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Journal of Peking University (Health Sciences) ›› 2023, Vol. 55 ›› Issue (5): 825-832. doi: 10.19723/j.issn.1671-167X.2023.05.008

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Risk factors for massive hemorrhage after radical nephrectomy and removal of venous tumor thrombus

Dong LAN1,2,Zhuo LIU1,Yu-xuan LI1,Guo-liang WANG1,Xiao-jun TIAN1,Lu-lin MA1,Shu-dong ZHANG1,Hong-xian ZHANG1,*()   

  1. 1. Department of Urology, Peking University Third Hospital, Beijing 100191, China
    2. Department of Urology, Guang'an People's Hospital, Guang'an 638500, Sichuan, China
  • Received:2023-03-25 Online:2023-10-18 Published:2023-10-09
  • Contact: Hong-xian ZHANG E-mail:zwl2006@163.com

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Abstract:

Objective: To investigate and analyze the risk factors of massive hemorrhage in patients with renal cell carcinoma and venous tumor thrombus undergoing radical nephrectomy and removal of venous tumor thrombus. Methods: From January 2014 to June 2020, 241 patients with renal cancer and tumor thrombus in a single center of urology at Peking University Third Hospital were retrospectively analyzed. All patients underwent radical nephrectomy and removal of venous tumor thrombus. The relevant preoperative indicators, intraoperative conditions, and postoperative data were statistically analyzed by using statistical software of SPSS 18.0. The main end point of the study was intraoperative bleeding volume greater than 2 000 mL. Logistic regression analysis was used to determine the relevant influencing factors. First, single factor Logistic regression was used for preliminary screening of influencing factors, and variables with single factor Logistic regression analysis P < 0.05 were included in multivariate Logistic regression. In all statistical analyses, P < 0.05 is considered statistically significant. Results: Among the 241 patients included, there were 60 cases of massive hemorrhage, 48 males and 12 females, with a median age of 62 years. The number of non-massive hemorrhage was 181. There were 136 males and 45 females, with a median age of 59 years. Univariate analysis showed that the clinical symptoms (both systemic and local symptoms, OR 2.794, 95%CI 1.087-7.181, P=0.033), surgical approach (open surgery, OR 9.365, 95%CI 4.447-19.72, P < 0.001), Mayo grade (Mayo 3-4, OR 5.257, 95%CI 2.806-10.886, P < 0.001), American Society of Anesthesiologists (ASA) score (ASA level 3, OR 2.842, 95%CI 1.338-6.036, P=0.007), preoperative hemoglobin (OR 0.978, 95%CI 0.965-0.991, P=0.001), preoperative platelet count (OR 0.996, 95%CI 0.992-1.000, P=0.037), maximum tumor thrombus width (OR 1.061, 95%CI 1.033-1.091, P < 0.001), Complicated with bland thrombus (OR 4.493, 95%CI 2.264-8.915, P < 0.001), adrenalectomy (OR 3.101, 95%CI 1.614-5.958, P=0.001), segmental resection of the inferior vena cava (OR 2.857, 95%CI 1.395-5.852, P=0.004). There was a statistically significant difference in these aspects(P < 0.05). Multivariate Logistic regression analysis showed that there was a statistically significant difference in surgical approach (open surgery, OR 6.730, 95%CI 2.947-15.368;P < 0.001), Mayo grade (Mayo 3-4, OR 2.294, 95%CI 1.064-4.948, P=0.034), Complicated with bland thrombus (OR 3.236, 95%CI 1.492-7.020, P=0.003). Conclusion: Combining the results of univariate and multivariate Logistic regression analysis, the surgical approach, Mayo grade, and tumor thrombus combined with conventional thrombus were associated risk factors for massive hemorrhage during surgery for renal cell carcinoma with tumor thrombus. Patients who undergo open surgery, high Mayo grade, and tumor thrombus combined with conventional thrombus are at a relatively higher risk of massive hemorrhage.

Key words: Renal cell carcinoma, Venous tumor thrombus, Hemorrhage

CLC Number: 

  • R737.1

Table 1

Comparison of clinicopathological characteristics between massive hemorrhage group and non-massive hemorrhage group"

Items Non-massive hemorrhage group (n=181) Massive hemorrhage group (n=60) P
Gender, n (%) 0.488
  Male 136 (75.1) 48 (80.0)
  Female 45 (24.9) 12 (20.0)
Age/years, M (P25, P75) 59 (53, 66) 62 (54, 68) 0.122
Clinical symptoms, n (%) 0.175
  None 44 (24.3) 9 (15.0)
  Local symptoms 93 (51.4) 31 (51.7)
  Systematic symptoms 16 (8.8) 4 (6.7)
  Both 28 (15.5) 16 (26.7)
BMI/(kg/m2), M (P25, P75) 23.3 (21.1, 25.8) 24.3 (21.4, 26.1) 0.107
Surgical approach, n (%) < 0.001*
  Laparoscopic surgery 118 (65.2) 10 (16.7)
  Open 63 (34.8) 50 (83.3)
Mayo classification, n (%) < 0.001*
  0 56 (30.9) 4 (6.7)
  1 40 (22.1) 2 (3.3)
  2 63 (34.8) 28 (46.7)
  3 16 (8.9) 11 (18.3)
  4 6 (3.3) 15 (25.0)
ASA grade, n (%) 0.001*
  1 16 (8.8) 0 (0)
  2 146 (80.7) 45 (75.0)
  3 19 (10.5) 15 (25.0)
Preoperative serum creatinine/(μmol/L), 91 (80.5, 107) 93 (81, 112) 0.431
M (P25, P75)
Preoperative hemoglobin/(g/L), M (P25, P75) 124 (109.5, 139.5) 113 (97, 125) ＜0.001*
Preoperative neutrophil/(×109/L), M (P25, P75) 4.5 (3.4, 5.5) 4.4 (3.7, 5.1) 0.754
Preoperative lymphocyte/(×109/L), M (P25, P75) 1.3 (1.0, 1.6) 1.2 (0.9, 1.5) 0.043*
Preoperative monocyte/(×109/L), M (P25, P75) 0.4 (0.3, 0.5) 0.4 (0.3, 0.5) 0.422
Preoperative platelet/(×109/L), M (P25, P75) 241 (189.0, 303.5) 213 (167.0, 291.0) 0.033*
Lesion side, n (%) 0.646
  Left 66 (36.5) 24 (40.0)
  Right 115 (63.5) 36 (60.0)
Tumor diameter/cm, M (P25, P75) 8.8 (6.7, 10.5) 8.7 (6.8, 10.9) 0.786
Maximum tumor thrombus width/mm, M (P25, P75) 20 (15, 30) 30 (20, 35) ＜0.001*
Clinical phase of M, n (%) 0.669
  M0 126 (69.6) 40 (66.7)
  M1 55 (30.4) 20 (33.3)
Complicated with bland thrombus, n (%) < 0.001*
  No 159 (87.8) 37 (61.7)
  Yes 22 (12.2) 23 (38.3)
Adrenalectomy, n (%) 0.011*
  No 92 (50.8) 15 (25.0)
  Yes 89 (49.2) 45 (75.0)
Segmental resection of IVC, n (%) 0.003*
  No 159 (87.8) 43 (71.7)
  Yes 22 (12.2) 17 (28.3)
Lymph node dissection, n (%) 0.248
  No 100 (55.2) 28 (46.7)
  Yes 81 (44.8) 32 (53.3)
Operation time/min, M (P25, P75) 289 (218, 374) 408 (342, 499) ＜0.001*
Blood loss/mL, M (P25, P75) 400 (150, 800) 3 000 (2 250, 4 000) ＜0.001*
Intraoperative infusion volume/mL, M (P25, P75) 0 (0, 400) 2 000 (1 300, 2 800) ＜0.001*
Pathological type, n (%) 0.854
  Clear cell carcinoma 148 (81.7) 52 (86.7)
  Papillary cell carcinoma 22 (12.2) 5 (8.3)
  Chromophobe cell carcinoma 2 (1.1) 0 (0)
  Unclassified cell carcinoma 7 (3.9) 3 (5.0)
  Xp11.2 cell carcinoma 2 (1.1) 0 (0)
Nuclear classification, n (%) 0.358
  1 3 (1.7) 0 (0)
  2 68 (37.5) 17 (28.3)
  3 74 (40.9) 26 (43.4)
  4 36 (19.9) 17 (28.3)
Sarcomatoid features, n (%) 0.128
  No 160 (88.4) 48 (80.0)
  Yes 21 (11.6) 12 (20.0)
Perirenal fat infiltration, n (%) 0.063
  No 129 (71.3) 35 (58.3)
  Yes 52 (28.7) 25 (41.7)
Postoperative hospital stay/d, M (P25, P75) 8 (6, 10) 12 (8, 15) ＜0.001*
     Serum creatinine after one week/(μmol/L),
M (P25, P75)		 98 (79.0, 115.5) 93 (80.0, 121.0) 0.799
Postoperative complications, n (%) ＜0.001*
  No 139 (76.8) 18 (30.0)
  Yes 42 (23.2) 42 (70.0)
Severe postoperative complications, n (%) 0.016*
  No 173 (95.6) 51 (85.0)
  Yes 8 (4.4) 9 (15.0)

Table 2

Logistic regressive analysis of univariate and multivariate of intraoperative massive haemorrhage"

Items Univariate Multivariate
OR (95%CI) P OR (95%CI) P
Gender
  Male Referent
  Female 0.756 (0.369-1.547) 0.443
Age 1.022 (0.993-1.052) 0.132
Clinical symptoms
  None Referent Referent
  Clinical symptoms 1.630 (0.715-3.716) 0.246 0.727
  Clinical symptoms 1.222 (0.33-4.527) 0.764 0.396
  Both 2.794 (1.087-7.181) 0.033* 0.276
BMI 1.050 (0.972-1.135) 0.212
Surgical approach
  Laparoscopic surgery Referent Referent
  Open surgery 9.365 (4.447-19.720) < 0.001* 6.730 (2.947-15.368) < 0.001*
Mayo classification
  0-2 Referent Referent
  3-4 5.527 (2.806-10.886) < 0.001* 2.294 (1.064-4.948) 0.034*
ASA grade
  1-2 Referent Referent
  3 2.842 (1.338-6.036) 0.007* 0.236
Preoperative serum creatinine 1.002 (0.998-1.005) 0.340
Preoperative hemoglobin 0.978 (0.965-0.991) 0.001* 0.105
Preoperative neutrophil 1.024 (0.976-1.075) 0.327
Preoperative lymphocyte 0.538 (0.282-1.026) 0.060
Preoperative monocyte 1.642 (0.381-7.080) 0.506
Preoperative platelet 0.996 (0.992-1.000) 0.037* 0.101
Lesion side
  Left Referent
  Right 0.861 (0.473-1.566) 0.861
Tumor diameter 1.047 (0.955-1.148) 0.328
Maximum tumor thrombus width 1.061 (1.033-1.091) < 0.001* 0.782
Clinical phase of M
  M0 Referent
  M1 1.145 (0.614-2.136) 0.669
Complicated with bland thrombus 4.493 (2.264-8.915) < 0.001* 3.236 (1.492-7.020) 0.003*
Adrenalectomy 3.101 (1.614-5.958) 0.001* 0.051
Segmental resection of IVC 2.857 (1.395-5.852) 0.004* 0.870
Lymph node dissection 1.411 (0.785-2.534) 0.249
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