Concomitant intraoperative renal artery embolization and resection of complex renal carcinoma

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.

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.

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, US dollars 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.

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.