Urological approach for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in a clinical care center

Association of intraoperative gross hematuria with acute kidney injury after cytoreductive surgery

Objectives

Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) has been established in the management of peritoneal carcinomatosis. Although it is still necessary to take adequate measures against major postoperative complications including acute kidney injury (AKI), consensus is lacking on how to assess and stratify risk for patients with postoperative AKI after CRS-HIPEC. The aim of this retrospective cohort study was to investigate the association of intraoperative gross hematuria as a surrogate marker of ureter injury with postoperative AKI incidence.

Methods

This retrospective cohort study investigated patients without impaired preoperative kidney function who underwent CRS-HIPEC at a single referral center, and evaluated the relationship between intraoperative gross hematuria and incidence of postoperative AKI as defined by the Kidney Disease Improving Global Outcomes practice guidelines. Logistic regression analysis was performed to calculate the odds ratio of intraoperative gross hematuria for AKI, adjusting for confounding factors and other risk factors for AKI.

Results

We enrolled 185 patients (males, 37%). Twenty-five patients developed intraoperative gross hematuria. Postoperative AKI occurred in 10 (40%) of 25 patients with hematuria and 28 (17.5%) of 160 patients without hematuria. The crude odds ratio for exposure to hematuria was 3.14 (95% confidence interval, 1.30–7.60; p=0.020) for postoperative AKI. Adjusted odds ratio as estimated by multivariate logistic regression was 4.57 (95% confidence interval, 1.55–13.45; p=0.006).

Conclusions

Intraoperative gross hematuria is significantly associated with postoperative AKI incidence after CRS-HIPEC.

–

Early detection and treatment of postoperative acute kidney injury is essential.

–

How to prevent acute kidney injury after cytoreductive surgery is unclear.

–

Intraoperative hematuria is related to postoperative acute kidney injury.

–

Hematuria is easily detectable and may reflect ureter injury.

–

This may improve long-term outcomes for patients undergoing cytoreductive surgery.

Clinical features and surgical outcomes of major urological interventions during cytoreductive surgery and hyperthermic intraperitoneal chemotheraphy

Background:

Urinary system resections and reconstructions are needed in peritoneal carcinomatosis due to abdominal malignancies. The effect of hyperthermic intraperitoneal chemotherapy on these urological procedures after reconstruction remains uncertain. The aim of the study is to evaluate major urological interventions during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in complex abdominal malignancies with peritoneal carcinomatosis.

Methods:

Forty-four cases underwent surgical intervention related to the urinary system among 208 cases who underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy because of peritoneal carcinomatosis. Urinary system procedures performed in these patients (radical-partial cystectomy, partial ureter resection ureteroneocystostomy, ureteroureterostomy, nephrectomy) were evaluated in terms of postoperative morbidity–mortality and survival.

Results:

Urinary system resections were performed during cytoreductive surgery in a total of 44 cases. The mean age was 54 years (20–73). Patients were diagnosed with peritoneal carcinomatosis due to colorectal cancer in 21 (47.8%), ovarian cancer in nine (20.4%), sarcomatosis in five (11.4%), cervical cancer in four (9%) and other cancers (mesothelioma, uterus, breast, gastric) in five (11.4%) cases. Total nephrectomy was performed in three cases and partial nephrectomy in one case. Cystectomy was performed in 21 cases; 16 of these were partial and five were total cystectomies. Ureteroureterocystostomy with double J was performed in four cases and ureteroneocystostomy in 12 cases. While Clavian–Dindo grade 3–4 complications were seen in nine cases (20.4%), three cases (6.8%) became exitus during the first 30-day follow-up.

Conclusions:

Although urinary system involvements have been regarded as inoperable in the past, we think that with adequate experience radical urinary interventions performed in suitable patients can be carried out with acceptable morbidity and mortality as seen in our series.