1. Ben Challacombe
Consultant Urologist & Senior Lecturer
Guy’s and St Thomas’ Hospitals, London
Tips to minimise warm ischaemia

3.  Why important?
 Time differences. 20 vs 30 vs more?
 Thompson RH et al ,Mayo Eur Urol. 2010.
 >25 mins cutoff
 Becker F et al. Eur Urol. <20 mins.
 Choi JD Eur Urol. 2010 28 mins
 In a single kidney porcine model the renal unit can
fully recover from WI times of up to 90 minutes.
 Laven BA et al. J Urol. 2004
Thompson RH et al ,Mayo Eur Urol. 2010. Every minute counts when the renal hilum is clamped during partial
nephrectomy.
Becker F et al. Eur Urol. Assessing the impact of ischaemia time during partial nephrectomy.
Choi JD Renal damage caused by warm ischaemia during laparoscopic and robot-assisted partial nephrectomy: an
assessment using Tc 99m-DTPA glomerular filtration rate. Eur Urol. 2010

4.  Bhayani SB. Robot-assisted partial
nephrectomy: evaluation of learning curve for
an experienced renal surgeon. J Endourol. 2010
 26 cases for WIT
 16 cases for OT
 Mottrie A, Ficarra V. Eur Urol. 2010. Impact of
the learning curve on perioperative outcomes
in patients who underwent robotic partial
nephrectomy for parenchymal renal tumours.
 30 for WIT, 20 for console time

5.  Full clamping until renorrhaphy complete
 Early unclamping
 Segmental vessel clamping
 “zero-ischaemia” RPN
 No clamping

6.  Aim for <20 mins from the start
 Team work vital
 Prior Preparation and Planning Prevents Poor
Performance
 Rehearse procedure
 Brief staff before clamping vessels
 Mannitol, frusemide, clamps, sutures, control room.
 Consider angles and directions of sutures
 Assistant to act semi- independently

8.  Needles inside before clamping
 Needles in correct direction of passage
 Deep scoring already done
 Posterior lip visible:
 Adequate mobilisation
 Scanlan clips
 Haemostatic agent ready
 Don't cut sutures or add 2nd clips until clamps
off
 Consider early unclamping after deep suture