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Laparoscopic Partial Nephrectomy: Real-time of Warm Ischemia

Explore the optimal warm ischemia time during laparoscopic partial nephrectomy and its impact on renal function. Discover alternative techniques and factors that may worsen kidney damage.

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Laparoscopic Partial Nephrectomy: Real-time of Warm Ischemia

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  1. Laparoscopic partial nephrectomy: what’s the real time of warm ischemia? Luca Cindolo & Luigi Schips“S. PiodaPietrelcina” Hospital, Urology Dept Vasto, Italy No For Profit relationships in the past twelve months, by presenters or spouse/partner is related to this presentation.

  2. 5.1.2.2 Racomandation NSS could be offered and performed for RCC between 4 and 7 cm, in centres with good expertise in laparoscopy and in well selectioned patients.

  3. Ischemic damage mechanism Aerobictowardanaerobic HOW LONG?

  4. Ward JP. Br J Urol 1975 Novick AC. Urol Clin North Am 1983 Gill IS, et al. J Urol 2002 Bhayani SB, et al. J Urol 2004 <30’ no permanentdamage Open vs Lap NSS WIT 17.5 vs 27.8’(p<0.001) … up to 55 minutes does not significantly influence long-term renal function after LPN!! Myers BD, et al. J Clin Invest 1984 ! open AAA repair with WIT >50’ azotemia about 80%

  5. serum creatinine creatinine 24h clearance clearance of different compounds by scintigraphy Who’s the best? equation

  6. WIT 43±10’ = no short term renal injury Kane CJ. Urology 2004 >32’ = damage Porpiglia F. Eur Urol. 2007 Funahashi Y. Eur Urol 2009

  7. Warm ischemia time: EVIDENCES Very difficult to assess the exact impact of WIT on renal function About 25-30minutes! ….. But there is a contralateral kidney!?!?! Small series collected prospectively, methods of investigation often unappropriate or unreliable Many studies on animals, with difficulties in translation on humans

  8. What is the best model? We need a series on humans, with solitary kidney, undergoing to nephron sparing surgery

  9. 537 solitarykidneypatients 85 no clamp, 174 warm ischemia, 278 cold ischemia Vascularclampassociatedwithincreasedriskof 1) Acute and chronicrenalfailure(4 foldif WI, 7 foldisCI) 2) Temporarydialysis Ifwarm ischemia >20’increasedriskof acute and chronicrenalfailurewithpermanentdialysis Ifcold ischemia >35’ 3 foldincreasedriskof acute renalfailure and urinaryfistula Thompson, J Urol 177, 2007

  10. What can we do? Very careful selection of the patients Very appassionate intraoperative care If you foresee a warm ischemia >30’, cold ischemia

  11. What alternative wehave? Manual Compression vs Vascular Occlusion Intermittent vs Continuous Clamping Capsulotomy Early unclamping

  12. How can I leave you? • What is the minimal ischemia time which can lead to damage? • What is the maximum ischemia time which can be tolerated by the majority of kidneys? • Are there other factors which may worsen the damage? • Are there protective substances and to which extend can they prolong ischemia times? • How safe is renal hypothermia, and to which temperature has the kidney to be cooled? The answers to all these questions will render laparoscopicnephron-sparingsurgerysafer and more reliable.

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