Journal of Vascular Surgery
Volume 38, Issue 3 , Pages 446-450, September 2003

Concomitant intraoperative renal artery embolization and resection of complex renal carcinoma☆

Presented at the Twenty-seventh Annual Meeting of the Southern Association for Vascular Surgery, Tucson, Ariz, Jan 15-18, 2003.

  • Peter H Lin, MD

      Affiliations

    • Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine,, Houston, Tex, USA
    • Corresponding Author InformationReprint requests: Peter H. Lin, MD, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston VAMC (112), 2002 Holcomb Blvd, Houston, TX 77030, USA
    • ,
  • Thomas T Terramani, MD

      Affiliations

    • Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine,, Houston, Tex, USA
    • ,
  • Ruth L Bush, MD

      Affiliations

    • Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine,, Houston, Tex, USA
    • ,
  • Thomas E Keane, MD

      Affiliations

    • Department of Urology, Emory University School of Medicine,, Atlanta, Ga, USA
    • ,
  • Robert G Moore, MD

      Affiliations

    • Department of Urology, Baylor College of Medicine., Houston, Tex USA
    • ,
  • Alan B Lumsden, MD

      Affiliations

    • Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine,, Houston, Tex, USA

Received 30 January 2003; accepted 9 March 2003.

Article Outline

Abstract 

Background

Renal cell carcinoma, which has the propensity for rapid enlargement and local invasion, may present a surgical challenge, in part because of extensive vascularity. Conventional treatment typically involves staged preoperative renal artery embolization followed by nephrectomy after 1 or 2 days. We evaluated the clinical outcome of concomitant intraoperative embolization and nephrectomy.

Methods

Over 7 years, eight patients with renal cell carcinoma underwent combined intraoperative renal artery coil embolization and nephrectomy. A cohort of 14 patients who underwent staged renal embolization and nephrectomy during the same period served as the control group. Renal tumor embolization was achieved via percutaneous femoral artery approach, followed by coil placement in the distal portion of the main renal artery. Complete renal artery embolization was confirmed with intraoperative angiography. Nephrectomy was performed either concomitantly or after renal artery embolization, dependent on treatment group. Intraoperative data, clinical outcome, and hospital cost were compared between the two groups.

Results

Renal artery embolization and nephrectomy were successfully performed in all patients. There was no perioperative mortality. Mean hospital length of stay in the combined and staged treatment groups was 5.6 ± 1.3 days and 10.2 ± 3.2 days, respectively. Post-infarction syndrome developed in four patients (36%) in the staged group, compared with no patients in the combined treatment group. Decreased room cost and radiology cost was noted in the combined treatment group compared with the staged group. Mean total hospital cost was significantly less in patients who underwent the combined treatment compared with the staged treatment approach (mean difference, $9214; P = .02) During mean follow-up of 36 months, six patients (27%) died of unrelated causes. There was no evidence of tumor recurrence in surviving patients.

Discussion

In patients with renal cell carcinoma, combined renal embolization and nephrectomy minimizes patient discomfort and post-infarction syndrome associated with traditional staged treatment. Moreover, it is associated with reduced hospital costs, due in part to decreased hospital length of stay. Vascular surgeons with endovascular skills are well suited to perform intraoperative renal artery embolization. Use of adjunctive endovascular techniques to facilitate large open procedures is a growing role for the endovascular-competent vascular surgeon.

 

Renal cell carcinoma has the propensity to enlarge rapidly and disseminate locally, which frequently results in a highly vascular tumor with local structural invasion. Patients with renal cell carcinoma often have gross hematuria, flank pain, and palpable abdominal mass.1 As many as 20% of patients with primary renal cell carcinoma have some degree of tumor thrombus extending into the renal pelvis, inferior vena cava, and even the hepatic veins.2, 3 Although nephrectomy is the only curative therapy, as well as the treatment of choice, for primary renal cell carcinoma, surgical treatment can present a daunting challenge, because of intraoperative hemorrhage associated with excision of such highly vascular and locally invasive tumors.

In an effort to improve treatment of renal cell carcinoma, Almgard et al,4 in 1973, proposed transarterial renal embolization as a means to induce kidney necrosis. Since then, this has become an accepted form of treatment of advanced or unresectable renal cell tumors with persistent bleeding or manifestations of paraneoplastic syndrome. Moreover, this treatment has become an accepted preoperative adjunct to nephrectomy. Although the predominant benefit of preoperative renal embolization is reduction of operative blood loss associated with nephrectomy,5 it also decreases vena cava tumor size and creates an easier dissection plane as a result of tissue edema.6, 7, 8, 9

Preoperative renal embolization to treat renal cell carcinoma is typically performed by interventional radiologists, using intravenous sedation, 1 or 2 days before nephrectomy. Because of renal infarction as a result of embolization, patients often have severe flank pain and fever after the procedure.6 In addition, staged treatment often creates added emotional anxiety for patients and families.6 We report a combined treatment approach to renal cell carcinoma, consisting of intraoperative renal embolization performed by a vascular surgeon and nephrectomy performed by a urologist. The purpose of this study was to evaluate our experience and the clinical outcome of combined treatment compared with traditional staged treatment.

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Material and methods 

Eight patients (mean age, 63 ± 5 years) with primary renal cell carcinoma underwent combined intraoperative renal artery embolization and nephrectomy between March 1995 and November 2002. Preoperative computed tomography (CT) scans of the abdomen demonstrated evidence of tumor extension into the inferior vena cava in two patients (25%) and retrohepatic vein in two patients (25%). For purposes of comparison, data for the eight patients (combined treatment group) were compared with data for a cohort group of 14 patients (staged treatment group) with primary renal cell carcinoma who underwent staged renal artery embolization and nephrectomy during the study period. Patient demographic data, intraoperative parameters, and clinical outcome were compared between the two groups (Table I). Hospital cost data, rather than hospital charges, were assessed by directly obtaining pertinent information from the hospital accounting department. Hospital cost for each category of expenditure for the two groups of patients also was compared (Table II). Statistical analysis was performed with the Student t test and the Fisher exact test, with a computer statistical software program (SAS Institute, Cary, NC). Test results were considered significant at P < .05.

Table I. Patient demographic data and treatment outcome
VariableCombined treatment group (n = 8)Staged treatment group (n = 14)P
Mean age (y)63 ± 568 ± 7.52
Male gender6 (75)11 (79).48
Mean tumor size (cm)7.6 ± 1.97.9 ± 2.2.39
Caval tumor involvement2 (25)4 (29).37
Hepatic vein involvement2 (25)1 (7).21
Mean operative blood loss (mL)320 ± 200410 ± 260.38
Mean operative time (min)260 ± 170230 ± 190.59
Mean hospital stay (d)5.6 ± 1.310.2 ± 3.2.02
Mean ICU stay (d)0.5 ± 0.61.1 ± 0.8.38
Postinfarction syndrome05 (36).03
Postoperative renal insufficiency01 (7).42

Numbers in parentheses are percent.

Table II. Comparison of hospital costs
Mean hospital cost per patientCombined treatment group (n = 8)Staged treatment group (n = 14)P
Operating room$3652 ± $1525$3158 ± $952.23
Room$4652 ± $1025$9832 ± $1952<.01
Radiology$952 ± $452$3250 ± $952<.02
Other$865 ± $336$1235 ± $419.08

For the purpose of cost analysis, four categories of expenditure encompassing all inpatient hospital costs were defined, as follows: operating room cost, which included operating room time, anesthesia time, equipment, operating room nursing, and recovery room; room cost, which included regular floor, telemetry bed, and intensive care unit; radiology cost, which included all diagnostic or therapeutic procedures, such as renal artery embolization, plus plain radiography, ultrasound scanning, and other diagnostic imaging; other costs, which included pharmacy, transfusion, and laboratory services.

Renal artery embolization 

Patients who underwent combined renal artery embolization and nephrectomy were placed supine in the operating room, and the renal artery embolization procedure was performed first. After administration of general anesthesia via orotracheal intubation, renal artery embolization was performed by the vascular surgeon. All embolization procedures were performed with a 12-inch digital C-arm fluoroscopy unit (Series 9600, 9800; OEC Medical Systems, Salt Lake City, Utah). A fluoroscopy operating table (Apix; OEC Medical Systems) was used in all cases. The contralateral femoral artery (opposite the renal cell carcinoma) was accessed percutaneously, followed by placement of a 7F introducer sheath (Meditech/Boston Scientific, Natick, Mass). After placement of a pigtail catheter (Meditech) over a 0.035-inch Bentson guide wire (Meditech), an aortogram was obtained to identify the renal artery feeding the renal cell carcinoma. A renal double-curve catheter (RDC; Meditech) was placed over a 0.035-inch Bentson guide wire to cannulate the renal artery. Then the double-curve catheter was removed. A 7F multipurpose guiding catheter (Meditech) was placed over the Bentson guide wire and positioned in the proximal renal artery. The double-curve catheter was inserted into the renal artery through the guiding catheter, and coils (Tornado; Cook, Bloomington, Ind) ranging in size from 3 to 5 mm were inserted in the distal portion of the main renal artery. A completion renal angiogram was obtained, using the guiding catheter, to demonstrate total occlusion of the renal artery by the coils. Next the guiding catheter was removed from the introducer sheath. The sheath was left in place in the groin during nephrectomy, and was removed after completion of the operation.

Nephrectomy 

In patients who underwent the combined approach, nephrectomy was performed immediately after renal embolization. This was accomplished via midline abdominal incision with retroperitoneal dissection. The renal vein was first ligated before nephrectomy, to minimize manipulation or propagation of tumor thrombus into the systemic venous circulation. The renal cell carcinoma, including the Gerota fascia, was completely excised in all six patients. Adrenalectomy was performed in one patient in whom the tumor had extended to the adrenal gland, as seen on the preoperative abdominal CT scan. All involved lymph nodes were removed adjacent to the renal hilum or the aorta. For patients who underwent staged treatment, mean duration between renal embolization and nephrectomy was 3.3 ± 1.2 days (range, 1-5 days).

All patients received intravenous antibiotic before and after nephrectomy. Narcotic analgesics with morphine were provided as needed, in the form of patient-controlled analgesia. Data relating to follow-up visits were evaluated. Mean follow-up was 36.6 months (range, 5-86 months).

Results 

The renal cell tumor was successfully resected in all patients. Renal artery embolization was also successfully performed in both the combined and staged treatment groups. Comparison of clinical variables between the two groups demonstrated increased length of hospital stay in the staged treatment group compared with the combined treatment group (5.6 ± 1.3 days vs 10.2 ± 3.2 days; P = .02; Table I). Post-infarction syndrome did not develop in any patients in the combined treatment group, but in four patients in the staged treatment group (P = .03; Table I). Operative time in the combined treatment group was longer than in the staged treatment group, but the difference did not reach statistical significance (Table I). Intraoperative autologous red blood cell transfusion was necessary in only one patient (13%) in the combined treatment group, who received 2 units of blood. There was no perioperative mortality in either group. Mean volume of contrast medium used in the combined treatment group was 20 mL, compared with 25 mL in the staged treatment group (difference not significant). Two patients (25%) in the combined treatment group underwent caval reconstruction with interposition polytetrafluoroethylene (PTFE) grafts (W. L. Gore & Associates, Flagstaff, Ariz), with assistance from a vascular surgeon after caval tumor thrombectomy. In contrast, concomitant caval reconstruction was necessary in four patients (29%) in the staged treatment group. One patient (13%) in the combined treatment group had to return to the operating room for repeat exploration, because of persistent hypotension and significant reduction in postoperative hematocrit. Repeat exploration revealed hemorrhage from a branch of the adrenal vein that was not adequately suture ligated at the initial operation. There were no other operative complications in the remaining patients. No patient in the combined treatment group had postoperative renal dysfunction, defined as serum creatinine concentration greater than 15% of baseline. In contrast, one patient (7%) in the staged treatment group had postoperative renal insufficiency. During follow-up three patients died of myocardial infarction, one patient died of osteomyelitis 3 years later, and two patients died of Alzheimer disease. There was no evidence of tumor recurrence in surviving patients in either group.

Comparison of hospital costs in four categories of expenditure revealed significantly increased room cost and radiology cost in the staged treatment group compared with the combined treatment group (Table II). Although the combined treatment group had slightly higher operating room cost and lower cost in the other expenditures category, these costs were not significantly different compared with those in the staged treatment group. Last, mean total hospital cost was significantly lower in the combined treatment group compared with the staged treatment group (mean cost difference, $9214; P = .02)

Discussion 

Renal artery embolization in treatment of renal cell carcinoma has become widely accepted since it was introduced nearly three decades ago.4 Craven et al9 in 1991 reported its use as a temporizing measure to minimize operative bleeding or to improve clinical status until delayed nephrectomy was performed. Since then, several clinical studies have shown that preoperative renal embolization significantly reduces blood loss during nephrectomy, especially in large hypervascular tumors.5, 7, 8, 10

Renal artery embolization is traditionally performed by an interventional radiologist. In this percutaneous procedure, the patient undergoes selective catheterization of the renal artery via the groin, followed by catheter-directed placement of embolic materials, such as alcohol or coils, to induce renal tumor infarction. Staged nephrectomy typically is performed several days later by a urologist. A major concern with the staged approach is post-infarction syndrome, characterized by flank pain lasting 24 to 48 hours, nausea, vomiting, ileus, fever, and leukocytosis associated with negative urine and blood cultures.11 The syndrome is caused by acute infarction of a large parenchymal organ, and has also been noted after nonrenal embolization, such as in the spleen.12

Combined intraoperative renal artery embolization and nephrectomy is a new treatment approach to renal cell carcinoma. Rather than an interventional radiologist performing the initial renal embolization, a vascular surgeon performs intraoperative renal embolization concomitant with nephrectomy, performed by a urologist. The catheter-based skills required to perform intraoperative renal artery embolization encompass the basic endovascular techniques that many vascular surgeons routinely use in their practice. The technical aspect of renal artery catheterization for embolization mirrors that of renal artery stent placement. Catheter-directed coil placement in the renal artery is also similar to hypogastric artery embolization performed in endovascular aortoiliac aneurysm repair. The mobile C-arm unit and fluoroscopic operating table used in this procedure are the identical equipment most vascular surgeons use when performing endovascular procedures in the operating room.

The combined treatment approach has several advantages over traditional staged treatment. First, renal artery embolization and nephrectomy are coordinated by the vascular surgeon and urologist; thus the patient receives one general anesthetic for two planned procedures. This provides the benefit of minimizing the undue emotional strain and mental anxiety associated with two procedures performed separately in the radiology suite and operating room. We previously described our experience of concomitant inferior vena cava filter placement in patients undergoing major orthopedic procedures, and noted that patients experienced less anxiety when two procedures are performed jointly under the same general anesthetic rather than performed separately in the radiology suite and operating room.13 Second, because nephrectomy is performed immediately after renal embolization, the possibility of post-infarction syndrome is averted. Patients are not subjected to the physical pain and emotional distress associated with tumor infarction. Abscess formation or sepsis may occur after tumor embolization performed before nephrectomy, particularly in patients with indwelling nephrostomy tubes because of obstructing renal cell carcinoma.14 Weckermann et al11 showed that if nephrectomy is performed more than 4 days after renal artery embolization, emphysematous pyelonephritis may occur, as evidenced by intrarenal gas formation on the abdominal CT scan. In this circumstance, mortality due to septic complications of post-infarction syndrome can reach as high as 10%.11 In our study, post-infarction syndrome did not occur in any patients in he combined treatment group, compared with 36% of patients in the staged treatment group. Another advantage of combined treatment is reduced hospital cost. Our analysis showed a significant reduction in hospital room cost and radiology cost in the combined treatment group compared with the staged treatment group (Table II). The reduction in the room cost was largely related to decreased hospital length of stay in the combined treatment group, because patients who underwent staged treatment waited on average 3.3 days after renal embolization before undergoing nephrectomy. Last, with more endovascular procedures being performed in the operating room, such as aortic endografting and iliac stent placement, vascular surgeons are ideally suited to perform renal artery embolization. Vascular surgeons are fully capable of handling potential complications of this percutaneous procedure, such as groin hematoma and femoral artery dissection. Moreover, vascular surgeons are often called on to assist with caval reconstruction after nephrectomy and caval thrombectomy. Coordinating these procedures with the urologist to facilitate operative treatment of renal cell carcinoma will no doubt benefit patient care and improve treatment outcome.

Numerous embolic materials have been described in the literature for use in pre-nephrectomy tumor embolization, including ethanol, occluding balloon catheter, and coils.15, 16, 17 Regardless of the thrombotic agent used, these embolic materials are all effective in achieving complete renal artery occlusion with tumor infarction. We prefer coil rather than ethanol, for several reasons. First, the radiolucency of ethanol makes it difficult to visualize the progression of embolization. The poor visibility of ethanol has been linked to aortic reflux or injection into nontargeted arteries. Complications as the result of improper ethanol injection have included death, left ventricular failure, spinal cord infarction, and colonic necrosis.18, 19, 20, 21 Second, we have gained considerable experience in coil occlusion, due in part to our efforts in hypogastric artery embolization in endovascular treatment of aortoiliac aneurysm.22 When performing catheter-directed renal artery coil placement, it is noteworthy that coils must be placed in the distal portion of the main renal artery to allow adequate length for proximal renal artery ligation at nephrectomy.15 Serious complications of improper coil placement, resulting in unintentional embolization of nontargeted organs, have similarly been reported, and include necrosis of the left colon, spinal cord, contralateral kidney, and testicular artery, and lower extremity gangrene.23, 24, 25, 26 Bearing these factors in mind, great care must be taken to ensure that the injection catheter is placed well within the main renal artery and that inadvertent coil placement near the renal ostium is averted.

One potential disadvantage of the combined approach may be related to renal dysfunction associated with contrast medium administration and nephrectomy. Although no patients in our series had renal failure after concomitant renal artery embolization and nephrectomy, we postulate that such a complication is possible if excessive contrast medium is administered in a dehydrated patient undergoing nephrectomy. In our series, vigilant efforts were made to limit the amount of contrast medium used in renal artery embolization. Furthermore, a central venous catheter was used perioperatively in all patients to ensure good hydration to minimize the likelihood of renal dysfunction.

There are several limitations to our study. The number of patients in this retrospective study is small, and the duration of follow-up is limited. Moreover the study encompassed a group of patients with heterogeneous renal cell carcinoma. A large-scale prospective study will no doubt provide further insight regarding the clinical efficacy of this combined treatment strategy.

In conclusion, our report illustrates the role of an adjunctive endovascular procedure in facilitating a conventional open operation. Intraoperative renal embolization can minimize blood loss and facilitate nephrectomy when performed jointly with a urologist. Moreover, we believe this approach minimizes post-infarction syndrome and reduces hospital cost, compared with the traditional staged treatment approach. Additional clinical studies will be necessary to further validate the benefit of combined treatment in patients with renal cell carcinoma.

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☆ Competition of interest: none.

PII: S0741-5214(03)00429-4

doi:10.1016/S0741-5214(03)00429-4

Journal of Vascular Surgery
Volume 38, Issue 3 , Pages 446-450, September 2003

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