Zero-ischemia minimally invasive partial nephrectomy

In the last decade, many authors reported single center experiences of "off-clamp", "clamp-less", or "unclamped" minimally invasive partial nephrectomy (MIPN). These procedures, despite the potential risk of increased intraoperative blood loss, attempted to minimize the loss of renal function by eliminating ischemic renal injury. "Zero ischemia" MIPN has emerged as new treatment option in 2011, initially performed under controlled hypotension, and later mainly by performing a "superselective microdissection". The former technique minimizes the arterial bleeding from the renal stump, allowing surgeon to dissect the tumor in a bloodless field; the latter consists of identifying, antegradely from the renal hilum, the tertiary and quaternary arterial branches directly supplying the kidney neoplasm, and then selectively controlling them before dissecting the renal mass. This review critically analyzes these techniques, focusing on perioperative, oncologic and functional outcomes.