Zero ischemia partial nephrectomy: Techniques and outcomes

Panagiotis Mourmouris, Christos Papachristou, Titos Markopoulos, Maria Zerva, Omer Burak Argun, Mustafa Bilal Tuna, Andreas Skolarikos


Νephron sparing techniques nowadays have replaced radical nephrectomy as the gold standard management for T1a tumors. Even though the basic step of this technique was hilar clamping in order to achieve a bloodless surgical field and ease tumor excision and rennoraphy, many surgeons have moved one step further and developed minimal or no vessel clamping.

These techniques were grouped under the title of zero ischemia partial nephrectomy. Nevertheless there is a great heterogeneity in the literature concerning every aspect of this term including surgical steps, oncological outcomes and functional results. The purpose of this paper is to review the literature about this interesting topic and to clarify the different aspects of this challenging procedure.


zero ischemia; partial nephrectomy; renal cell carcinoma; clampless

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Ljungberg B, Bensalah K, Canfield SE, et al. EAU guidelines on renal cell carcinoma: 2014 update. Eur Urol 2015 May; 67(5): 913-24.

Choi J E, et al. Comparison of perioperative outcomes between robotic and laparoscopic partial nephrectomy: A systematic review and meta-analysis. Eur Urol 2015; 67: 891.

Ficarra V, Rossanese M, Gnech M, et al. Outcomes and limitations of laparoscopic and robotic partial nephrectomy. Curr Opin Urol 2014 ; 24: 441-447.

Nguyen M & Gill I. Halving ischemia time during laparoscopic partial nephrectomy. J Urol 2008; 179: 627-632.

Thompson RH, Lane BR, Lohse CM, et al Every minute counts when the renal hilum is clamped during partial nephrectomy. Eur Urol 2010; 58(3):340-5.

Gill I S, et al. “Zero ischemia” partial nephrectomy: Novel laparoscopic and robotic technique. Eur Urol 2011; 59:128-134.

Alenezi A, Novara G, Mottrie A, et al. Zero ischemia partial nephrectomy: A call for standardized nomenclature and functional outcomes. Nat Rev Urol 2016; 13(11): 674-683.

Borofsky MS, Gill IS, Hemal AK, et al. Near-infrared fluorescence imaging to facilitate super-selective arterial clamping during zero-ischaemia robotic partial nephrectomy. BJU Int 2013;111(4):604-10.

Smith GL, Kenney PA, Lee Y, et al. Non-clamped partial nephrectomy: Techniques and surgical outcomes. BJU Int 2011;107:1054-8.

Kopp RP, Mehrazin R, Palazzi K, et al. Factors affecting renal function after open partial nephrectomy-a comparison of clampless and clamped warm ischemic technique.Urology 2012;80: 865-70.

Simone G, Gill IS, Mottrie A. Indications, techniques, outcomes, and limitations for minimally ischemic and off-clamp partial nephrectomy: a systematic review of the literature. Eur Urol 2015; 68(4):632-40

Bigot P, Bouvier A, Panayotopoulos P, et al. Partial nephrectomy after selective embolization of tumor vessels in a hybrid operating room: A new approach of zero ischemia in renal surgery. J Surg Oncol 2016;113(2):135-7.

Gallucci M, Guaglianone S, Carpanese L, et al. Superselective embolization as first step of laparoscopic partial nephrectomy. Urology 2007;69: 642-6.

Simone G, Papalia R, Guaglianone S, et al. Zero ischemia laparoscopic partial nephrectomy after superselective transarterial tumor embolization for tumors with moderate nephrometry score: Long-term results of a single-center experience. J Endourol 2011;25:1443-6.

Hou CP, Lin YH, Hsu YC. Using a Harmonic Scalpel “Drilling and Clamping” Method to Implement Zero Ischemic Robotic-assisted Partial Nephrectomy: An Observation Case Report Study.

Rizkala ER, Khalifeh A, Autorino R, et al. Zero ischemia robotic partial nephrectomy: Sequential preplaced suture renorrhaphy technique. Urology 2013; 82(1):100-4.

Imkamp F, Tolkach Y, Wolters M. Initial experiences with the Hemopatch® as a hemostatic agent in zero-ischemia partial nephrectomy. World J Urol 2015; 33(10):1527-34.

Levey A S, et al. A new equation to estimate glomerular filtration rate. Ann Intern Med 2009; 150: 604-612.

Hougardy J M, Delanaye P, Le Moine, et al. Estimation of the glomerular filtration rate in 2014 by tests and equations: Strengths and weaknesses. Rev Med Brux 2014; 35: 250-257.

Sankin A, et al. Assessing renal function following partial neprectomy using renal nuclear scintigraphand eGFR. Urology 2012; 80:343-346.

Thomas A, et al. Acute kidney injury: Novel biomarkers and potential utility for patient care in urology. Urology 2011; 77: 5-11.

Komninos C, Shin TY, Tuliao P. Renal function is the same 6 months after robot-assisted partial nephrectomy regardless of clamp technique: Analysis of outcomes for off-clamp, selective arterial clamp and main artery clamp techniques, with a minimum follow-up of 1 year. BJU Int 2015;115(6): 921-8.

Liu W, Li Y, Chen M, Tong S, Lei Y, Qi L. Off-clamp versus complete hilar control partial nephrectomy for renal cell carcinoma: A systematic review and meta-analysis. J Endourol 2014; 28: 567-76.

Trehan A. Comparison of off-clamp partial nephrectomy and on clamp partial nephrectomy: A systematic review and meta-analysis. Urol Int 2014; 93:125-34.

Mearini L, Nunzi E, Vianello A, et al. Margin and complication rates in clampless partial nephrectomy: A comparison of open, laparoscopic and robotic surgeries. J Robot Surg 2016;10(2):135-44.