Improving surgical outcomes in renal cell carcinoma involving the inferior vena cava

Abstract

Radical nephrectomy with tumor thrombectomy remains the mainstay of treatment in renal cell carcinoma with inferior vena cava extension. Despite the rapid improvements experienced in perioperative care in recent years, this intervention still often results in significant morbidity and mortality. A deeper understanding of salient features of this complex operation provides a valuable insight into the clinical mechanisms underlying the variations observed in surgical outcomes. The ‘operation profile’ serves not only as a basis for making an adequate prognostic assessment, but also creates a platform from which ‘innovative’ strategies for improving quality and safety can be made. The present review aims to set a ‘profile’ for radical nephrectomy and tumor thrombectomy, and to propose a number of strategies that may reduce the complication rates of this intervention.

Keywords::

• complications
• inferior vena cava
• morbidity
• mortality
• operation profile
• quality
• renal cell carcinoma
• safety
• surgical outcomes
• tumor thrombus

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• • Improvements in surgical management have placed us in a vantage position of judging the potential of our treatment modalities to cause harm.

• • Classifying and evaluating the complications arising after surgical treatment would provide the adequate environment in which comparisons between individual surgeons, institutional experiences and different techniques can be accomplished in a systematic, objective and reproducible way, thereby, facilitating the adoption of preventive changes in care in an effort to decrease morbidity and mortality.

• • Radical nephrectomy and tumor thrombectomy still often result in significant morbidity and mortality, with complication rates exceeding 50% and postoperative mortality rates as high as 23.5%.

• • The radical nephrectomy and tumor thrombectomy ‘operation profile’ tries to capture all relevant features of this operation to: provide a deeper understanding of surgical outcomes; provide a basis for assessing the intervention; expand operative assessment beyond patient factors and technical skills of the surgeon and extend assessment of surgical skills beyond bench models to the operating room.

• • This profile provides a valuable insight into the clinical mechanisms and the detection of underlying variations in outcomes and possible mishaps in care that occur, and to develop effective quality improvement strategies.

• • Factors influencing surgical complications in renal cell carcinoma with inferior vena cava invasion include: preoperative factors (comorbidity status, disease features and accurate diagnosis); operative factors (hemorrhage, accidental injuries and pulmonary embolism); surgeon and team-related factors; postoperative factors (patient independence, antithrombotic therapy and nursing staff education) and environment factors.

• • Rarely, surgical ‘innovations’ have the potential to incite major shifts in surgical paradigms, but the vast majority do not achieve this end point. Although they may not attract the same attention as true paradigm shifts, they are still vitally important in the evolution of a surgical subspecialty.

• • Some of the ‘innovations’ or strategies provided in this review may decrease the number and severity of perioperative complications when dealing with renal cell carcinoma and inferior vena cava extension.