Laparoscopic partial nephrectomy without ischemia.

The warm ischaemia time appears the most prominent modifiable risk factor for the development of renal impairment following laparoscopic partial nephrectomy. Historically, hilar clamping was the 'gold standard' technique, but now we are pushing our techniques to achieve the ultimate: 'zero ischaemia' approach. Results from 'early unclamping' techniques reinforced the importance of 'every minute counts' (28). Subsequent techniques in non-hilar clamping demonstrated that this approach was indeed feasible, but at the expense of higher bleeding, positive margins, and collecting system breach rates. With the advancement of technology, through the use of robotic assistance, improved haemostatic agents, as well as various imaging modalities (laparoscopic ultrasound, CT angiography), the surgeon can now potentially perform Nephron Sparing Surgery (NSS) in a more precise manner. Specifically, with the use of superselective clamping of the feeding vessel(s) to the tumour, the remaining healthy renal parenchyma should be less compromised, with associated low bleeding rates. NSS in the form of laparoscopic partial nephrectomy is clearly evolving, with increasing demands on the surgeon, requiring more expertise and experience, with the added assistance from other specialties (anaesthetists, radiologists etc). To be able to regularly perform Laparoscopic Partial Nephrectomy (LPN) without ischaemia safely, the laparoscopist must develop his / her experience in a stepwise fashion, perhaps commencing with artery-only clamping, leading on to early declamping, and then 'on demand' clamping. When moving on to LPN without ischaemia, patient selection is paramount. The ideal patient would harbour a single small, polar, exophytic renal mass with a normal functioning contralateral kidney. Although currently the techniques and outcomes laparoscopic partial nephrectomy without ischaemia published are limited to a few authors, with no current long term results to prove its full worth and reproducibility, early results are very encouraging. The pursuit of acquiring 'zero ischaemia' is clearly worthwhile, but needs to be measured against the potential risks of increased morbidity and positive margin rates.