"Zero ischemia" partial nephrectomy: Novel laparoscopic and robotic technique

Inderbir S. Gill, Manuel S. Eisenberg, Monish Aron, Andre Berger, Osamu Ukimura, Mukul B. Patil, Vito Campese, Duraiyah Thangathurai, Mihir M. Desai

Research output: Contribution to journalArticlepeer-review

251 Scopus citations


Background: Ischemic injury impacts renal function outcomes following partial nephrectomy. Efforts to minimize, better yet, eliminate renal ischemia are imperative. Objective: Describe a novel technique of "zero ischemia" laparoscopic (LPN) and robotic-assisted (RAPN) partial nephrectomy. Design, setting, and participants: Data were prospectively collected into an institutional review board-approved database. Fifteen consecutive patients underwent zero ischemia procedures: LPN (n = 12), RAPN (n = 3). Included were all candidates for LPN or RAPN, irrespective of tumor complexity, including tumors that were central (n = 9; 60%), hilar (n = 1), in solitary kidney (n = 1), in patients with chronic kidney disease grade 3 or greater (n = 3). Anesthesia-related monitoring included pulmonary artery catheter (ie, Swan-Ganz), transesophageal echocardiography, cerebral oximetry, electroencephalographic bispectral index, mixed venous oxygen measurements, and vigorous hydration/diuresis. Pharmacologically induced hypotension was carefully timed to correspond with excision of the deepest aspect of the tumor. Renal parenchymal reconstruction was completed under normotension, ensuring complete hemostasis. Measurements: Intraoperative and early postoperative data were collected prospectively. Results and limitations: All cases were successfully completed without hilar clamping. Ischemia time was zero in all cases. Median tumor size was 2.5 cm (range: 1-4); operative time was 3 h (range: 1.3-6); blood loss was 150 ml (range: 20-400); and hospital stay was 3 d (range: 2-19). Nadir mean arterial pressure ranged from 52-65 mm Hg (median: 60), typically for 1-5 min. No patient had intraoperative transfusion or complication, acute or delayed renal hemorrhage, or hypotension-related sequelae. Postoperative complications (n = 5) included urine retention (n = 1), septicemia from presumed prostatitis (n = 1), atrial fibrillation (n = 1), urine leak (n = 2). Pathology confirmed renal cell carcinoma in 13 patients (87%), all with negative margins. Median pre- and postoperative serum creatinine (0.9 mg/dl and 0.95 mg/dl, respectively) and estimated glomerular filtration rate (eGFR) (75.3 and 72.9, respectively) were comparable. Median absolute and percent change in discharge serum creatinine and eGFR were 0 and 0%, respectively. Conclusions: A novel zero ischemia technique for RAPN and LPN for substantial renal tumors is presented. The initial experience is encouraging.

Original languageEnglish (US)
Pages (from-to)128-134
Number of pages7
JournalEuropean urology
Issue number1
StatePublished - Jan 1 2011


  • Ischemia
  • Kidney mass
  • Kidney tumor
  • Laparoscopy
  • Partial nephrectomy
  • Robotic
  • Unclamped

ASJC Scopus subject areas

  • Urology


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