Review of nephron sparing surgery for localized renal tumors

Nephron sparing surgery for localized renal tumors has gained increasing acceptance as a standard of care in appropriately selected patients.

Much has been made of the importance of limiting ischemia time to the kidney, during renal artery clamping and tumor resection, to avoid irreversible ischemic damage to the retained renal parenchyma. Some clinicians have proposed that the renal artery rarely needs to be occluded during tumor resection, but rather external compression ("the grip of death") can be used as an alternative to control bleeding during tumor resection and thus minimize ischemic time to the rest of the kidney. Here, Duvdevani and colleagues examine their experience with nephron sparing surgery over a 15 year period in a retrospective fashion, to determine the potential morbidity and benefits of renal artery occlusion during nephron sparing surgery for localized renal tumors.

The authors report on 301 patients who underwent nephron sparing surgery for a localized renal tumor. Of these, 181 patients had renal artery occlusion with cold ischemia, while the remaining 120 patients were managed with external compression alone to control hemorrhage. Mean tumor size was 3.56cm and there was a higher incidence of centralized tumors in the arterial occlusion group (p less than 0.05). The authors noted no difference in blood loss, transfusion rates, tumor size, or complications between the two groups. Two renal units (1.2%) were "lost" due to ischemic damage in the renal artery occlusion group, which was not a complication in the external compression group. More importantly, there was a significantly higher incidence of positive margins in the external compression group (4.2%) relative to the group with renal artery occlusion during resection (0.6%), (p less than 0.05).

Renal artery occlusion during partial nephrectomy may result in ischemic damage to the remaining renal parenchyma, particularly if prolonged, but is clearly superior for optimal visualization during tumor resection. This study demonstrates that external compression (the "grip of death") does not significantly minimize morbidity over renal artery clamping, and may, in fact, be associated with an increased positive margin rate due to poor visibility during tumor resection.

Duvdevani M, Mor Y, Kastin A, Laufer M, Nadu A, Golomb J, Zilberman D, Nativ O, Ramon J

Urology 68(5): 960-963, 2006.

By Christopher G. Wood, MD