Schmitz, John J.

Objectives To evaluate the peri‐operative and renal functional outcomes of patients undergoing synchronous bilateral partial nephrectomy (PN) or percutaneous cryoablation (PCA). Patients and Methods We retrospectively reviewed our institutional nephrectomy and renal mass ablation registries to identify all patients with synchronous bilateral renal masses who underwent simultaneous bilateral PN ( n = 76) or PCA ( n = 13) between 1974 and 2013. Changes in estimated glomerular filtration rate (eGFR) as well as peri‐operative complications are descriptively reported for each procedure. Results The number of treated renal masses in the 76 patients in the PN group and the 13 patients in the PCA group was 249 and 28, respectively. The median (interquartile range [IQR]) age at treatment was 62 (50, 71) years for the PN group and 67 (56, 72) for the PCA group. The median (IQR) maximum tumour sizes were 4.6 (3.4, 6.5) cm and 2.6 (2.4, 3.2) cm for the PN and PCA groups, respectively. The median (IQR) length of hospital stay was 7 (5, 8) days for the PN group and 1 (1, 10) days for the PCA group. The median (IQR) change in eGFR from baseline to discharge was −32 (−46, −15)% for the PN group and −17% (−33, −3) for the PCA group. By 3 months, median (IQR) renal function improved, with changes of −9 (−19, 0)% and −8 (−11, 15)%, respectively, compared with baseline. No patient in either group required renal replacement therapy in the peri‐operative period. Early postoperative complications (within 30 days) occurred in 16 patients (21.6%) in the PN and four patients in the PCA group. In particular, angioembolization for bleeding was required in the postoperative period in two patients (2.7%) in the PN and one patient in the PCA group. Conclusions Our experience suggests that synchronous bilateral PN or PCA are feasible treatment options for select patients presenting with bilateral renal masses. In select cases, both approaches appear to have reasonable rates of peri‐operative complications and effects on renal function.

Objective To evaluate the clinical and radiographic predictors of the need for partial or circumferential resection of the inferior vena cava ( IVC ) requiring complex vascular reconstruction during venous tumour thrombectomy for renal cell carcinoma ( RCC ). Patients and Methods Data were collected on 172 patients with RCC and IVC (levels I– IV ) venous tumour thrombus who underwent radical nephrectomy with tumour thrombectomy at the Mayo Clinic between 2000 and 2010. Preoperative imaging was re‐reviewed by one of two radiologists blinded to details of the patient's surgical procedure. Univariable and multivariable associations of clinical and radiographic features with IVC resection were evaluated by logistic regression. A secondary analysis was used to assess the ability of the model to predict histological invasion of the IVC by the tumour thrombus. Results Of the 172 patients, 38 (22%) underwent IVC resection procedures during nephrectomy. Optimum radiographic thresholds were determined to predict the need for IVC resection based on preoperative imaging included a renal vein diameter at the renal vein ostium ( RV o) of 15.5 mm, maximum anterior–posterior ( AP ) diameter of the IVC of 34.0 mm and AP and coronal diameters of the IVC at the RV o of 24 and 19 mm, respectively. On multivariable analysis, the presence of a right‐sided tumour (odds ratio 3.3; P = 0.017), an AP diameter of the IVC at the RV o of ≥24.0 mm (odds ratio 4.4; P = 0.017), and radiographic identification of complete occlusion of the IVC at the RV o (odds ratio 4.9; P < 0.001) were associated with a significantly increased risk of IVC resection. The c‐index for the model was 0.81. Conclusions We present a multivariable model of the radiographic features associated with the need for IVC resection during tumour thrombectomy. Pending external validation, this model may be used for preoperative planning, patient counselling and planned involvement of vascular surgical colleagues in anticipation of the need for complex vascular repair.