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


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.
Shuch
Brian
B
Departments of Urology and Biostatistics, University of CaliforniaDepartment of Urology, University of Southern Califormia, Los Angeles, CAMayo Clinic Department of Urology, Rochester, MN, USADepartment of Urology, RennesDepartment of Urology, Nantes, France.
Crispen
Paul L
PL
Departments of Urology and Biostatistics, University of CaliforniaDepartment of Urology, University of Southern Califormia, Los Angeles, CAMayo Clinic Department of Urology, Rochester, MN, USADepartment of Urology, RennesDepartment of Urology, Nantes, France.
Leibovich
Bradley C
BC
Departments of Urology and Biostatistics, University of CaliforniaDepartment of Urology, University of Southern Califormia, Los Angeles, CAMayo Clinic Department of Urology, Rochester, MN, USADepartment of Urology, RennesDepartment of Urology, Nantes, France.
LaRochelle
Jeff C
JC
Departments of Urology and Biostatistics, University of CaliforniaDepartment of Urology, University of Southern Califormia, Los Angeles, CAMayo Clinic Department of Urology, Rochester, MN, USADepartment of Urology, RennesDepartment of Urology, Nantes, France.
Pouliot
Frederic
F
Departments of Urology and Biostatistics, University of CaliforniaDepartment of Urology, University of Southern Califormia, Los Angeles, CAMayo Clinic Department of Urology, Rochester, MN, USADepartment of Urology, RennesDepartment of Urology, Nantes, France.
Pantuck
Allan J
AJ
Departments of Urology and Biostatistics, University of CaliforniaDepartment of Urology, University of Southern Califormia, Los Angeles, CAMayo Clinic Department of Urology, Rochester, MN, USADepartment of Urology, RennesDepartment of Urology, Nantes, France.
Liu
Weiqing
W
Departments of Urology and Biostatistics, University of CaliforniaDepartment of Urology, University of Southern Califormia, Los Angeles, CAMayo Clinic Department of Urology, Rochester, MN, USADepartment of Urology, RennesDepartment of Urology, Nantes, France.
Crepel
Maxime
M
Departments of Urology and Biostatistics, University of CaliforniaDepartment of Urology, University of Southern Califormia, Los Angeles, CAMayo Clinic Department of Urology, Rochester, MN, USADepartment of Urology, RennesDepartment of Urology, Nantes, France.
Schuckman
Anne
A
Departments of Urology and Biostatistics, University of CaliforniaDepartment of Urology, University of Southern Califormia, Los Angeles, CAMayo Clinic Department of Urology, Rochester, MN, USADepartment of Urology, RennesDepartment of Urology, Nantes, France.
Rigaud
Jerome
J
Departments of Urology and Biostatistics, University of CaliforniaDepartment of Urology, University of Southern Califormia, Los Angeles, CAMayo Clinic Department of Urology, Rochester, MN, USADepartment of Urology, RennesDepartment of Urology, Nantes, France.
Bouchot
Oliver
O
Departments of Urology and Biostatistics, University of CaliforniaDepartment of Urology, University of Southern Califormia, Los Angeles, CAMayo Clinic Department of Urology, Rochester, MN, USADepartment of Urology, RennesDepartment of Urology, Nantes, France.
Patard
Jean-Jacques
JJ
Departments of Urology and Biostatistics, University of CaliforniaDepartment of Urology, University of Southern Califormia, Los Angeles, CAMayo Clinic Department of Urology, Rochester, MN, USADepartment of Urology, RennesDepartment of Urology, Nantes, France.
Skinner
Donald
D
Departments of Urology and Biostatistics, University of CaliforniaDepartment of Urology, University of Southern Califormia, Los Angeles, CAMayo Clinic Department of Urology, Rochester, MN, USADepartment of Urology, RennesDepartment of Urology, Nantes, France.
Belldegrun
Arie S
AS
Departments of Urology and Biostatistics, University of CaliforniaDepartment of Urology, University of Southern Califormia, Los Angeles, CAMayo Clinic Department of Urology, Rochester, MN, USADepartment of Urology, RennesDepartment of Urology, Nantes, France.
Blute
Michael L
ML
Departments of Urology and Biostatistics, University of CaliforniaDepartment of Urology, University of Southern Califormia, Los Angeles, CAMayo Clinic Department of Urology, Rochester, MN, USADepartment of Urology, RennesDepartment of Urology, Nantes, France.
D000368:Aged; D002292:Carcinoma, Renal Cell / Q000150:complications / Q000401:mortality / Q000601:surgery*; D002315:Cardiopulmonary Bypass; D050792:Circulatory Arrest, Deep Hypothermia Induced; D004812:Epidemiologic Methods; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007680:Kidney Neoplasms / Q000150:complications / Q000401:mortality / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000379:methods / Q000401:mortality*; D019990:Perioperative Care / Q000401:mortality*; D017131:Thrombectomy / Q000379:methods / Q000401:mortality*; D013927:Thrombosis / Q000150:complications / Q000401:mortality / Q000601:surgery*