Radical nephrectomy and vena caval thrombectomy with the use of cardiopulmonary bypass and hypothermic circulatory arrest: Experience at a large tertiary institution

Objective: This study aimed to review the experience at a large regional tertiary centre of open radical nephrectomy (RN) with vena caval thrombectomy with cardiopulmonary bypass (CPB) and hypothermic circulatory arrest (HCA) for the management of renal masses. Method: Data on patients with renal masses who had undergone RN and vena caval thrombectomy with CPB and HCA had been prospectively collected at two centres over a 19-year period (2000-2019). Twenty-three consecutive patients were identified and retrospectively analysed for operative and tumour characteristics and for postoperative outcome. Kaplan-Meier survival analysis was performed to compare patient outcomes based on tumour characteristics. Results: Median operating time was 358 minutes (interquartile range (IQR)=94 minutes), median bypass time was 117 minutes (IQR=28.5 minutes) and median circulation arrest time was 25 minutes (IQR=18.5 minutes). The median hospital length of stay was 11 days (IQR=5.3 days). Total complication rate was 52% (n=12), consisting of four minor and eight major complications (Clavien-Dindo score >IIIa), including one intraoperative death. The overall five-year survival rate was 73% (11/15), with a median follow-up time of 53.1 months. Eleven (48%) patients were surgically cured, with a median follow-up time of 60.1 months (IQR=71.8 months). Disease recurrence was seen in eight (35%) patients, of whom four died. Patients who died survived for a median of 46.5 months. Median survival after the diagnosis of metastatic disease was seven months. Conclusions: We report the largest Australian cohort of RN with vena caval thrombectomy with CPB and HCA. We demonstrate outcomes comparable to major overseas centres, with an overall five-year survival rate of 73%. This suggests that even patients with extensive venal caval thrombus from renal masses can experience long-term survival benefit from RN and venal caval thrombectomy.