Every decade counts: a narrative review of functional recovery after partial nephrectomy

Objective To provide a narrative review of the major advances regarding ischaemia and functional recovery after partial nephrectomy (PN), along with the ongoing controversies. Methods Key articles reflecting major advances regarding ischaemia and functional recovery after PN were identified. Special...

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Bibliographic Details
Published in:BJU international 2023-02, Vol.131 (2), p.165-172
Main Authors: Campbell, Steven C., Campbell, Jack A., Munoz‐Lopez, Carlos, Rathi, Nityam, Yasuda, Yosuke, Attawettayanon, Worapat
Format: Article
Language:English
Subjects:
Acute Kidney Injury - etiology
Clinical trials
functional recovery
Glomerular Filtration Rate
Humans
Ischemia
Ischemia - surgery
kcsm
Kidney - surgery
Kidney cancer
Kidney diseases
Kidney Neoplasms - complications
KidneyCancer
Nephrectomy
Nephrectomy - adverse effects
parenchymal mass preservation
partial nephrectomy
Recovery of function
Retrospective Studies
Review
Reviews
uroonc
Warm Ischemia - adverse effects
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Summary:Objective To provide a narrative review of the major advances regarding ischaemia and functional recovery after partial nephrectomy (PN), along with the ongoing controversies. Methods Key articles reflecting major advances regarding ischaemia and functional recovery after PN were identified. Special emphasis was placed on contributions that changed perspectives about surgical management. Priority was also placed on randomized trials of off‐clamp vs on‐clamp cohorts. Results A decade ago, ‘Every minute counts' was published, showing strong correlations between duration of ischaemia and development of acute kidney injury (AKI) and chronic kidney disease after clamped PN. This reinforced perspectives that ischaemia was the main modifiable factor that could be addressed to improve functional outcomes and helped spur efforts towards reduced or zero ischaemia PN. These approaches were associated with strong functional recovery and some peri‐operative risk, although they were generally safe in experienced hands. Further research demonstrated that, when parenchymal volume changes were incorporated into the analyses, ischaemia lost statistical significance, and percent parenchymal volume saved proved to be the main determinant. Cold ischaemia was confirmed to be highly protective, and limited warm ischaemia also proved to be safe. The reconstructive phase of PN, with avoidance of parenchymal devascularization, appears to be most important for functional outcomes. Randomized trials of on‐clamp vs off‐clamp PN have shown minimal impact of ischaemia on functional recovery. Conclusions The past decade has witnessed great progress regarding functional recovery after PN, with many lessons learned. However, there are still unanswered questions, including: What is the threshold of warm ischaemia at which irreversible ischaemic injury begins to develop? Are some cohorts at increased risk for AKI or irreversible ischaemic injury? and Which patients should be prioritized for zero‐ischaemia PN?
ISSN:1464-4096
1464-410X
DOI:10.1111/bju.15848