1. Quality Assurance Conference 4/30/2015 Department of Surgery Division of Urology

2. Complications From Last Month CONFIDENTIAL COMPLICATIONS Quality Assurance Conference Division: UrologyDate: 4/30/2015 InitialsAge/SexAttendingResident/FellowDiagnosisDeath Y/NOperationComplicationAssessmentAction PH56 FKlausnerDolatInterstitial CystitisN Cysto, hydrodistention, bladder biopsy, fulgurationBladder perforation AJ56 MHamptonDolatRight orchalgiaNRight scrotal orchiectomyWound dehiscence and bleeding MA5 MKrillDolatPhimosisN Circumcision, Byars flap tissue rearrangement and V-plastyHematoma BB70 MGuruliHabibiTCCN Cystoprostatectomy, PLND, catheterizable pouchReadmission, partial SBO WM66 MOrtonZhouTCCNTURBT with mitomycinReadmission, leukocytosis, AKI Assessment: Error in Technique (ET) Error in Judgement (EJ) Error in Diagnosis (ED) Systems Error(SE) Patient Disease (PD) 1Error unavoidable or minimal effect on patient outcome 2Preventable Error 3Error with significant deleterious effect on patient outcomePlease highlight the case you find to be the best educational case Submit your list to Doris Farquhar on a weekly basis

3. Service VA Joseph Habibi Shaoqing Zhou Sarah Caulkins Lab -Jay Sulek VCU Albert Petrossian Mary Ellen Dolat Andrew Colhoun E. D. Bell

4. Case Presentation Staff: B. Mayer Grob, MD; Gabor Bagameri, MD Resident: Albert Petrossian, MD Diagnosis: Renal mass with atrial thrombus Operation: Right nephrectomy, cavotomy, cardiopulmonary bypass, thrombectomy Other services: Cardiothoracic surgery Complication: DIC Outcome: Death

5. Background HPI -30 yo woman who was otherwise healthy presented to outside ER with shortness of breath, palpitations and right flank pain. CT scan showed presence of large renal mass extending into IVC and right atrium. Imaging also showed liver lesions as well as lung nodules that were suspicious for metastatic disease. -She underwent a FNA of the renal mass with path showing spindle cell neoplasm with the differential of sarcomatoid renal cell carcinoma or leiomyosarcoma.

6. Background (cont’d) PMH –Possible hypothyroidism but does not take any meds PSH –None Meds –Ferrous sulfate, folic acid, multivitamins SH –Quit smoking 6 years ago –Married with children FM –Positive for breast cancer in aunt.

7. Imaging CT abd/pelvis with and w/o contrast shows a heterogeneously enhancing and calcified 7.4cm mass in the right renal hilum with extension into bilateral renal veins, infrarenal and suprarenal IVC, hepatic veins, and extension into right atrium across the tricuspid valve into the right ventricle Mesenteric lymphadenopathy seen as well.

8. Imaging

10. Labs Na143 K 3.9 Cr0.91 AST40 ALT26 Bili, T3.7 Album3.7 WBC9.0 Hgb11.2 Plt163 UA neg PT18.5 INR1.6 APTT35

11. Pathology Paracentesis was performed and ascitic fluid was submitted for cytology. Macrophages and atypical cells were seen, but inconclusive.

12. Operative Course Patient was admitted preoperatively for bowel prep and venous access. She proceeded to the operating room the next day concomitantly with cardiothoracic surgery and transplant surgery A hemi-chevron incision was made. No evidence of obvious peritoneal disease or carcinomatosis upon entry. Colon was reflected and the duodenum was Kocherized Renal vessels isolated and right nephrectomy performed.

13. Operative Course Mobilization of the liver was performed by Transplant Surgery. Cardiopulmonary bypass initiated by Cardiothoracic Surgery. Right atrium and supra- and infra-hepatic vena cava was entered. Tumor bulk was removed. However the tumor was noted to be invading into the atrial septum thus complete resection was not possible. Upon reversal of CPB, patient became diffusely coagulopathic despite use of products. Temporary vacuum dressing was used on the chest and abdomen. Pt transferred to CICU on ECMO. She expired later that evening. EBL: 2.7L PRBC: 6 U FFP: 4 U Cryoprecipitate: 5 U Platelets: 4 U

14. Pathology Final pathology reported as high grade sarcoma most consistent with high grade leiomyosarcoma.

15. Literature

16. Introduction <1% of RCC have tumor thrombus extending above the hepatic veins. Most reports of upper-level thrombectomy are from single institution with small sample size. Goal is to report contemporary outcomes in a multi-center setting.

17. All patients with renal mass and level 3 or 4 IVC tumor thrombus who underwent surgery between 2000 and 2012 were selected. A total of 162 patients were identified –93 pts with thrombus extending above diaphragm (level 4) –69 pts with thrombus above hepatic vein but below diaphragm (level 3)

18. Results: -37.5% pts required cardiopulmonary bypass -IVC was incised and repaired in 76% of patients. -Median estimated blood loss was 3000ml and 93.1% required blood transfusion -Major complications (Clavien >3a) reported in 34% within 90 days -Mortality reported in 9 and 17 patients within 30 and 90 day period -4 deaths reported within 24 hours postop.

19. Predictors of perioperative mortality:

20. Conclusion 1 in 3 patients who undergo resection of upper level thrombus will experience major complications Poor performance status and low serum albumin, in addition to lymph node metastasis status, are poor prognostic factors for mortality Carefully counseling and patient selection required to manage expectations and outcome.

21. Questions or Comments