ZIRK-Technique: Zero Ischemia Resection in the Kidney for High-Risk Renal Masses: Perioperative Outcome

Abstract

Objectives: This study evaluates the feasibility and safety of open-partial nephrectomies in the ZIRK-technique (Zero Ischemia Resection in the Kidney) for renal masses with high-risk anatomical features - objectified by the PADUA score. Methods: We identified 40 consecutive cases of partial nephrectomies performed without clamping of the renal artery in our department of urology. Retrospective analysis of the preoperative CT or MRI scans showed 27 cases with a PADUA score ≥8, of which 15 cases had a score ≥10. Cases were in particular assessed regarding operation time (ORT), estimated blood loss (EBL), surgical margins and postoperative complications using the Clavien classification. Results: The mean age of the study population was 67.6 years with an average BMI of 26.8 kg/m². The mean ORT was 1:46 with an average EBL of 521 ml. Clavien grade II complications were observed seven times, while 3 patients had a grade IIIa complication. Despite complex and adverse location of the tumors, nephron-sparing surgery without ischemia could be performed with negative surgical margins for all cases. EBL, transfusion rate and complication were considerably more frequent in high-risk tumors. Conclusion: Highly complex renal tumors, PADUA ≥10, can be resected in ZIRK-technique with good operative outcome and a low complication rate.

Long-Term Outcome of Nephron-Sparing Surgery Compared to Radical Nephrectomy for Renal Cell Carcinoma ≥4 cm - A Matched-Pair Single Institution Analysis

“…This matches the findings of a large multicentre analysis from 2007 comprising >500 patients [26] . Although at our institution we exclusively work with temporary clamping of the renal artery and thus ischemia, off-clamp techniques have been successfully evaluated even for large and highrisk renal masses [24,27] whereas the choice for on-or off-clamp PN does not seem to affect postoperative outcomes [28] . Additionally, we have to declare limiting that we did not assess other elements affecting ischemia time additional to tumor size [28,29] in this study.…”

Tumor size and invasiveness matters for partial nephrectomy: External validation and modification of the arterial based complexity score

“…RPN was performed in a transperitoneal approach with the DaVinci® SI or XI system (from 2016) (Intuitive Surgical, CA) in lateral position. Resection of the tumor was either performed with clamping of the kidney vessels or in zero ischemia technique . A ureter stent or a nephrostomy tube was not inserted.…”

Glomerular Morphology and Renal Function after Warm Ischemia by Main Artery or Selective Clamping in a Porcine Model

“…Bleeding control during PN can be achieved in several ways [5][6][7] , but vascular clamping is still the most important maneuver used for this purpose [19] . Although renal ischemia improves the surgical field, it remains a concern as it represents the most frequent cause of acute and chronic renal failure [3,4] .…”