Department of Urology, University of Saarland, Kirrbergerstrasse, Homburg/Saar, Germany.
Eur Urol. 2009 Oct;56(4):625-34. doi: 10.1016/j.eururo.2009.07.016. Epub 2009 Jul 28.
The impact of applying renal ischaemia during nephron-sparing surgery to avoid renal damage in the treated kidney has gained importance in different surgical techniques.
The main objective of the present study is to point out the limit of renal ischaemia times for warm and cold ischaemia approaches. Important results of research on renal ischaemia and different surgical techniques as well as results of clinical studies concerning renal function after renal ischaemia in partial nephrectomy are highlighted.
A Medline literature research was performed, combining queries on the keywords nephron-sparing surgery, partial nephrectomy, and ischemia. Links to related articles and cross-reading of citations in related articles were surveyed, as were reviews, letters to editors, and information collected from urologic textbooks. The references formed the basis of this review article, with selection and deletion based on the relevance and importance of the content. In a final step, interactive peer review by the expert panel of coauthors completed the review.
Renal ischaemia research showed an increasing renal damage proportional to ischemic time. Current clinical data support safe ischaemia times, within 20 min of warm ischaemia and up to 2 h of cold ischaemia, to minimise renal ischemic damage. To date, no ischaemia dose-response curve or algorithm is available to predict the risk of acute kidney injury and chronic kidney disease in patients undergoing intraoperative ischaemia. In general, there seems to be a higher risk for comorbidity caused by renal damage in patients suffering from kidney tumour.
If ischaemia is required, the tumour should be removed within 20 min of warm ischaemia, regardless of surgical approach. Efforts should be made to start immediately with cold ischaemia, if the feasibility within this span of time seems to be jeopardised. Thus, cold ischaemia times up to 2 h can be tolerated by the kidney, depending on the individual method. Nevertheless, cold ischaemia with ice slush should be kept as short as possible--at best within 35 min. In ischemic nephron-sparing surgery, one of the surgeon's main aims should be to avoid loss of renal function. Only after optimal preoperative appraisal and planning can the best postoperative outcomes for renal function be achieved.
在保肾手术中应用肾缺血以避免治疗肾脏损伤的影响在不同的手术技术中变得越来越重要。
本研究的主要目的是指出温热和冷缺血方法的肾缺血时间限制。强调了关于肾缺血和不同手术技术的研究的重要结果以及在部分肾切除术的肾缺血后肾功能的临床研究结果。
进行了 Medline 文献研究，结合了保肾手术、部分肾切除术和缺血的关键词查询。调查了相关文章的链接和引用的交叉阅读，以及综述、给编辑的信件和泌尿科教科书收集的信息。这些参考文献构成了本综述文章的基础，根据内容的相关性和重要性进行了选择和删除。最后，由合著专家小组进行了互动同行评审，完成了综述。
肾缺血研究表明，肾损伤与缺血时间成正比。目前的临床数据支持安全的缺血时间，在 20 分钟的温热缺血和长达 2 小时的冷缺血内，以最大限度地减少肾缺血损伤。迄今为止，尚无缺血剂量反应曲线或算法可用于预测术中缺血患者发生急性肾损伤和慢性肾脏病的风险。一般来说，患有肾肿瘤的患者，由于肾损伤导致的合并症风险似乎更高。
如果需要缺血，应在温热缺血 20 分钟内切除肿瘤，无论手术方法如何。如果在这段时间内似乎无法实现，应立即开始冷缺血。因此，取决于个体方法，肾脏可以耐受长达 2 小时的冷缺血。然而，冰泥的冷缺血应尽可能缩短-最好在 35 分钟内。在缺血性保肾手术中，外科医生的主要目标之一应该是避免肾功能丧失。只有在最佳的术前评估和规划后，才能实现最佳的术后肾功能结果。
