of 14.5 and 15 minutes. Median estimated blood loss (EBL) was 192.5 mL. Median operative time was 160 minutes. There were no Clavien grade 3 or 4 complications. One patient had a postoperative ileus and 1 patient had a blood transfusion and deep vein thrombosis. One patient had a positive tumor parenchymal margin, but negative excisional bed margin. Median hospital stay was 3 days and median follow-up was 8.4 months. Sequential preplaced suture renorrhaphy technique is a safe and effective technique that may be useful in renal function preservation by limiting or eliminating WIT while aiding in maximizing nephron preservation, especially in those patients with solitary kidneys and multiple tumors.Urology 07/2013; 82(1):100-104. · 2.42 Impact Factor
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ABSTRACT: To evaluate the prevalence of baseline chronic kidney disease (CKD) in a large cohort of patients with renal masses in a single Chinese institution. Estimated glomerular filtration rate (eGFR) and CKD stage are more clinically relevant to predict the risk of morbidity and mortality in patients after nephrectomy. But, sCr reflects renal function poorly. We retrospectively identified patients undergoing kidney surgery between January 2002 and June 2012. eGFR was calculated using the modification of diet in renal disease formulas modified based on Chinese people. CKD stages I-V were defined using the National Kidney Foundation definitions. A total of 2769 patients had adequate data available to calculate a preoperative eGFR (mL/min/1.73m(2)) with renal cancer confirmed by pathology. Of all patients, 97.7 % awaiting surgery at our institution had a "normal" baseline sCr (≤1.4 mg/dL), and 3.2 % of patients had CKD stage III or worse. Of the 401 patients ≥70 years old, 16.7 % (67/401) had CKD stage III. Many patients with a seemingly normal sCr have CKD stage III or worse, especially in patients over 70 years old. Given the high prevalence of baseline CKD in patients with renal cancer, it is important to preserve renal parenchyma when treating them surgically.World Journal of Urology 10/2013; · 2.89 Impact Factor