ABSTRACT

The objectives of partial nephrectomy are to establish good cancer control with maximum preservation of kidney function, minimize chronic kidney disease related cardiovascular morbidity and improve overall survival. Minimizing ischemia time is the key of this purpose. Traditionally 30 minutes of warm ischemia time has been considered to be the maximum ischemic insult a normal kidney can be exposed to without permanent loss of function. However recent data suggest that this is 20 minutes at most, but every minute of ischemia even below this limit is damaging.

Partial nephrectomy can be performed by open and minimally invasive (laparoscopic and robot assisted) techniques. To maximize both oncological and renal functional outcomes, a robust dialogue between minimally invasive and open surgeons concerning case selection, surgical technique based on the tumor location and size and the anticipated ischemic time required to resect the tumor is necessary in centers where both approaches are performed. In the absence of prospective and randomized clinical trials, the final choice of surgical technique for a small renal mass requires a frank discussion of the risks and benefits of each of the approaches and the anticipated degree of difficulty will provide a surgeon.

However, it is clear that an inflexible blind allegiance to one technique or the other will cause kidney wasting operations and will not be in the patient's best interest.

It is not adequate to tailor the surgical technique according to the patient. Instead regarding the surgical expertise of the surgeon, it will be appropriate to determine which patient will be operated by which surgeon and which approach.