Cardiopulmonary bypass and renal cell carcinoma with level IV tumour thrombus

Can deep hypothermic circulatory arrest limit perioperative mortality?

Brian Shuch, Paul L. Crispen, Bradley C. Leibovich, Jeff C. Larochelle, Frederic Pouliot, Allan J. Pantuck, Weiqing Liu, Maxime Crepel, Anne Schuckman, Jerome Rigaud, Oliver Bouchot, Jean Jacques Patard, Donald Skinner, Arie S. Belldegrun, Michael L. Blute

Research output: Contribution to journalArticle

33 Citations (Scopus)

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.

Original languageEnglish (US)
Pages (from-to)724-738
Number of pages15
JournalBJU International
Volume107
Issue number5
DOIs
StatePublished - Mar 2011
Externally publishedYes

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Deep Hypothermia Induced Circulatory Arrest
Cardiopulmonary Bypass
Renal Cell Carcinoma
Thrombosis
Mortality
Neoplasms
Thrombectomy
Nephrectomy
Confidence Intervals
Kidney
Survival
Hospital Mortality
Proportional Hazards Models
Tertiary Care Centers
Blood Transfusion
Blood Vessels
Length of Stay

Keywords

  • bypass
  • nephrectomy
  • RCC
  • thrombectomy
  • tumour thrombus

ASJC Scopus subject areas

  • Urology

Cite this

Cardiopulmonary bypass and renal cell carcinoma with level IV tumour thrombus : Can deep hypothermic circulatory arrest limit perioperative mortality? / Shuch, Brian; Crispen, Paul L.; Leibovich, Bradley C.; Larochelle, Jeff C.; Pouliot, Frederic; Pantuck, Allan J.; Liu, Weiqing; Crepel, Maxime; Schuckman, Anne; Rigaud, Jerome; Bouchot, Oliver; Patard, Jean Jacques; Skinner, Donald; Belldegrun, Arie S.; Blute, Michael L.

In: BJU International, Vol. 107, No. 5, 03.2011, p. 724-738.

Research output: Contribution to journalArticle

Shuch, B, Crispen, PL, Leibovich, BC, Larochelle, JC, Pouliot, F, Pantuck, AJ, Liu, W, Crepel, M, Schuckman, A, Rigaud, J, Bouchot, O, Patard, JJ, Skinner, D, Belldegrun, AS & Blute, ML 2011, 'Cardiopulmonary bypass and renal cell carcinoma with level IV tumour thrombus: Can deep hypothermic circulatory arrest limit perioperative mortality?', BJU International, vol. 107, no. 5, pp. 724-738. https://doi.org/10.1111/j.1464-410X.2010.09488.x
Shuch, Brian ; Crispen, Paul L. ; Leibovich, Bradley C. ; Larochelle, Jeff C. ; Pouliot, Frederic ; Pantuck, Allan J. ; Liu, Weiqing ; Crepel, Maxime ; Schuckman, Anne ; Rigaud, Jerome ; Bouchot, Oliver ; Patard, Jean Jacques ; Skinner, Donald ; Belldegrun, Arie S. ; Blute, Michael L. / Cardiopulmonary bypass and renal cell carcinoma with level IV tumour thrombus : Can deep hypothermic circulatory arrest limit perioperative mortality?. In: BJU International. 2011 ; Vol. 107, No. 5. pp. 724-738.
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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.",
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T2 - Can deep hypothermic circulatory arrest limit perioperative mortality?

AU - Shuch, Brian

AU - Crispen, Paul L.

AU - Leibovich, Bradley C.

AU - Larochelle, Jeff C.

AU - Pouliot, Frederic

AU - Pantuck, Allan J.

AU - Liu, Weiqing

AU - Crepel, Maxime

AU - Schuckman, Anne

AU - Rigaud, Jerome

AU - Bouchot, Oliver

AU - Patard, Jean Jacques

AU - Skinner, Donald

AU - Belldegrun, Arie S.

AU - Blute, Michael L.

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Y1 - 2011/3

N2 - 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.

AB - 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.

KW - bypass

KW - nephrectomy

KW - RCC

KW - thrombectomy

KW - tumour thrombus

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