Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
Johns Hopkins School of Medicine, Baltimore, MD, USA.
BJU Int. 2023 Feb;131(2):165-172. doi: 10.1111/bju.15848. Epub 2022 Jul 25.
To provide a narrative review of the major advances regarding ischaemia and functional recovery after partial nephrectomy (PN), along with the ongoing controversies.
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.
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.
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?
对肾部分切除术（PN）后缺血和功能恢复的主要进展进行叙述性综述，并探讨当前存在的争议。
确定反映 PN 后缺血和功能恢复主要进展的关键文章。特别强调那些改变手术管理观点的贡献。还优先考虑了无夹闭与夹闭队列的随机试验。
十年前，发表了“每一分钟都很重要”一文，该文显示 PN 夹闭后缺血时间与急性肾损伤（AKI）和慢性肾脏病的发展之间存在强烈相关性。这强化了缺血是主要可调节因素的观点，通过减少缺血可改善功能结果，并有助于推动减少或消除缺血性 PN 的努力。这些方法与强烈的功能恢复和一些围手术期风险相关，尽管在经验丰富的医生手中它们通常是安全的。进一步的研究表明，当将实质体积变化纳入分析时，缺血失去了统计学意义，保存的实质体积百分比成为主要决定因素。冷缺血被证实具有高度保护作用，有限的热缺血也被证明是安全的。PN 的重建阶段，避免实质去血管化，似乎对功能结果最重要。夹闭与非夹闭 PN 的随机试验表明缺血对功能恢复的影响很小。
过去十年见证了 PN 后功能恢复方面的巨大进展，从中吸取了许多经验教训。然而，仍有一些未解决的问题，包括：热缺血的阈值是多少，开始出现不可逆的缺血性损伤？哪些队列发生 AKI 或不可逆缺血性损伤的风险增加？哪些患者应优先考虑进行无缺血性 PN？
