Simultaneous abdominal aortic aneurysm repair and nephrectomy for neoplasm

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Simultaneous Abdominal Aortic Aneurysm Repair and Nephrectomy for Neoplasm Spencer W. Gait, MD, Walter J. McCarthy, MD, William H. Pearce, MD, Michael F. Carter, MD, Daniel P. Dalton, MD, John E. Garnett, MD, Joseph R. Durham, MD, James S.T. Yao, MD, PhD, Chicago, Mnois

BACKGROUND: Abdominal aortic aneurysm and renal neoplasm are occasionally discovered concurrently. Simultaneous operative therapy may be an effective alternate management strategy to a staged procedure. PATIENTS AND METHODS: The medical records of 10 consecutive patients undergoing abdominal aortic aneurysm repair and nephrectomy for renal neoplasm were reviewed. Data collected included mode of presentation, preoperative evaluation, renal pathology, and in-hospital morbidity and mortality. Long-term follow-up was obtained through office records and telephone contact. RESULTS: In 7 patients, the renal mass was identified during evaluation of abdominal aortic aneurysm. The aneurysm was identified during evaluation of hematuria in 2 patients. One patient was discovered to have both conditions simultaneously. All patients underwent successful aneurysm repair and nephrectomy. Pathology revealed 6 renal cell carcinomas, 2 complex cysts, 1 hemangiopericytoma, and 1 oncocytoma. Four patients have died in the follow-up period: 1 of metastatic cancer and 3 of unrelated causes. There have been no cases of graft infection. CONCLUSION: Simultaneous abdominal aortic aneurysm repair and nephrectomy for neoplasm is an appropriate management strategy for selected patients. Am J Surg. 1995;170:227-230.

the aneurysm are generally preferred, minimizing the risk of bacterial seeding of the prosthetic graft. However, simultaneous nephrectomy should not increase this ri5k, as the upper urinary tract is normally sterile. TherefLlrr, >unultaneous aneurysm resection and nephrectomy may be a preferable approach. Although nephrectomy for renc)vascular hypertension at the time of aneurysm repair is generally accepted as appropriate, nephrectomy for neoplasm during aortic surgery has received scant attention in the literature. In the present study, we reviewed our experience with 10 patients undergoing this combined approach. PATIENTS AND METHODS The records of 10 consecutive patients who underwent simultaneous aortic aneurysm repair and nephrectomy for renal neoplasm between 1983 and 1993 were reviewed. The records were analyzed for mode of presentation of each condition, preoperative evaluation, surgical technique, and perioperative morbidity and mortality. I_ong-term follow-up was obtained by review of ofYice records and telephone contact with the patients, or relatives if the patient had died. Complete follow-up was obtained for every parlent. Patient characteristics are listed in the Table. RESULTS Seven patients were found to have renal neoplasms on abdominal computed tomographic (CT) scans during the evaluation of known or suspected abdominal aortic aneurysm (Figure). One patient underwent angiography tar the evaluation of claudication and was found to have a suspicious renal mass, prompting CT scanning. The CT scan confirmed the presence of a renal neoplasm and :I ~hr~mhosed ahdominal aortic aneurysm. In the remaining 7 patients, unsuspected aneurysms were identified by CT scan during the diagnostic evaluation of hematuria. Preoperative evaluation was completed at the discretion of the vascular and urologic surgeons. Four pat-ients underwent angiography for delineation of the vascular anatomy related to the aneurysm operation; besides the patlent mentioned above in whom the angiogram diagnosed the renal tumor, 1 patient underwent angiography as ;I rcrutine preoperative study and the other 2 patients cmderwent angiography for disabling claudication. In 7 of the s patients in whom the renal masses were discovered xcrendipitously, no further evaluation beyond CT scanning was ohtamed. In the eighth patient, magnetic resonance imktging (MRI) was obtaine’;l for suspected tumor thrombus m the renal vein; none ‘was identified, and no further ev;rIuation was pursued. In the 2 patients who presented with hematuria, initial cystography and retrograde pyelcqraphv were per-

hdc)mmal aortic aneurysm is a disease of aging. The general population is aging, and the incidence of aneurysms is increasing. 1-1 Since this is the same patient population in which intra-abdominal malignancies most often occur, there will be an increasingly large subset c~fpatients with concurrently diagnosed aortic aneurysm and mtra-ahdominal malignancy. For tumors of the gastrointestinal ,md hiliary tracts, staged resections of the tumor and

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From the Division of Vascular Surgery (SWG, WJM, WHP, JSTY), the Department of Urology (MFC, DPD, JEG), Northwestern University Medical School, and the Section of Vascular Surgery (JRD), Columbus Hospital, Chicago, Illinois. Requests for reprints should be addressed to Walter J. McCarthy, MD, Division of Vascular Surgery, Northwestern University Medical School, 251 East Chicago Avenue, #626, Chicago, Illinois 60611. Presented at the 23rd Annual Meeting of The Society for Clinical Vascular Surgery, Fort Lauderdale, Florida, March 22-26, 1995.

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Four patients have died. The patient with the hemangiopericytoma died of metastatic disease at 4 months. Three patients have died of unrelated causes: 1 of end-stage chronic obstructive pulmonary disease (COPD) at 12 months, 1 of biliary sepsis at 15 months, and 1 of myocardial infarction at 24 months. There have been no cases of graft infection in the follow-up period.

TABLE Patient

Characteristics

Mean age (y) (range) Sex (M/F) Comorbidities (number of patients) Chronic obstructive pulmonary disease Hypertension Hypercholesterolemia Coronary artery disease Chronic renal failure Smoking history (number of patients) Mean aneurysm size (cm) (range) Involved kidney

71 (55-85) 9/l 4 6 2 5 1 7 6.0 (3.0-10.0) 6 left/4 right

COMMENTS The incidence

Figure. Computed tomographic image of an infrarenal abdominal aortic aneurysm and an incidentally discovered renal neoplasm (arrow). The heterogeneous solid appearance of the tumor is suspicious for malignancy.

formed, neither of which revealed evidence of tumor. CT scans were then obtained in each, revealing a mass confined to the kidney and an aortic aneurysm. All operations were performed transperitoneally. In 7 patients, aneurysm replacement preceded nephrectomy. In the remaining 3, the sequence was reversed, at the discretion of the surgeons. Vascular reconstructions included 2 tube grafts, 5 bi-iliac grafts, and 3 femoral anastomoses. There were no in-hospital or 30-day deaths. Mean hospitalization was 11 days (range 7 to 17). Morbidity was limited to 1 patient who suffered respiratory failure requiring a 7-day intensive care unit stay and 1 patient with chronic renal failure who suffered a prolonged ileus. These patients were discharged home on postoperative days 15 and 17, respectively. Final pathology revealed renal cell carcinoma in 6 patients, complex benign cysts in 2, a hemangiopericytoma in 1, and an oncocytoma in 1 patient. All cases of renal cell carcinoma were confined to the kidney (stage 1). The oncocytoma was also limited to the kidney. The hemangiopericytoma had invaded the fat and soft tissue of the renal pelvis and one perihilar lymph node, although this had not been apparent on preoperative CT scan. Follow-up has ranged from 4 to 48 months (mean 25). Six patients are alive and well. Of these 6, 5 patients had renal cell carcinoma. None has had any evidence of recurrent disease. The sixth patient had a complex benign renal cyst. 228

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of abdominal aortic aneurysm is increasing.lF3 This, in combination with the aging of the general population, will assuredly result in an increasing number of patients who are diagnosed with an abdominal aortic aneurysm and a coexistent intra-abdominal malignancy. Therefore, it is important to develop appropriate management strategies for these patients. Performing both operative procedures at the same setting has obvious benefits. The patient is spared a second major abdominal procedure and the risk of a second general anesthetic. The necessary exposure of the retroperitoneum for aneurysm repair makes simultaneous nephrectomy especially attractive, as the approach for each of these operations is similar either transperitoneally or through the retroperitoneum. Furthermore, repeat exposure of the retroperitoneum at the second of staged operations is often substantially more difficult. Additionally, there is theoretically an increased risk of aneurysm rupture in the interim period if aneurysm repair is chosen as the second portion of staged operations; and delay of nephrectomy in staging operations increases the risk of metastasis. Finally, patients are afforded greater peace of mind knowing that two potentially lethal conditions have been treated at a single setting. If simultaneous operations are proposed, they must be done without incurring excessive risk. Ideally, the risk of a combined procedure should be lower than the sum of the two procedures if petformed independently. When combining abdominal aortic aneurysm repair and a second procedure, we feel that there are primarily two areas of concern: (1) the increased operative time and blood loss added to an already substantial physiologic insult, and (2) the risk of bacterial seeding of the graft. For the patients reported herein, there were no in-hospital or 30-day deaths. Morbidity was limited. One patient suffered a prolonged ileus, requiring nasogastric aspiration for 7 days. She was hemodialysis dependent, and we feel that uremia may have contributed to her slow return of gastrointestinal function. A second patient with severe COPD required 7 days of postoperative intubation, but was discharged home 8 days after extubation. In neither patient do we feel that the addition of the nephrectomy was solely responsible for the observed morbidity. The present series is consistent with reports by other authors who have combined aneurysm repair with nonvascular intraabdominal procedures. For example, DeMasi et al4 reported on 4 patients who successfully underwent combined aneurysm resection and nephrectomy for renal cell carcinoma. Cholecystectomy is undoubtedly the procedure most commonly performed in conjunction with aneurysm repair, and there appears to be no increase in early morbidity or mortality among patients undergoing this combined approach, when AUGUST

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1 compared with aneurysm resection alone.5sh Other authors have reported sporadic cases of simultaneous aneurysm repair and cc)Iectomy for colon carcinomai-’ and gastrectomy for gasrric adenc~c~lrcin~~rna’~-‘! with good early results. Nevertheless, each of these series is small, and none is controlled. Therefore, caution must he exercised when choosing the combined appro&. The mdividual patient must he deemed fit for a longer operation with p~~tentlally greater hlood loss. Graft infection IS the most catastrophic late complicatic)n foll~~u.ing anerqsm repa”. For years, many surgeons were reticent IO oprr,lte on the hiliary tract at the time of aneurysm repair. tearing bacterial seeding of the graft. However, multiple studieb have failed to demonstrate an increased incidence of graft infection in patients who have undergone conpchrative events or the patient becomes unstable, the abdomen may he closed, anticipating a staged approach. In general, we perform the aneurysm repair first unless it is small (< 5 cm 1 or thromhnsed. THE AMERICAN

The path~.~logy of the renal masses deserves comment. Two of our patitnts had benign cysts, which oh\iously diil not require resection. Both were complex, heterogenec )us masses on CT scan, and ditferentiation hetween .I hcnign complex cyst and a malignancy is not always possihle.‘i In hoth cases, however, the kidney removed was nonfunctional: 1 from a patient with chronic renal failure and the other from a patient who had an mx~t~ild renal artery and a sm,lll i&rcted kidney. Hcmangiopericytotna is a rare tumor stemming from capillary pericytcts. It is usually highly aggressive, with a 50% mortality rate. Ii 0n final pathology, there was invasion of the perinephric fat and soft tissue and a positive hilar lymph node. Despite the lack of radiologic evidence to the contrary and the absence of tumor spread outside the kdnry by tntraoperative asse:;sment, this tumor had undoubtedly micrometas, tasized, c;lu.jing this patient’s death only 4 months after resection. Known metastatic disease with such a malignant tumor type would have precluded aneurysm repair at all. There wa:; 1 case of an oncocytc)ma, a tumor thought to stem from the distal renal tubules. lh .4lthiding the difficulties and patient discomfort of two major operations. REFERENCES 1. Fowkes FG. Macintyre CC, Ruckley CV. Increasing incidence of aortic anru~v
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2. Hallett ]W Jr, NaessensJM, Ballard D]. Early and late outcome of surgical repair for small ahdominal aortic aneurysms: a populationbased analysis. J Vast Surg. 1993;18:654-691. 3. Melton L, BIckerstaff L, Hollier L, et al. Changing incidence of abdominal aortic aneurysms: a population-based study. Am J Epidemiol. 1984;120:379-386. 4. DeMasi RJ, Gregory RT, Snyder SO, et al. Coexistent abdominal aortic aneurysm and renal carcinoma: management options. Am Surg. 1994;60:961-966, 5. Ouriel K, Ricotta JJ, Adams JT, Deweese JA. Management of cholelithiasis in patients with abdominal aortic aneurysm. Ann Surg. 1983;198:717-719. 6. Ameli FM, Weiss M, Provan IL, Johnston KW. Safety of cholecystectomy with abdominal aortic surgery. Can J Surg. 1987;30:17@-173. 7. Velanovich V, Andersen CA. Concomitant abdominal aortic aneurysm and colorectal cancer: a decision analysis approach to a therapeutic dilemma. A review. Ann Vast Surg. 1991;5:449455. 8. Nora JD, Pairolero PC, Nivatvongs S, et al. Concomitant abdominal aortic aneurysm and colorectal carcinoma: priority of resection. .l Varc Surg. 1989;9:630-636. 9. Hardy JD, Tompkins WC, Chavez CM, Conn JH. Combining intraabdominal arterial grafting with gastrointestinal or biliary tract pro-

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cedure. Am J Surg. 1973;126:598-600. 10. Komori K, Okadome K, Odashiro T, et al. Successful simultaneous resection of abdominal aortic aneurysm and gastric cancer by retroperitoneal approach and transperitoneal approach. Eur J Vax En&ox Surg. 1992;6:639-641. 11. Komori K, Okadome K, Funahashi S, et al. Surgical strategy of concomitant abdominal aortic aneurysm and gastric cancer. J Vast Surg. 1994;19:573-576. 12. Sigler L, Geary JE, Bodon GR. One-stage resection of abdominal aortic aneurysm and gastrectomy for carcinoma. Arch Surg. 1968;97: 525-526. 13. Baskin LS, McClure RD, Rapp JH, et al. Simultaneous resection of renal carcinoma and abdominal aortic aneurysm. Ann Vast Surg. 1991;5:363-365. 14. Newhouse JH. The radiologic evaluation of the patient with renal cancer. LJrol Clin North Am. 1993;20:231-246. 15. Heppe RK, Donohue RE, Clark JE. Bilateral renal hemangiopericytoma. Urology. 1991;38:249-253. 16. Lieber MM. Renal oncocytoma. Ural Clin North Am. 1993;20: 355-359. 17. Thrasher JB, Paulson DE Prognostic factors in renal cancer. UroL Clin North Am. 1993;20:247-262.

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