Introduction: The objective is to determine the clinical and experimental evidences of the renal responses to warm and cold ischemia, kidney tolerability, and available practical techniques of protecting the kidney during nephron-sparing surgery.
Materials and methods: Review of the English and non-English literature using MEDLINE, MD Consult, and urology textbooks.
Results and discussion: There are three main mechanisms of ischemic renal injury, including persistent vasoconstriction with an abnormal endothelial cell compensatory response, tubular obstruction with backflow of urine, and reperfusion injury. Controversy persists on the maximal kidney tolerability to warm ischemia (WI), which can be influenced by surgical technique, patient age, presence of collateral vascularization, indemnity of the arterial bed, and so forth.
Conclusions: When WI time is expected to exceed from 20 to 30 minutes, especially in patients whose baseline medical characteristics put them at potentially higher, though unproven, risks of ischemic damage, local renal hypothermia should be used.