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Thoracoabdominal radical nephrectomy: is a postoperative thoracostomy tube necessary?
ADULT UROLOGY
THORACOABDOMINAL RADICAL NEPHRECTOMY: IS A POSTOPERATIVE THORACOSTOMY TUBE NECESSARY? CHARLES J. ROSSER, DAVID L. MCCULLOUGH,
AND
M. CRAIG HALL
ABSTRACT Objectives. To report our results of patients undergoing thoracoabdominal radical nephrectomy without intraoperative placement of a thoracostomy tube. It has been routine in our hospital to not place a thoracostomy tube in patients undergoing thoracoabdominal radical nephrectomy since 1988. Methods. We conducted a retrospective review of 47 thoracoabdominal radical nephrectomies performed from January 1988 through November 1998 at our institution. Of the 47 patients, 39 did not have a thoracostomy tube placed intraoperatively; the other 8 patients did. The development of all postoperative complications, length of hospital stay, and hospital charges were noted. Results. No postoperative mortality was noted in our study. Of the 47 patients in the study, 20 patients had a total of 29 complications. The overall number of complications was not increased in the group without a thoracostomy tube compared with the group with a thoracostomy tube (P ⫽ 0.104). No patient treated without a thoracostomy tube required subsequent placement of a tube for persistent pneumothorax. The mean length of hospital stay in patients with a thoracostomy tube after radical nephrectomy was 9.14 ⫾ 2.65 days; in patients without a thoracostomy tube, the mean length of stay was 7.07 ⫾ 3.97 days (P ⫽ 0.071). Conclusions. In patients without parietal pleural injury, thoracoabdominal radical nephrectomy without the placement of a thoracostomy tube can be performed safely and effectively, with a low risk of postoperative complications and a decrease in the overall hospital stay and hospital charges. UROLOGY 55: 847–851, 2000. © 2000, Elsevier Science Inc.
T
he thoracoabdominal incision was first described by Marshall1 in 1946 for combined kidney, chest, and abdominal injuries. Subsequently, in 1949, Chute and associates2,3 adopted the thoracoabdominal approach for resecting large renal tumors. By definition the thoracoabdominal radical nephrectomy implies transpleural, transdiaphragmatic, and transabdominal exposure of retroperitoneal structures and the pleural and peritoneal cavities through a ninth or tenth rib incision. The advantage of this incision over a standard flank incision, transperitoneal incision, or lumbar incision is that the incision gives wide and excellent exposure of the involved kidney, ultimately allowing primary ligation of the renal vasculature before manipulation of the tumor. Furthermore, the thoracoabdominal incision allows for the re-
From the Department of Urology, Wake Forest University School of Medicine, Winston-Salem, North Carolina Reprint requests: Charles J. Rosser, M.D., Department of Urology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157 Submitted: August 9, 1999, accepted (with revisions): September 21, 1999 © 2000, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
moval of Gerota’s fascia, the ipsilateral adrenal gland, and local lymph nodes. The disadvantages of the thoracoabdominal incision include that it is a large incision that crosses many muscles and that it is an incision that opens the retroperitoneal, peritoneal, and pleural cavities. Indications for a thoracoabdominal approach during a radical nephrectomy include a large upper pole tumor (greater than 7 cm), adjacent organ involvement, inferior vena cava involvement with tumor,4 or the surgeon’s preference.5,6 The standard intraoperative procedure in patients undergoing a thoracoabdominal approach includes placement of a thoracostomy tube to evacuate fluid and air from the pleural space.5–11 The pleura consist of the visceral pleura, which surrounds the lung parenchyma, the parietal pleura, which covers the inside of the thoracic cage, and the pleural fluid, which is found in between the visceral and parietal pleura.12 On the inception of the thoracoabdominal nephrectomy in the 1940s, if the visceral pleura was not injured, the diaphragm and pleura were closed, and the lung reexpanded without the placement of a thoracos0090-4295/00/$20.00 PII S0090-4295(99)00457-4 847
TABLE I. Patient characteristics Variables Age (yr) Sex (M/F) Tobacco use (Y/N) COPD (Y/N) Side of nephrectomy (R/L)
Thoracostomy Tube (n ⴝ 8)
No Thoracostomy Tube (n ⴝ 39)
P Value
61.2 ⫾ 13.2 6/2 6/2 0/8 6/2
58.8 ⫾ 15.4 20/19 14/25 3/36 28/11
0.301 0.178 0.143 0.211 0.674
KEY: M/F ⫽ male/female; Y/N ⫽ yes/no; COPD ⫽ congestive obstructive pulmonary disease; R/L ⫽ right/left.
tomy tube.2,3,13 However, over time it became commonplace for urologists to place a thoracostomy tube at the completion of the procedure. Since 1988, we have routinely not placed a thoracostomy tube in our patients undergoing radical thoracoabdominal nephrectomy. Therefore, we report our experience of patients undergoing thoracoabdominal radical nephrectomy without intraoperative placement of a thoracostomy tube. To our knowledge no such study has been undertaken. MATERIAL AND METHODS We conducted a retrospective review of 50 thoracoabdominal radical nephrectomies performed as described by Skinner7 from January 1988 through November 1998 at our institution. Of the 50 patients, 39 did not have a thoracostomy tube placed intraoperatively, and the other 11 patients did. Eight of the 11 patients with thoracostomy tubes were patients of one attending physician who routinely placed a thoracostomy tube after thoracoabdominal nephrectomy. The other 3 patients with postoperative thoracostomy tubes were excluded from the study because 2 patients had undergone lung resection of metastatic disease and 1 patient had known violation of the visceral pleura on opening the thoracic cavity and thus had a thoracostomy tube placed intraoperatively. This patient’s pleura defect was closed anatomically with absorbable suture. The medical records of the 47 patients were extensively reviewed. Each flank surgery was considered an independent event. Furthermore, the operative reports were reviewed for what side the nephrectomy was performed on, whether a rib was resected, whether the visceral pleura was violated, and whether other surgical procedures were performed during the same operation. All postoperative chest radiographs were interpreted by an attending radiologist. The development of postoperative complications, length of hospital stay, and patient charges were noted.
PATIENT AND TUMOR CHARACTERISTICS Of the 47 patients, 25 were men (53.1%) and 22 were women (46.9%); the mean age of patients in the study was 61.2 ⫾ 13.2 years (range 26 to 90). Three patients had a past medical history significant for pulmonary complications, two with a history of chronic obstructive pulmonary disease and one with a history of asthma. Of the 47 patients, 21 reported a significant history of tobacco use (more than 1 pack daily). A right-sided radical nephrectomy was done in 35 patients and a left-sided radical nephrectomy in 12 patients. All but 1 patient had a rib resected to facilitate exposure. Table I summarizes the patient characteristics in both groups. Table II presents the 848
TABLE II. Stage of tumor resected Tumor Stage
Thoracostomy Tube (n ⴝ 8)
No Thoracostomy Tube (n ⴝ 39)
1 2 3 4
0 1 7 0
4 12 20 3
TABLE III. Additional operations/procedures performed at the time of radical nephrectomy* Procedure
Thoracostomy Tube (n ⴝ 8)
Hepatic resection Splenectomy Cholecystectomy Partial small bowel resection Oophorectomy Total
No Thoracostomy Tube (n ⴝ 39)
0 1 1 0
3 2 3 2
0 2
1 11
* P ⫽ 0.159.
stage of the renal tumors in both groups. Of the 47 renal tumors resected, 43 were renal cell carcinoma, 1 was liposarcoma, 1 was lymphoma, 1 was angiomyolipoma, and 1 was a multilocular cyst.
OTHER OPERATIONS OR PROCEDURES Fifteen of the 47 patients in the study had other procedures performed at the time of the radical nephrectomy. Table III illustrates the additional operations or procedures performed in both groups.
STATISTICAL ANALYSIS Data analysis was performed using computer software. Calculations of statistical significance were performed using Student’s t test, Fisher’s exact test, and chi-square analysis.
RESULTS No postoperative mortality was noted in our study. Of the 47 patients in the study, 20 patients had a total of 26 complications. Table IV depicts all UROLOGY 55 (6), 2000
TABLE IV. Postoperative complications* Complications
Thoracostomy No Thoracostomy Tube Tube (n ⴝ 39) (n ⴝ 8)
Prolonged intubation Fever 2° atelectasis Pleural effusion Ileus Pulmonary embolus Arrhythmias Jaundice Pseudomembranous colitis Total
0 1 0 1 0 2 0 0
0 6 6 0 2 6 1 1
4
22
* P ⫽ 0.117.
the complications encountered in both groups. The overall number of complications was not increased in the group without thoracostomy tube placement compared with the group with thoracostomy tube placement (P ⫽ 0.117). One of the 8 patients with a thoracostomy tube had a persistent pneumothorax. The mean number of days a patient had a thoracostomy tube in place was 3.73 ⫾ 3.44 days. Seven of the 39 patients who did not have a thoracostomy tube placed intraoperatively developed pneumothoraces. These pneumothoraces were without symptoms and were small, with a mean size of 10%. The mean time to resolution of these pneumothoraces was approximately 2.33 days (range 1 to 4). All the patients with persistent pneumothoraces were observed, and none experienced adverse sequelae or required placement of a thoracostomy tube or needle aspiration. The only complication that was elevated in patients without a thoracostomy tube compared with patients with a thoracostomy tube was the development of pleural effusions. Pleural effusions were noted in 6 patients without a thoracostomy tube. No patients with a thoracostomy tube developed pleural effusions. These effusions were characterized as small (less than 5% to 10%) and asymptomatic. All the patients with pleural effusions were observed, and none experienced adverse sequelae or required the placement of a thoracostomy tube or needle aspiration. The mean length of hospital stay in patients with a thoracostomy tube after radical nephrectomy was 9.14 ⫾ 2.65 days; in patients without a thoracostomy tube, the mean length of stay was 7.07 ⫾ 3.97 days (P ⫽ 0.071). Patients with a thoracostomy tube in place had on average six more chest radiographs during their postoperative convalescence than patients without a thoracostomy tube. As would be expected with the increase in hospital stay and increase in radiographs, the average hospital cost of a patient undergoing thoracoabdomiUROLOGY 55 (6), 2000
nal radical nephrectomy with intraoperative placement of a thoracostomy tube was $19,405.81; the average hospital cost of a patient undergoing thoracoabdominal nephrectomy without intraoperative placement of a thoracostomy tube was $13,970.17. Thus, the hospital charges for patients without a thoracostomy tube were on average $5435.64 less than for patients with a thoracostomy tube. COMMENT Previous reports quote postoperative complication rates after thoracoabdominal nephrectomy of between 24% and 50% and a mortality rate of 6.8% to 8.3%.8,9,14 We had no mortalities in our study group, which can be attributed to better surgical technique and better intraoperative care and improved postoperative critical care. Our overall complication rate was 55.3%. This rate was not elevated when assessing patients with and without thoracostomy tubes (50% versus 56%). Cole and associates15 mentioned not observing an increase in morbidity in an unspecified number of patients undergoing thoracoabdominal nephrectomy without the placement of a thoracostomy tube. In the 39 patients in our study without a thoracostomy tube, pneumothoraces were evident in 7 patients compared with 1 of the 8 patients with a thoracostomy tube. However, of these 7 patients with pneumothoraces, none were symptomatic and none required thoracostomy tube placement or aspiration of the pneumothorax. These pneumothoraces were characterized as small (less than 10%) and were only evident on the immediate postoperative chest radiograph routinely performed to detect postoperative pneumothorax. We found that the key to not having to place a thoracostomy tube intraoperatively was our closure of the chest and diaphragm. The diaphragm is adequately mobilized to facilitate closure. Before closing the diaphragmatic pleurotomy, a 12F rubber catheter is placed in the pleural space and the pleura closed with a running absorbable suture. The surrounding diaphragm may be incorporated into this suture line to bolster it. The lung is expanded with positive pressure ventilation, and the remaining air is evacuated with direct negative pressure aspiration through the catheter or by placement of the tip of the catheter in a fluid-filled container. The catheter is removed when no more air can be aspirated or when bubbling ceases in the “water seal device.” The suture is subsequently tied while the lung is kept expanded with continuous positive pressure ventilation.16 Finally, the chest and abdominal wounds are closed in standard fashion. With this approach, we did not notice an in849
crease in the number of postoperative pulmonary complications. Previous reports have noted pneumonia and wound infections to be the most common complications after thoracoabdominal nephrectomy.8,9,14 No patient developed pneumonia, which is attributed to aggressive chest physiotherapy, early ambulation, and the judicious use of preoperative antibiotics. Furthermore, no postoperative wound complications were noted in our group. We attribute this to stringent mechanical and antibiotic bowel preparation preformed preoperatively, the administration of a broad-spectrum antibiotic 30 minutes before incision, and meticulous closure of the extensive wound. Our most common postoperative complication was the development of arrhythmias in 8 patients; six with supraventricular tachycardia (SVT) and two with atrial fibrillation. All 6 patients with SVT had resolution of their SVT without any postoperative sequelae. The 2 patients with atrial fibrillation had their rate initially controlled by Lanoxin, and 6 months postoperatively they had a normal sinus rhythm without the need for Lanoxin to control their heart rate or rhythm. The next most common complication was postoperative fever, manifested by atelectasis on chest radiographs. With aggressive chest physiotherapy and early ambulation, these transient febrile episodes did not require further evaluation or treatment. Another common complication was the development of pleural effusions on the ipsilateral side in patients without a thoracostomy tube placed. Placement of a thoracostomy tube not only evacuates any air from the pleural space but also evacuates any fluid that may accumulate from the surgical trauma in the pleural space. No patient with a thoracostomy tube had a pleural effusion noted on the postoperative chest radiographs. Even though patients without a thoracostomy tube had a higher incidence on pleural effusions, the effusions were not symptomatic, and none required postoperative treatment. Some of the unusual postoperative complications seen in our study group included 1 patient with jaundice and 1 patient with pseudomembranous colitis. The patient who developed jaundice postoperatively had had a large right-sided renal cell carcinoma resected with a small liver resection for localized disease and cholecystectomy for cholelithiases. Because of the extensive dissection around the porta hepatis, the patient developed a transient episode of jaundice with elevation of direct bilirubin. The jaundice resolved without any medical intervention. The patient who developed pseudomembranous colitis received prophylactic antibiotics before the surgical procedure, which were thought to be the culprit. The patient was 850
successfully treated with oral vancomycin and had no postoperative sequelae. We noted a decrease in the length of stay in patients without a thoracostomy tube compared with patients with a thoracostomy tube (7.07 ⫾ 3.97 days versus 9.14 ⫾ 2.65 days, respectively). These patients also had lower hospital charges ($13,970.17 without a thoracostomy tube versus $19,405.81 with a thoracostomy tube). Just in this small study, the overall projected cost savings for all of our patients undergoing thoracoabdominal radical nephrectomy without thoracostomy tube placement was $59,792.04. Within the past several months, 2 patients undergoing radical thoracoabdominal nephrectomy without thoracostomy tube placement intraoperatively were discharged home on the fourth postoperative day. Because of the decrease in hospital charges and no increase in postoperative complications in patients undergoing thoracoabdominal radical nephrectomy without thoracostomy tube placement, we believe that thoracoabdominal radical nephrectomy can be performed safely and efficiently without the placement of a thoracostomy tube if the visceral pleura has not been breached. If the visceral pleura is breached for whatever reason, we believe a thoracostomy tube should be placed and managed in the usual fashion. CONCLUSIONS We realize the limitation of this retrospective study with its inherent biases in analyzing the length of hospital stay and charges in the two groups; thus, a prospective randomized study is necessary to better assess these and other points. However, we demonstrated that in patients without parietal pleural injury, thoracoabdominal radical nephrectomy without thoracostomy tube placement can be performed safely and effectively, with a low risk of postoperative complications and a decrease in overall hospital stay and hospital charges. REFERENCES 1. Marshall DF: Urogenital wounds in an evacuation hospital. J Urol 55: 119 –132, 1946. 2. Chute R, and Soutter L: Thoraco-abdominal nephrectomy for large kidney tumors. J Urol 61: 688 – 696, 1949. 3. Chute R, Soutter L, and Kerr WS: The value of the thoraco-abdominal incision in the removal of kidney tumors. N Engl J Med 241: 951–1000, 1949. 4. Novick AC, and Cosgrove DM: Surgical approach for removal of renal cell carcinoma extending into the vena cava and the right atrium. J Urol 123: 947–950, 1980. 5. Barry J: Supracostal and thoracoabdominal approaches to radical nephrectomy, in Johnson DE, and Boileau MA (Eds): Genitourinary Tumors. New York, Grune & Stratton, 1982, pp 337–347. 6. Scott RF, and Selzman HM: Complications of nephrecUROLOGY 55 (6), 2000
tomy: review of 450 patients and a description of a modification of the transperitoneal approach. J Urol 95: 307–312, 1996. 7. Skinner DG: Thoraco-abdominal approach to retroperitoneal surgery, in Johnson DE, and Boileau MA (Eds): Genitourinary Tumors. New York, Grune & Stratton, 1982, pp 169 –183. 8. Schmiedt E, Carl P, and Wanner K: Thoraco-abdominal approach in tumour nephrectomy. Int Urol Nephrol 4: 253– 261, 1975. 9. Khourny EN: Thoraco-abdominal approach in lesions of the kidney, adrenal and testis: morbidity studies. J Urol 96: 631– 634, 1966. 10. Christmas TJ: Retrocrural lymph node metastases from testis germ cell tumours: removal via a thoraco-abdominal extraperitoneal approach after chemotherapy. Br J Urol 79: 468 – 470, 1997.
UROLOGY 55 (6), 2000
11. Christmas TJ, Doherty AP, Rustin GJS, et al: Excision of residual masses of metastatic germ cell tumours after chemotherapy: the role of extraperitoneal surgical approaches. Br J Urol 81: 301–308, 1998. 12. Iberti TJ, and Stern PM: Chest tube thoracostomy. Crit Care Clin 8: 879 – 895, 1992. 13. Mortensen H: Transthoracic nephrectomy. J Urol 60: 855– 858, 1948. 14. Robson CJ: Results of radical thoraco-abdominal nephrectomy in the treatment of renal cell carcinoma. Prog Clin Biol Res 100: 481– 488, 1982. 15. Cole AT, Fried FA, and Bissada NK: The supine subcostal modification of the thoraco-abdominal incision. J Urol 112: 168 –171, 1974. 16. Poore RE, Sexton WJ, Hart LJ, et al: Is radiographic evaluation of the chest necessary following flank surgery? J Urol 155: 849 – 851, 1996.
851
THORACOABDOMINAL RADICAL NEPHRECTOMY: IS A POSTOPERATIVE THORACOSTOMY TUBE NECESSARY? CHARLES J. ROSSER, DAVID L. MCCULLOUGH,
AND
M. CRAIG HALL
ABSTRACT Objectives. To report our results of patients undergoing thoracoabdominal radical nephrectomy without intraoperative placement of a thoracostomy tube. It has been routine in our hospital to not place a thoracostomy tube in patients undergoing thoracoabdominal radical nephrectomy since 1988. Methods. We conducted a retrospective review of 47 thoracoabdominal radical nephrectomies performed from January 1988 through November 1998 at our institution. Of the 47 patients, 39 did not have a thoracostomy tube placed intraoperatively; the other 8 patients did. The development of all postoperative complications, length of hospital stay, and hospital charges were noted. Results. No postoperative mortality was noted in our study. Of the 47 patients in the study, 20 patients had a total of 29 complications. The overall number of complications was not increased in the group without a thoracostomy tube compared with the group with a thoracostomy tube (P ⫽ 0.104). No patient treated without a thoracostomy tube required subsequent placement of a tube for persistent pneumothorax. The mean length of hospital stay in patients with a thoracostomy tube after radical nephrectomy was 9.14 ⫾ 2.65 days; in patients without a thoracostomy tube, the mean length of stay was 7.07 ⫾ 3.97 days (P ⫽ 0.071). Conclusions. In patients without parietal pleural injury, thoracoabdominal radical nephrectomy without the placement of a thoracostomy tube can be performed safely and effectively, with a low risk of postoperative complications and a decrease in the overall hospital stay and hospital charges. UROLOGY 55: 847–851, 2000. © 2000, Elsevier Science Inc.
T
he thoracoabdominal incision was first described by Marshall1 in 1946 for combined kidney, chest, and abdominal injuries. Subsequently, in 1949, Chute and associates2,3 adopted the thoracoabdominal approach for resecting large renal tumors. By definition the thoracoabdominal radical nephrectomy implies transpleural, transdiaphragmatic, and transabdominal exposure of retroperitoneal structures and the pleural and peritoneal cavities through a ninth or tenth rib incision. The advantage of this incision over a standard flank incision, transperitoneal incision, or lumbar incision is that the incision gives wide and excellent exposure of the involved kidney, ultimately allowing primary ligation of the renal vasculature before manipulation of the tumor. Furthermore, the thoracoabdominal incision allows for the re-
From the Department of Urology, Wake Forest University School of Medicine, Winston-Salem, North Carolina Reprint requests: Charles J. Rosser, M.D., Department of Urology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157 Submitted: August 9, 1999, accepted (with revisions): September 21, 1999 © 2000, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
moval of Gerota’s fascia, the ipsilateral adrenal gland, and local lymph nodes. The disadvantages of the thoracoabdominal incision include that it is a large incision that crosses many muscles and that it is an incision that opens the retroperitoneal, peritoneal, and pleural cavities. Indications for a thoracoabdominal approach during a radical nephrectomy include a large upper pole tumor (greater than 7 cm), adjacent organ involvement, inferior vena cava involvement with tumor,4 or the surgeon’s preference.5,6 The standard intraoperative procedure in patients undergoing a thoracoabdominal approach includes placement of a thoracostomy tube to evacuate fluid and air from the pleural space.5–11 The pleura consist of the visceral pleura, which surrounds the lung parenchyma, the parietal pleura, which covers the inside of the thoracic cage, and the pleural fluid, which is found in between the visceral and parietal pleura.12 On the inception of the thoracoabdominal nephrectomy in the 1940s, if the visceral pleura was not injured, the diaphragm and pleura were closed, and the lung reexpanded without the placement of a thoracos0090-4295/00/$20.00 PII S0090-4295(99)00457-4 847
TABLE I. Patient characteristics Variables Age (yr) Sex (M/F) Tobacco use (Y/N) COPD (Y/N) Side of nephrectomy (R/L)
Thoracostomy Tube (n ⴝ 8)
No Thoracostomy Tube (n ⴝ 39)
P Value
61.2 ⫾ 13.2 6/2 6/2 0/8 6/2
58.8 ⫾ 15.4 20/19 14/25 3/36 28/11
0.301 0.178 0.143 0.211 0.674
KEY: M/F ⫽ male/female; Y/N ⫽ yes/no; COPD ⫽ congestive obstructive pulmonary disease; R/L ⫽ right/left.
tomy tube.2,3,13 However, over time it became commonplace for urologists to place a thoracostomy tube at the completion of the procedure. Since 1988, we have routinely not placed a thoracostomy tube in our patients undergoing radical thoracoabdominal nephrectomy. Therefore, we report our experience of patients undergoing thoracoabdominal radical nephrectomy without intraoperative placement of a thoracostomy tube. To our knowledge no such study has been undertaken. MATERIAL AND METHODS We conducted a retrospective review of 50 thoracoabdominal radical nephrectomies performed as described by Skinner7 from January 1988 through November 1998 at our institution. Of the 50 patients, 39 did not have a thoracostomy tube placed intraoperatively, and the other 11 patients did. Eight of the 11 patients with thoracostomy tubes were patients of one attending physician who routinely placed a thoracostomy tube after thoracoabdominal nephrectomy. The other 3 patients with postoperative thoracostomy tubes were excluded from the study because 2 patients had undergone lung resection of metastatic disease and 1 patient had known violation of the visceral pleura on opening the thoracic cavity and thus had a thoracostomy tube placed intraoperatively. This patient’s pleura defect was closed anatomically with absorbable suture. The medical records of the 47 patients were extensively reviewed. Each flank surgery was considered an independent event. Furthermore, the operative reports were reviewed for what side the nephrectomy was performed on, whether a rib was resected, whether the visceral pleura was violated, and whether other surgical procedures were performed during the same operation. All postoperative chest radiographs were interpreted by an attending radiologist. The development of postoperative complications, length of hospital stay, and patient charges were noted.
PATIENT AND TUMOR CHARACTERISTICS Of the 47 patients, 25 were men (53.1%) and 22 were women (46.9%); the mean age of patients in the study was 61.2 ⫾ 13.2 years (range 26 to 90). Three patients had a past medical history significant for pulmonary complications, two with a history of chronic obstructive pulmonary disease and one with a history of asthma. Of the 47 patients, 21 reported a significant history of tobacco use (more than 1 pack daily). A right-sided radical nephrectomy was done in 35 patients and a left-sided radical nephrectomy in 12 patients. All but 1 patient had a rib resected to facilitate exposure. Table I summarizes the patient characteristics in both groups. Table II presents the 848
TABLE II. Stage of tumor resected Tumor Stage
Thoracostomy Tube (n ⴝ 8)
No Thoracostomy Tube (n ⴝ 39)
1 2 3 4
0 1 7 0
4 12 20 3
TABLE III. Additional operations/procedures performed at the time of radical nephrectomy* Procedure
Thoracostomy Tube (n ⴝ 8)
Hepatic resection Splenectomy Cholecystectomy Partial small bowel resection Oophorectomy Total
No Thoracostomy Tube (n ⴝ 39)
0 1 1 0
3 2 3 2
0 2
1 11
* P ⫽ 0.159.
stage of the renal tumors in both groups. Of the 47 renal tumors resected, 43 were renal cell carcinoma, 1 was liposarcoma, 1 was lymphoma, 1 was angiomyolipoma, and 1 was a multilocular cyst.
OTHER OPERATIONS OR PROCEDURES Fifteen of the 47 patients in the study had other procedures performed at the time of the radical nephrectomy. Table III illustrates the additional operations or procedures performed in both groups.
STATISTICAL ANALYSIS Data analysis was performed using computer software. Calculations of statistical significance were performed using Student’s t test, Fisher’s exact test, and chi-square analysis.
RESULTS No postoperative mortality was noted in our study. Of the 47 patients in the study, 20 patients had a total of 26 complications. Table IV depicts all UROLOGY 55 (6), 2000
TABLE IV. Postoperative complications* Complications
Thoracostomy No Thoracostomy Tube Tube (n ⴝ 39) (n ⴝ 8)
Prolonged intubation Fever 2° atelectasis Pleural effusion Ileus Pulmonary embolus Arrhythmias Jaundice Pseudomembranous colitis Total
0 1 0 1 0 2 0 0
0 6 6 0 2 6 1 1
4
22
* P ⫽ 0.117.
the complications encountered in both groups. The overall number of complications was not increased in the group without thoracostomy tube placement compared with the group with thoracostomy tube placement (P ⫽ 0.117). One of the 8 patients with a thoracostomy tube had a persistent pneumothorax. The mean number of days a patient had a thoracostomy tube in place was 3.73 ⫾ 3.44 days. Seven of the 39 patients who did not have a thoracostomy tube placed intraoperatively developed pneumothoraces. These pneumothoraces were without symptoms and were small, with a mean size of 10%. The mean time to resolution of these pneumothoraces was approximately 2.33 days (range 1 to 4). All the patients with persistent pneumothoraces were observed, and none experienced adverse sequelae or required placement of a thoracostomy tube or needle aspiration. The only complication that was elevated in patients without a thoracostomy tube compared with patients with a thoracostomy tube was the development of pleural effusions. Pleural effusions were noted in 6 patients without a thoracostomy tube. No patients with a thoracostomy tube developed pleural effusions. These effusions were characterized as small (less than 5% to 10%) and asymptomatic. All the patients with pleural effusions were observed, and none experienced adverse sequelae or required the placement of a thoracostomy tube or needle aspiration. The mean length of hospital stay in patients with a thoracostomy tube after radical nephrectomy was 9.14 ⫾ 2.65 days; in patients without a thoracostomy tube, the mean length of stay was 7.07 ⫾ 3.97 days (P ⫽ 0.071). Patients with a thoracostomy tube in place had on average six more chest radiographs during their postoperative convalescence than patients without a thoracostomy tube. As would be expected with the increase in hospital stay and increase in radiographs, the average hospital cost of a patient undergoing thoracoabdomiUROLOGY 55 (6), 2000
nal radical nephrectomy with intraoperative placement of a thoracostomy tube was $19,405.81; the average hospital cost of a patient undergoing thoracoabdominal nephrectomy without intraoperative placement of a thoracostomy tube was $13,970.17. Thus, the hospital charges for patients without a thoracostomy tube were on average $5435.64 less than for patients with a thoracostomy tube. COMMENT Previous reports quote postoperative complication rates after thoracoabdominal nephrectomy of between 24% and 50% and a mortality rate of 6.8% to 8.3%.8,9,14 We had no mortalities in our study group, which can be attributed to better surgical technique and better intraoperative care and improved postoperative critical care. Our overall complication rate was 55.3%. This rate was not elevated when assessing patients with and without thoracostomy tubes (50% versus 56%). Cole and associates15 mentioned not observing an increase in morbidity in an unspecified number of patients undergoing thoracoabdominal nephrectomy without the placement of a thoracostomy tube. In the 39 patients in our study without a thoracostomy tube, pneumothoraces were evident in 7 patients compared with 1 of the 8 patients with a thoracostomy tube. However, of these 7 patients with pneumothoraces, none were symptomatic and none required thoracostomy tube placement or aspiration of the pneumothorax. These pneumothoraces were characterized as small (less than 10%) and were only evident on the immediate postoperative chest radiograph routinely performed to detect postoperative pneumothorax. We found that the key to not having to place a thoracostomy tube intraoperatively was our closure of the chest and diaphragm. The diaphragm is adequately mobilized to facilitate closure. Before closing the diaphragmatic pleurotomy, a 12F rubber catheter is placed in the pleural space and the pleura closed with a running absorbable suture. The surrounding diaphragm may be incorporated into this suture line to bolster it. The lung is expanded with positive pressure ventilation, and the remaining air is evacuated with direct negative pressure aspiration through the catheter or by placement of the tip of the catheter in a fluid-filled container. The catheter is removed when no more air can be aspirated or when bubbling ceases in the “water seal device.” The suture is subsequently tied while the lung is kept expanded with continuous positive pressure ventilation.16 Finally, the chest and abdominal wounds are closed in standard fashion. With this approach, we did not notice an in849
crease in the number of postoperative pulmonary complications. Previous reports have noted pneumonia and wound infections to be the most common complications after thoracoabdominal nephrectomy.8,9,14 No patient developed pneumonia, which is attributed to aggressive chest physiotherapy, early ambulation, and the judicious use of preoperative antibiotics. Furthermore, no postoperative wound complications were noted in our group. We attribute this to stringent mechanical and antibiotic bowel preparation preformed preoperatively, the administration of a broad-spectrum antibiotic 30 minutes before incision, and meticulous closure of the extensive wound. Our most common postoperative complication was the development of arrhythmias in 8 patients; six with supraventricular tachycardia (SVT) and two with atrial fibrillation. All 6 patients with SVT had resolution of their SVT without any postoperative sequelae. The 2 patients with atrial fibrillation had their rate initially controlled by Lanoxin, and 6 months postoperatively they had a normal sinus rhythm without the need for Lanoxin to control their heart rate or rhythm. The next most common complication was postoperative fever, manifested by atelectasis on chest radiographs. With aggressive chest physiotherapy and early ambulation, these transient febrile episodes did not require further evaluation or treatment. Another common complication was the development of pleural effusions on the ipsilateral side in patients without a thoracostomy tube placed. Placement of a thoracostomy tube not only evacuates any air from the pleural space but also evacuates any fluid that may accumulate from the surgical trauma in the pleural space. No patient with a thoracostomy tube had a pleural effusion noted on the postoperative chest radiographs. Even though patients without a thoracostomy tube had a higher incidence on pleural effusions, the effusions were not symptomatic, and none required postoperative treatment. Some of the unusual postoperative complications seen in our study group included 1 patient with jaundice and 1 patient with pseudomembranous colitis. The patient who developed jaundice postoperatively had had a large right-sided renal cell carcinoma resected with a small liver resection for localized disease and cholecystectomy for cholelithiases. Because of the extensive dissection around the porta hepatis, the patient developed a transient episode of jaundice with elevation of direct bilirubin. The jaundice resolved without any medical intervention. The patient who developed pseudomembranous colitis received prophylactic antibiotics before the surgical procedure, which were thought to be the culprit. The patient was 850
successfully treated with oral vancomycin and had no postoperative sequelae. We noted a decrease in the length of stay in patients without a thoracostomy tube compared with patients with a thoracostomy tube (7.07 ⫾ 3.97 days versus 9.14 ⫾ 2.65 days, respectively). These patients also had lower hospital charges ($13,970.17 without a thoracostomy tube versus $19,405.81 with a thoracostomy tube). Just in this small study, the overall projected cost savings for all of our patients undergoing thoracoabdominal radical nephrectomy without thoracostomy tube placement was $59,792.04. Within the past several months, 2 patients undergoing radical thoracoabdominal nephrectomy without thoracostomy tube placement intraoperatively were discharged home on the fourth postoperative day. Because of the decrease in hospital charges and no increase in postoperative complications in patients undergoing thoracoabdominal radical nephrectomy without thoracostomy tube placement, we believe that thoracoabdominal radical nephrectomy can be performed safely and efficiently without the placement of a thoracostomy tube if the visceral pleura has not been breached. If the visceral pleura is breached for whatever reason, we believe a thoracostomy tube should be placed and managed in the usual fashion. CONCLUSIONS We realize the limitation of this retrospective study with its inherent biases in analyzing the length of hospital stay and charges in the two groups; thus, a prospective randomized study is necessary to better assess these and other points. However, we demonstrated that in patients without parietal pleural injury, thoracoabdominal radical nephrectomy without thoracostomy tube placement can be performed safely and effectively, with a low risk of postoperative complications and a decrease in overall hospital stay and hospital charges. REFERENCES 1. Marshall DF: Urogenital wounds in an evacuation hospital. J Urol 55: 119 –132, 1946. 2. Chute R, and Soutter L: Thoraco-abdominal nephrectomy for large kidney tumors. J Urol 61: 688 – 696, 1949. 3. Chute R, Soutter L, and Kerr WS: The value of the thoraco-abdominal incision in the removal of kidney tumors. N Engl J Med 241: 951–1000, 1949. 4. Novick AC, and Cosgrove DM: Surgical approach for removal of renal cell carcinoma extending into the vena cava and the right atrium. J Urol 123: 947–950, 1980. 5. Barry J: Supracostal and thoracoabdominal approaches to radical nephrectomy, in Johnson DE, and Boileau MA (Eds): Genitourinary Tumors. New York, Grune & Stratton, 1982, pp 337–347. 6. Scott RF, and Selzman HM: Complications of nephrecUROLOGY 55 (6), 2000
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