Carmine Del Rossi Department of Pediatric Surgery, Azienda Ospedaliera, Parma, Italy Giovanni Mosiello* Department of Urodynamics and Neuro-Urology, Ospedale Pediatrico Bambino Gesu’ Rome, Italy Anna Attanasio Department of Anesthesiology, Istituto Europeo Oncologico, Milan, Italy Simone Del Curto Department of Anesthesiology, Ospedale Civile, Sondrio, Italy Roberto De Castro Department of Pediatric Surgery, Ospedale Maggiore, Bologna, Italy *Corresponding author. Department of Urodynamics and Neuro-Urology, Ospedale Pediatrico Bambino Gesu `, Piazza S. Onofrio 4, 00165 Roma, Italy. Tel. +399 06 68592299; Fax: +39 06 68592839 E-mail address: mosiello@opbg.net (A. Mosiello) November 5, 2007 Published online ahead of print on November 20, 2007 doi:10.1016/j.eururo.2007.11.014 DOI of original article: 10.1016/j.eururo.2007.07.001 Re: Gu ¨ nter Janetschek. Laparoscopic Partial Nephrectomy for RCC: How Can We Avoid Ischemic Damage of the Renal Parenchyma? Eur Urol 2007;52:1303–5 The major drawback of laparoscopic partial nephrectomy (LPN) is the control of bleeding and, moreover, the certainty of performing a tumour dissection under vision allows the surgeon to follow oncologically correct procedures. We agree with the author about the management of small renal tumours; probably arterial (and renal parenchyma) clamping is not necessary. Several technical modifications have been cited in the editorial, such as ice slush renal hypothermia, renal hypothermia achieved by retrograde intraca- vitary saline perfusion, and renal parenchyma clamps. All these technical modifications can have an impact on postoperative renal function, con- sidering that these techniques require a vascular or a renal parenchyma clamp and ischaemia times can be >30 min, specially for non-expert surgeons. We recently reported our experience of LPNs performed in 50 patients preoperatively treated by superselective arterial embolisation. Operative data and midterm oncologic data seemed to be compar- able to those of open partial nephrectomy series [1]. This technique, currently performed 2–5 h before LPN, allows us to have preoperatively exact infor- mation about the excretory path involvement thanks to arteriography that is the first step of embolisation. In addition, the ischaemic area after the procedure can be visualised thanks to a white line that marks the ischaemic area and makes it easier to avoid a positive surgical margin (0% in our series). Mean blood loss was 200 ml. Reduced intraoperative bleeding can have a double impact on the surgical procedure; the surgeon can work safely because a quick procedure is not necessary if bleeding is controlled and renal vessels are not clamped and perfect vision of the mass allows the surgeon to perform a good dissection respecting oncologic principles. Cost analysis evaluation (presented at 24th Con- gress of Endourology, Cleveland, OH, USA) demon- strated good results because of reduced blood loss (no patient needed transfusion in the series), shorter hospitalisation (average 3 d in the last year), and reduced operating times (average 45 min in the last year). Preliminary results of our series seemed encoura- ging regarding preservation of renal function (no kidney functionally excluded, filtration rates reduc- tion of treated kidney ranged from 5 to 25%). In our experience, small (<3 cm) and peripheral tumours can be managed by laparoscopy without using clamps and without performing preoperative superselective arterial embolisation. Tumours >3 cm and not peripheral tumours can be treated by open surgery or by LPN after arterial embolisation. In any of these cases, we perform vessel or parenchyma clamping in order to optimise renal function preservation. We believe that LPN can be considered a standard treatment for small peripheral tumours in centres where laparoscopy is the standard access to the kidney. Renal tumours >3 cm, or not peripheral, require surgical expertise and perhaps some technical modifications to gain best results. european urology 53 (2008) 1301–1307 1302