Assessment of Warm and Cold Ischemia on Functions of the Operated Kidney with ^99mTc-DMSA in Renal Masses: A Prospective and Randomized Study

Abdullah Demirtas, Numan Baydilli, Nurettin Sahin, Oguz Ekmekcioglu, Deniz Demirci, Atila Tatlisen

Department of Urology, Medical Faculty, Erciyes University, Kayseri, Turkey.

DOI: 10.4236/oju.2013.32012                

Abstract

Objective: To examine the effect of warm and cold ischemia on functions of the operated kidney in cases with a normal contralateral kidney undergoing nephron sparing surgery. Methods: This study enrolled 40 patients with a normal contralateral kidney and without a renal function threatening risk factor, who were operated with NSS. The patients were randomized at admission. They were divided into 2 equal groups as warm and cold ischemia. An ice application for 10 minutes was done to cold ischemia group after clamping renal artery. Renal functions were evaluated with Technesium-99m-Dimercaptosuccinic Acid (DMSA) and serum creatinine at the preoperative and postoperative (day 1, day 15, month 6, and month 12) period. Statistical analysis was done with Mann Whitney U test, Wilcoxon Signed Rank test, and Fredman test. A p value below 0.05 was considered statistically significant. Results: There were no significant differences between the groups in terms of age, body mass index, ischemia time, tumor size, amount of hemorrhage, and procedure time. Both groups had a significantly higher DMSA uptake at the preoperative period compared with the postoperative period (postoperative day 1, day 15, month 6, and month 12) (p < 0.001). However, both groups had similar DMSA uptake results at the postoperative period. Preoperative and postoperative creatinine levels were not significantly different from each other in both groups. Conclusion: Based on tumor localization, nephron sparing surgery without use of superficial cooling appears as a viable option for small renal masses.

Keywords

Cold Ischemia Times; Nephron Sparing Surgery; Renal Cancer; Technetium-99m-Dimercaptosuccinic Acid; Warm Ischemia Times

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	R. G. Uzzo and A. C. Novick, “Nephron Sparing Surgery for Renal Tumors: Indications, Techniques and Outcomes,” The Journal of Urology, Vol. 166, No. 1, 2001, pp. 6-18. doi:10.1016/S0022-5347(05)66066-1
[2]	S. E. Lerner, C. A. Hawkins, M. L. Blute, et al., “Disease Outcome in Patients with Low Stage Renal Cell Carcinoma Treated with Nephron Sparing or Radical Surgery,” The Journal of Urology, Vol. 155, No. 6, 1996, pp. 1868-1873. doi:10.1016/S0022-5347(01)66032-4
[3]	S. Pahernik, F. Roos, C. Hampel, et al., “Nephron Sparing Surgery for Renal Cell Carcinoma With Normal Contralateral Kidney: 25 Years of Experience,” The Journal of Urology, Vol. 175, No. 6, 2006, pp. 2027-2031. doi:10.1016/S0022-5347(06)00271-0
[4]	A. Finelli and I. Gill, “Laparoscopic Partial Nephrectomy, in Rosette JMCH and Gill I: Laparoscopic Urologic Surgery in Malignancies,” Springer, Berlin, 2005, pp. 49-57. doi:10.1007/3-540-27606-8_6
[5]	S. Kaul, R. Laungani, R. Sarle, et al., “Da Vinci-Assisted Robotic Partial Nephrectomy: Technique and Results at a Mean of 15 Months of Follow-Up,” European Urology, Vol. 51, No. 1, 2007, pp. 186-191. doi:10.1016/j.eururo.2006.06.002
[6]	A. Taylor Jr., “Quantitation of Renal Function with Static Imaging Agents,” Seminars in Nuclear Medicine, Vol. 12, No. 4, 1982, pp. 330-344. doi:10.1016/S0001-2998(82)80014-7
[7]	H. W. Herr, “A History of Partial Nephrectomy for Renal Tumors,” The Journal of Urology, Vol. 173, No. 3, 2005, pp. 705-708. doi:10.1097/01.ju.0000146270.65101.1d
[8]	W. K. Lau, M. L. Blute, A. L. Weaver, et al., “Matched Comparison of Radical Nephrectomy vs Nephron-Sparing Surgery in Patients with Unilateral Renal Cell Carcinoma and a Normal Contralateral Kidney,” Mayo Clinic Proceedings, Vol. 75, No. 12, 2000, pp. 1236-1242. doi:10.4065/75.12.1236
[9]	M. Mullerad, A. Kastin, E. Issaq, et al., “The Value of Quantitative 99m Technetium Dimercaptosuccinic Acid Renal Scintigraphy for Predicting Postoperative Renal Insufficiency in Patients Undergoing Nephrectomy,” The Journal of Urology, Vol. 169, No. 1, 2003, pp. 24-27. doi:10.1016/S0022-5347(05)64026-8
[10]	F. L. Grene and I. D. Fleming, “AJCC Cancer Staging Handbook from the AJCC Cancer Staging Manual,” 6nd Edition, Lippinchott, Philadelphia, 2002, pp. 355-360.
[11]	B. A. Laven, M. A. Orvieto, M. S. Chuang, et al., “Renal Tolerance to Prolonged Warm Ischemia Time in a Laparoscopic versus Open Surgery Porcine Model,” The Journal of Urology, Vol. 172, No. 6, 2004, pp. 2471-2474. doi:10.1097/01.ju.0000138158.16968.8d
[12]	A. C. Novick, “Renal Hypothermia: In Vivo and ex Vivo,” The Urologic Clinics of North America, Vol. 10, 1983, pp. 637-644.
[13]	R. H. Thompson, B. R. Lane, C. M. Lohse, et al., “Every Minute Counts When the Renal Hilum Is Clamped during Partial Nephrectomy,” European Urology, Vol. 58, 2010, pp. 340-345. doi:10.1016/j.eururo.2010.05.047
[14]	B. R. Lane, P. Russo, R. G. Uzzo, et al., “Comparison of Cold and Warm Ischemia during Partial Nephrectomy in 660 Solitary Kidneys Reveals Predominant Role of Nonmodifiable Factors in Determining Ultimate Renal Function,” The Journal of Urology, Vol. 185, No. 3, 2011, pp. 421-427. doi:10.1016/j.juro.2010.09.131
[15]	G. S. Sandhu, E. H. Kim, Y. S. Tanagho, et al., “RobotAssisted Partial Nephrectomy: Off-Clamp Technique,” Journal of Endourology, Vol. 27, No. 1, 2013, pp. 4-7. doi:10.1089/end.2012.0170
[16]	I. S. Gill, M. M. Desai, J. H. Kaouk, et al., “Laparoscopic partial Nephrectomy for Renal Tumor: Duplicating Open Surgical Techniques,” The Journal of Urology, Vol. 167, No. 2, 2002, pp. 475-476. doi:10.1016/S0022-5347(01)69066-9
[17]	J. S. Wolf, Jr., B. D. Seifman and J. E. Montie, “Nephron Sparing Surgery for Suspected Malignancy: Open Surgery Compared to Laparoscopy with Selective Use of Hand Assistance,” The Journal of Urology, Vol. 163, No. 6, 2000, pp. 1659-1664. doi:10.1016/S0022-5347(05)67515-5
[18]	H. Bakirtas, M. Eroglu, S. Naldoken, et al., “NephronSparing Surgery: The Effect of Surface Cooling and Temporary Renal Artery Occlusion on Renal Function,” Urology International, Vol. 82, 2009, pp. 24-27. doi:10.1159/000176020
[19]	T. Kondo, H. Nakazawa, F. Ito, et al., “Impact of Arterial Occlusion during Partial Nephrectomy on Residual Renal Function: An Evaluation with (99m) Technetium-Dimercaptosuccinic Acid Scintigraphy,” International Journal of Urology, Vol. 9, No. 8, 2002, pp. 435-440. doi:10.1046/j.1442-2042.2002.00498.x