Cardiopulmonary bypass and renal cell carcinoma with level IV tumour thrombus: can deep hypothermic circulatory arrest limit perioperative mortality?

Abstract

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Removal of a renal cell carcinoma with a level IV tumour thrombus is a challenging surgery and generally is performed in a tertiary care centre. Performing these cases generally requires a multi‐disciplinary approach consisting of urological and vascular/cardiovascular surgeons. This study sheds light on the high surgical morbidity and mortality of these cases even at experienced centres. For patients requiring cardiopulmonary bypass, approximately 20% may not survive. In these challenging surgeries, deep hypothermic circulatory arrest may limit mortality and further studies should investigate the protective effect of this modality. OBJECTIVE • To review experience with nephrectomy/thrombectomy for a renal cell carcimoma (RCC) with a level IV tumour thrombus and to evaluate the benefit of deep hypothermic circulatory arrest (DHCA) with cardiopulmonary bypass (CPBP). PATIENTS AND METHODS • A multi‐institutional retrospective database was created to assess the outcomes of surgery for RCC and associated level IV tumour thrombus from 1983 to 2007. Patients were identified based on radiographic records/operative findings. • Only cases using CPBP were analysed. Clinicopathological and operative characteristics including use of DHCA were recorded. • Overall survival (OS) for all patients and by use of DHCA was assessed. Comparisons of clinical and operative characteristics by use of DHCA were performed. • A Cox regression model determined predictors of perioperative/in‐hospital mortality. RESULTS • In all, 63 patients underwent resection with CPBP; overall perioperative mortality was 22.2%. • There were no significant differences in clinicopathological characteristics, operative duration, estimated blood loss, transfusions, and hospital stay by use of DHCA. • Perioperative mortality rate was lower in patients undergoing DHCA (8.3% vs 37.5%, P = 0.006). • The median OS was longer for the patients undergoing DHCA (15.8 vs 7.7 months); however, this failed to reach statistical significance ( P = 0.357). • On multivariate analysis, age of >60 years (hazard ratio [HR] 6.7, 95% confidence interval [CI] 1.5–31.1, P = 0.015) and the use of DHCA (HR 0.13, 95% CI 0.036–0.51, P = 0.003) were independent predictors of perioperative mortality. CONCLUSIONS • Radical nephrectomy and level IV tumour thrombectomy is associated with significant mortality. • The use of DHCA does not appear to adversely affect operative characteristics and may limit perioperative mortality. • Further prospective studies should be performed to confirm the benefit of DHCA.