Debate: Does Ischemia Still Matter During Partial Nephrectomy?

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There are differing opinions on whether ischemia still matters during partial nephrectomy in patients with locally advanced renal cell carcinoma.
There are differing opinions on whether ischemia still matters during partial nephrectomy in patients with locally advanced renal cell carcinoma.

MIAMI—There are differing opinions on whether ischemia still matters during partial nephrectomy in patients with locally advanced renal cell carcinoma, according to a debate at the 14th International Kidney Cancer Symposium (IKCS).1

“The degree of ischemia affects postoperative renal function,” argued Karim Touijer, MD, MPH, of the Memorial Sloan Kettering Cancer Center and the Department of Urology at Weill Cornell Medical College in New York, NY.

Dr. Touijer presented evidence that warm ischemia time and renal volume loss were predictors of outcome in a bilateral kidney model. Specifically, a warm ischemia time greater than 32 minutes was associated with worse renal function. In another study, reducing warm ischemia time was found to be associated with better renal function preservations, in particular a warm ischemia time of 14.4 minutes was associated with a 90-day estimated glomerular filtration rate reduction of 11% compared with 20% for a warm ischemia time of 31.6 minutes (P < .001).

Both warm and cold ischemia are associated with increased risk of acute and chronic renal failure and temporary dialysis compared with no ischemia.

Dr. Touijer noted, however, that the evidence is based on retrospective and animal data, and although prospective evidence is limited, it is provocative.

Countering from an alternative perspective, Dipjen J. Parekh, MD, of the Department of Urology at University of Miami Miller School of Medicine in Miami, FL, argued that “limited ischemia is safe to perform partial nephrectomy.”

In a study of 40 patients undergoing open partial nephrectomy, there was no correlation of duration of ischemia and kidney injury.

Furthermore, Dr. Parekh discussed a study that compared cold and hot ischemia during partial nephrectomy in 660 solitary kidneys. Results showed that ischemia time was not an independent predictor of ultimate renal function after partial nephrectomy.

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“It is overly simplistic and naïve to consider a single value ischemia time cut-off to act as a dichotomous marker for renal injury,” Dr. Parekh concluded.

The audience voted and nearly two-thirds felt Dr. Parekh presented the most compelling argument.

Reference

  1. Touijer K, Parekh DJ. Debate: Does Ischemia still matter [Oral presentation at 14th International Kidney Cancer Symposium].

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