Commentary - Morbidity and Mortality of Radical Nephrectomy of Patients with Disseminated Cancer: An Analysis of the National Surgical Quality Improvement Program Database - Beyond the Abstract

Cytoredutive nephrectomy (CN) is one procedure for patients with metastic renal cell carcinoma (mRCC) that has been declining due to the introduction of other therapies targeting mRCC pathway1,2. Because of this, there is a need to characterize contemporary perioperative morbidity of CN to further inform patient selection for surgery and balance oncologfical benefit with perioperative risk. Previous groups have reported on perioperative outcomes following CN3-8, however these studies lacked a comparative group to allow for a complete assessment of the incremental effect of disseminated disease on perioperative outcomes. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database is a multi-institutional, multinational registry focused on perioperative outcomes within 30 days of surgery9. Utilizing the NSQIP, this study’s aim is to characterize complication rates in patients undergoing nephrectomy in the setting of disseminated cancer and compare those to patients without disseminated cancer.

A restrospective cohort study of patients undergoing radical nephrectomy for kidney cancer from 2005 to 2014 was conducted using the NSQIP. Patients were stratified according to the presence of absence of disseminated cancer at the time of surgery. The primary outcome was to examine major complications, and secondary outcomes included: pulmonary complications, infectious complications, venous thromboembolism, bleeding requiring transfusion, and prolonged length of stay. To characterize the operative complexity of nephrectomy performed in the setting of disseminated cancer, they captured the type of frequency of concomitant procedures. Adjusted odds ratio (aOR) and 95% confidence interval (95% CI) were calculated using multivariate logical regression models
In total, 7800 patients were included in the study who met both the inclusion and exclusion criteria. The results of the study revealed that patients with disseminated cancer were more likely to be young, male, Caucasian, have a low BMI, active smokers, and have a higher ASA class. These patients were also less likely to undergo minimally invasive surgery, have higher proportions undergoing a concurrent procedure, and have an increase occurrence of bowel procedures, splenectomy, hepatectomy, and major vascular repair when compared to those without disseminated cancer. Patients with disseminated cancer is associated with greater risks of major complications including higher mortality and reoperation, as well as pulmonary complications, infections, thromboembolism, bleeding complications, and prolong length of stay.

In conclusion, nephrectomy in patients with disseminated cancer is associated with significant perioperative morbidity and mortality. The results of this study may be used for preoperative counseling of patients undergoing CN. Future studies should continue to work on optimizing patient selection for oncological benefits and to minimize perioperative complications. Some significant limitations of the study includes NSQIP lack of cancer-specific information, and the study lacked variables necessary to understand patient symptoms or tumor burden.

Authors: Christopher J. D. Wallis, Georg Bjarnason, James Byrne, Douglas C. Cheung, Azik Hoffman, Girish S. Kulkarni, Avery B. Nathens, Robert K. Nam, and Raj Satkunasivam

Read the Abstract

Reference:

1. Heng DY, Wells JC, Rini BI, et al. Cytoreductive nephrectomy in patients with synchronous metastases from renal cell carcinoma: results from the International Metastatic Renal Cell Carcinoma Database Consortium. Eur Urol. 2014;66:704-710.
2. Choueiri TK, Xie W, Kollmannsberger C, et al. The impact of cytoreductive nephrectomy on survival of patients with metastatic renal cell carcinoma receiving vascular endothelial growth factor targeted. J Urol. 2011;185:60-66.
3. Corcoran AT, Kaffenberger SD, Clark PE, et al. Hypoalbuminaemia is associated with mortality in patients undergoing cytoreductive nephrectomy. BJU Int. 2015;116:351-357.
4. Gershman B, Moreira DM, Boorjian SA, et al. Comprehensive characterization of the perioperative morbidity of cytoreductive nephrectomy. Eur Urol. 2016;69:84-91.
5. Silberstein JL, Adamy A, Maschino AC, et al. Systematic classification and prediction of complications after nephrectomy in patients with metastatic renal cell carcinoma (RCC). BJU Int. 2012;110:1276-1282.
6. Jackson BL, Fowler S, Williams ST; British Association of Urological Surgeons—Section of Oncology. Perioperative outcomes of cytoreductive nephrectomy in the UK in 2012. BJU Int. 2015;116:905-910.
7. Sun M, Abdollah F, Schmitges J, et al. Cytoreductive nephrectomy in the elderly: a population-based cohort from the USA. BJU Int. 2012;109:1807-1812.
8. Trinh QD, Bianchi M, Hansen J, et al. In-hospital mortality and failure to rescue after cytoreductive nephrectomy. Eur Urol. 2013;63:1107-1114.
Pelvic Health Weekly Newsletter