Partial Nephrectomy for Renal Cell Carcinoma: Risk Factors for Acute Post-Operative Hemorrhage and Impact on Subsequent Hospital Course and Complete Nephrectomy Rate. An Analysis of 200 Consecutive Cases

doi:10.4236/ijcm.2013.412A1002

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International Journal of Clinical Medicine, 2013, 4, 5-9

Published Online December 2013 (http://www.scirp.org/journal/ijcm)

http://dx.doi.org/10.4236/ijcm.2013.412A1002

Open Access IJCM

Partial Nephrectomy for Renal Cell Carcinoma: Risk

Factors for Acute Post-Operative Hemorrhage and Impact

on Subsequent Hospital Course and Complete

Nephrectomy Rate. An Analysis of 200 Consecutive Cases

James Cavalcante, Alan Perrotti, Philip Rabadi, Alicia McCarthy, Michael Perrotti*

Urologic Oncology Service, Saint Peter’s Hospital Cancer Care Center, Saint Peter’s Health Partners, Albany, New York, USA.

Email: *[email protected]

Received October 29th, 2013; revised November 25th, 2013; accepted December 10th, 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In accor-

ABSTRACT

Purpose: Clinical guidelines recommend partial nephrectomy (PN) as the preferred method of surgical excision of the

small renal tumor whenever feasible. PN has comparable cancer cure rates to that of radical nephrectomy in this setting,

and decreased risk of chronic kidney disease. A recognized devastating complication following partial nephrectomy is

acute post-operative hemorrhage (APOH) from the reconstructed kidney. Risk factors for hemorrhage following partial

nephrectomy remain poorly elucidated, as does the impact of hemorrhage on subsequent hospital stay. Identification of

risk factors for hemorrhage may lead to a better understanding of and reduction of this complication. Material and

Methods: We utilized a prospectively managed database comprised of patients undergoing open partial nephrectomy at

our institution by the same surgical team from January 2006 to July 2012. Clinicopathologic factors assessed APOH for

their relationships, including patient age, gender, diabetes, smoking, hypertension, coronary artery disease, American

Society of Anesthesia Score (ASA), tumor size, RENAL nephrotomy score, pathologic result, cancer margin status,

operative time, and intra-operative blood loss. The impact of APOH on subsequent hospital course was evaluated and

compared with the entire cohort. Results: Data were analyzed from 200 consecutive patients. We identified 7 patients

(3.5%) who experienced APOH. Compared with the entire cohort, APOH resulted in an increased hospital length of

stay (median, 5 days; range, 2 - 11 days, p = 0.001), an increased transfusion requirement (median, 6 units; range, 1 - 16

units. p = 0.001), a greater risk of selective angiographic embolization (median, 2 procedures; range, 0 - 3, p = 0.001),

and completion nephrectomy (n = 2, p = 0.001). One patient in the APOH group experienced cardiac arrest and was

resuscitated. Clinicopathologic factors associated with the increased risk of APOH in the present cohort were male gen-

der (p = 0.03) and hypertension (p = 0.006). Conclusion: In the present analysis, APOH was associated with extended

hospitalization, the increased transfusion requirement and the need for more ancillary procedures. APOH patients were

at significantly increased risk of renal loss. Male gender and hypertension were associated with increased risk for

APOH. We have incorporated this information into an APOH risk reduction program at our institution.

Keywords: Kidney Neoplasms; Partial Nephrectomy; Renal Cell Carcinoma

1. Introduction

Clinical guidelines recommend partial nephrectomy (PN)

as the preferred method of surgical excision of the small

renal tumor whenever feasible [1]. PN has comparable

cancer cure rates to that of radical nephrectomy in this

setting [2], and decreased risk of chronic kidney disease

[3]. A recognized devastating complication following

partial nephrectomy is acute post-operative hemorrhage

(APOH) from the reconstructed kidney. Risk factors for

hemorrhage following partial nephrectomy remain poorly

elucidated, as does the impact of hemorrhage on subse-

quent hospital stay. Identification of risk factors for he-

*Corresponding author.

Partial Nephrectomy for Renal Cell Carcinoma: Risk Factors for Acute Post-Operative Hemorrhage

and Impact on Subsequent Hospital Course and Complete Nephrectomy Rate.

An Analysis of 200 Consecutive Cases

morrhage may lead to a better understanding of and re-

duction of this complication. In the present investigation,

we sought to determine risk factors for acute post-opera-

tive hemorrhage after partial nephrectomy utilizing a

prospectively managed patient database. We also evalu-

ated the impact of APOH on subsequent hospital stay.

2. Material and Methods

A prospectively managed database was utilized com-

prised of patients undergoing open partial nephrectomy

at our institution. The current investigation includes all

patients operated from January 2006 to July 2012 by a

single surgical team. Clinicopathologic factors assessed

for their relationship to APOH included patient age,

gender, diabetes, smoking, hypertension, coronary artery

disease, American Society of Anesthesia Score (ASA),

R.E.N.A.L. nephrotomy score [4], tumor size, pathologic

result, cancer margin status, operative time, and intra-

operative blood loss. The impact of APOH on subsequent

hospital course was evaluated and compared to the entire

cohort.

We identified patients with and without APOH. For

the purposes of this investigation, APOH was defined as

acute post-operative drop in hemoglobin (<8 mg/dl) and

radiographic CT scan evidence of either peri-nephric

retroperitoneal hematoma or blood within the renal col-

lecting system of the operated kidney. APOH could be

associated with acute hypotension (i.e., systolic BP < 100

mmHg), gross hematuria and increasing flank pain, but

this was not required for the diagnosis of APOH. Evalu-

ated subsequent hospital course outcome measures in-

cluded blood transfusion, renal angiography procedure

with or without selective renal embolization, and com-

pletion nephrectomy.

Univariate statistical analysis was performed using the

X2 test and Fisher’s exact test as appropriate for cate-

gorical data [5]. These included gender, hypertension,

smoking, diabetes, coronary artery disease, American

Society of Anesthesiologists (ASA) score (dichotomized

as 1 and 2 versus 3, 4 and 5), tumor laterality, pathologic

result (cancer versus benign), surgical margin status (i.e.,

cancer at margin versus not). The Mann-Whitney test [5]

was utilized for continuous data including age, tumor

size, R.E.N.A.L. nephrotomy score, operative time, renal

artery clamp time, and intra-operative blood loss.

In assessing the impact of APOH on subsequent hos-

pital course, measured variables were dichotomized as

length of stay (LOS) ≤3 days versus >3 days; transfusion

as none versus ≥1 unit of packed red blood cell (PRBC);

no angiographic embolization versus angiographic em-

bolization regardless of number of procedures performed

for each patient; completion nephrectomy as either per-

formed or not performed.

3. Results

Data were analyzed from 200 consecutive patients oper-

ated from January 1st, 2006 to July 30th 2012. Table 1

presents the clinicopathologic features for the APOH

cohort and the non-APOH cohort.

APOH was identified in 7 patients. The only clinico-

pathologic factor associated with increased risk of APOH

in the present cohort were male gender (p = 0.03) and

hypertension (p = 0.006). This data is shown in Table 1.

Only a subset of the current cohort had calculation of

R.E.N.A.L. nephrotomy score following its description in

2009. In the present investigation, R.E.N.A.L. nephro-

tomy score did not correlate with APOH in the subset

evaluated. Age, diabetes, smoking, coronary artery dis-

ease, American Society of Anesthesia Score (ASA), tu-

mor size, pathologic result, cancer margin status, opera-

tive time, and intra-operative blood loss did not correlate

with APOH.

Table 2 illustrates the impact of APOH on subsequent

hospital course. Compared to the entire cohort, APOH

resulted an increased hospital length of stay (median, 5

days; range, 2 - 11 days, p = 0.001), increased transfu-

sion requirement (median 6 units; range, 1 - 16 units, p =

0.001), greater risk of selective angiographic emboliza-

tion (median, 2 procedures; range, 0 - 3, p = 0.001), and

greater risk of completion nephrectomy (n = 2, p =

0.001). One patient in the APOH group experienced car-

diac arrest and was resuscitated. There were no deaths in

either cohort.

4. Discussion

It is estimated that there will be 65,140 new cases of

kidney cancer in the United States in 2013, and the inci-

dence is increasing [6,7]. Greater than 70% of newly

detected renal tumors are incidentally detected, often less

than 4 cm [8], and potentially amenable to either surveil-

lance (lesions ≤ 2 cm), emerging percutaneous treatments

(i.e., radiofrequency ablation; cryosurgery), compete

nephrectomy and partial nephrectomy [9]. For those pa-

tients felt best to be managed with surgical excision,

clinical guidelines recommend partial nephrectomy (PN)

as the preferred method of surgical excision of the small

renal tumor whenever feasible [1]. PN has comparable

cancer cure rates to that of radical nephrectomy in this

setting [2], and decreased risk of chronic kidney disease

[3]. Despite this, investigators have reported that PN ap-

pears to be underutilized in the United States, even in

Open Access IJCM

Partial Nephrectomy for Renal Cell Carcinoma: Risk Factors for Acute Post-Operative Hemorrhage

and Impact on Subsequent Hospital Course and Complete Nephrectomy Rate.

An Analysis of 200 Consecutive Cases

Open Access IJCM

Table 1. Clinical features of patient with and without acute post-operative hemorrhage.

APOH Cohort Non-APOH Cohort

Pt. No. 7 193

Age (years) 60 (54 - 73) 58 (28 - 84) p = NS

Tumor Size (cm) 3.1 (2.2 - 7.5) 2.8 (0.6 - 11) p = NS

Gender p = 0.03

Male 7 (100%) 115 (59%)

Female - 78 (41%)

Tumor Side p = NS

Left 3 (42%) 92 (48%)

Right 4 (57%) 101 (52%)

Hypertension 7 (100%) 96 (49%) p = 0.006

Diabetes 1 (14%) 23 (12%) p = NS

Smoking 3 (42%) 84 (43%) p = NS

CAD 1 (14%) 22 (11%) p = NS

ASA 2 (2 - 3) 2 (2 - 3) p = NS

APOH = acute post-operative hemorrhage; Pt. No. = patient number; ASA = American Society of Anesthesiology score; age, tumor size and ASA are expressed

as the median and range; NS = statistically not significantly different.

Table 2. Impact of acute post-operative hemorrhage on subsequent hospital course.

APOH Cohort Non-APOH Cohort

Length of Stay p = 0.001

≤3 days 1 (14%) 140 (72%)

>3 day 6 (85%) 53 (27%)

Transfusion p = 0.001

none 1 (14%) 184 (95%)

≥1 unit PRBC 6 (85%) 9 (5%)

Renal Angiography p = 0.001

none 2 (28%) -

≥1 procedure 5 (72%) 193 (100%)

Completion Nephrectomy p = 0.001

yes 2 (28%) 4 (2%)

no 5 (72%) 189 (98%)

APOH = acute post-operative hemorrhage; PRBC = packed red blood cells; renal angiography denotes angiogram of the bleeding kidney with or without at-

tempted embolization.

patients with pre-existing renal insufficiency who may

benefit most from PN [9]. Investigators utilizing the Na-

tional Cancer Database recently reported a decrease in

the median tumor size of stage 1 tumors from 4.1 to 3.6

cm between 1993 and 2004 [10], indicating that many of

these tumors may be amenable to partial nephrectomy.

Partial Nephrectomy for Renal Cell Carcinoma: Risk Factors for Acute Post-Operative Hemorrhage

and Impact on Subsequent Hospital Course and Complete Nephrectomy Rate.

An Analysis of 200 Consecutive Cases

However, a recent analysis utilizing the Surveillance,

Epidemiology ad End Results program during that same

time period showed that in the US only 35.2% of patients

with T1a (≤4 cm) renal masses received partial nephrec-

tomy between 1999 and 2006 [11]. That same study re-

vealed that only 50% of tumors <2 cm were treated with

partial nephrectomy, and 48% of tumors between 2 and 4

cm were treated with partial nephrectomy [12].

There is increasing evidence that surgically induced

chronic kidney disease [13,14] following complete neph-

rectomy is associated with increased risk of cardiovascu-

lar disease including death [15,16] and metabolic adverse

consequences including anemia, acidosis, and osteoporo-

sis [17,18] and associated significant adverse health con-

sequences.

The reason for underutilization of partial nephrectomy

compared to radical nephrectomy for management of the

T1a (<4 cm) and select T1b 4 - 7 cm) renal mass is un-

clear, and is beyond the scope of the current investigation.

Investigators have suggested that the explanation may be

multifactorial, including physician and patient factors,

and that the decision making requires complex multi

perspective reasoning [19]. It is generally recognized that

partial nephrectomy is a complex procedure requiring

surgical expertise, a dedicated operating room team and

advanced surgical technology, and that partial nephrec-

tomy is associated with increased surgical risk both in-

tra-operative and post-operative, the most devastating

being post-operative hemorrhage. The present study

sought to identify risk factors for APOH after partial

nephrectomy. Though a rare event, APOH increased the

hospital length of stay, the transfusion rate, the need for

ancillary procedures and most importantly, the complete

nephrectomy rate which was 29% in the APOH cohort

compared to 2% in the non-APOH group. Furthermore,

we sought to identify risk factors associated with APOH.

So that such knowledge may allow preemptive risk re-

duction. At our institution all hypertensive males are

treated under the care of a cardiologist to maximize hy-

pertension management for at least 1 month prior to par-

tial nephrectomy. In addition, we have instituted a

peri-operative protocol to maintain normotensive status

throughout the intra-operative and post-operative period.

Whereas in the past all patients received PRN supple-

mental meds for hypertension, now our protocol admin-

isters that medication (usually beta-blockade) as standing

order with hold parameter (i.e. Systolic BP < 100 mmHg

or HR < 60 bpm). We attempt to maintain a mean arterial

pressure of 70 - 80. Since the institution of this protocol

in October 2011 we have not experienced an APOH.

During this period, our patient criteria, volume, surgical

technique and post-operative pathway [20] remain con-

stant.

5. Conclusion

In the present analysis, APOH was associated with ex-

tended hospitalization, the increased transfusion require-

ment and the need for more ancillary procedures. APOH

patients were at significantly increased risk of renal loss.

Male gender and hypertension were associated with in-

creased risk for APOH. We have incorporated this in-

formation into an APOH risk reduction program at our

institution.

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Open Access IJCM

Partial Nephrectomy for Renal Cell Carcinoma: Risk Factors for Acute Post-Operative Hemorrhage

and Impact on Subsequent Hospital Course and Complete Nephrectomy Rate.

An Analysis of 200 Consecutive Cases

Open Access IJCM

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