The UT Southwestern group also published their 15-year experience of managing patients with renal cell carcinoma (RCC) and IVC thrombus.2 Among 146 consecutive patients who underwent radical nephrectomy with IVC thrombectomy between 1998 and 2012, data on patient history, staging, surgical techniques, morbidity, and survival were analyzed. Additionally, complication rates between two surgical eras, 1998-2006 and 2006-2012, were assessed. The overall complication rate was 53 %, including high-grade complications (Clavien III -V) occurring in 10 % of patients. Most importantly, there was a lower incidence of overall and high-grade complications (45 % and 8 %, respectively, p = 0.008) in the last 6 years compared to the earlier surgeries included in the study (67 % and 13 % respectively, p = 0.03). The 30-day postoperative mortality was 2.7 %, the 5-year overall survival was 51%, and the 5-year cancer-specific survival was 40 %.
Dr. Master has also recently assessed outcomes of his institution’s multi-disciplinary approach.3 Patients who underwent resection of RCC with IVC tumor thrombus from 2005 to 2016 at Emory University were included for analysis. Of 140 patients, 102 (73%) had tumor thrombus below the level of the hepatic vein confluence, and 96 (69%) were performed for curative-intent, while 43 (31%) were cytoreductive procedures for clinical trial consideration. The median overall survival OS of the entire cohort was 43.8 months (5-year OS: 43%), and 73.6 months (5-year OS: 59%) for those without metastatic disease. Fifty-one patients underwent resection from 2005 to 2010 and 89 from 2011 to 2016. All procedures since 2011 were performed by the same cross-discipline dedicated team of two surgeons, composed of a surgical and urological oncologist. When comparing the two time-periods, the team-approach after 2011 had shorter operative-times (5.3 vs 6.7 hours; p = 0.009), decreased ICU-utilization (25% vs 72%; p < 0.001), and decreased ICU length-of-stay (0.4 vs 2.2 days; p = 0.001). The post-2011 group also trended towards less blood loss (1.2 vs 1.8 L), shorter average hospital length-of-stay (10 vs 11 days), and decreased 90-day mortality (6% vs 10%). Dr. Master also notes that this is not just about the surgeons, but also the residents, circulating nurses, scrub techs, post-op floor nurses, and many others involved in the team-based approach.
So, the question is why is a hybrid team necessary?
- A hybrid team of two specialties offers distinct advantages in that there are different domains of knowledge and complementary skills
- Having a co-pilot for pre-op case planning and intra-operative problem solving
- Each surgeon concentrates on different features of the case, as it is easy to lose the forest for the trees especially during complex cases
- Conversations in the operating room may include interpretation of anatomy, ie. “where is the accessory right hepatic vein?”
Dr. Master notes that there are several limitations to this data/approach, in that these are associations, not causation, and the data is scant. However, this provides an opportunity to learn from other fields. One important caveat is that many other fields feel that all team members are interchangeable (ie. the military, aviation), however Dr. Master feels that he’s not sure this pertains to complex surgery.
In summary, Dr. Master notes:
- A dedicated, cross-discipline, team-based approach optimizes patient outcome
- May improve value by decreasing case length, length of stay, and length of ICU stay
- If the patient can be an R0 resection, this may create value by avoiding the need for systemic therapies
Presented by: Viraj A. Master, MD, PhD, FACS, Director, Clinical Research Unit, Associate Chair for Clinical Affairs and Quality, Department of Urology, Emory University, Atlanta, Georgia
Written By: Zachary Klaassen, MD, MSc – Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, @zklaassen_md, at the 20th Annual Meeting of the Society of Urologic Oncology (SUO), December 4 - 6, 2019, Washington, DC
References:
1. Toren P, Abouassaly R, Timilshina N, et al. Results of a national population-based study of outcomes of surgery for renal tumors associated with inferior vena cava thrombus. Urology 2013;82(3):572-577.
2. Gayed BA, Youssef R, Darwish O, et al. Multi-disciplinary surgical approach to the management of patients with renal cell carcinoma with venous tumor thrombus: 15 year experience and lessons learned. BMC Urol 2016;16(1):43.
3. Master VA, Ethun CG, Kooby DA, et al. The value of cross-discipline team-based approach for resection of renal cell carcinoma with IVC tumor thrombus: A report of a large, contemporary, single-institution experience. J Surg Oncol 2018;118(8)1219-1226.