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

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 center dot 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 center dot 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. center dot Only cases using CPBP were analysed. Clinicopathological and operative characteristics including use of DHCA were recorded. center dot 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. center dot A Cox regression model determined predictors of perioperative/in-hospital mortality. RESULTS center dot In all, 63 patients underwent resection with CPBP; overall perioperative mortality was 22.2%. center dot There were no significant differences in clinicopathological characteristics, operative duration, estimated blood loss, transfusions, and hospital stay by use of DHCA. center dot Perioperative mortality rate was lower in patients undergoing DHCA (8.3% vs 37.5%, P = 0.006). center dot 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). center dot 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 center dot Radical nephrectomy and level IV tumour thrombectomy is associated with significant mortality. center dot The use of DHCA does not appear to adversely affect operative characteristics and may limit perioperative mortality. center dot Further prospective studies should be performed to confirm the benefit of DHCA.