International Journal of Clinical Medicine, 2013, 4, 5-9
Published Online December 2013 (http://www.scirp.org/journal/ijcm)
http://dx.doi.org/10.4236/ijcm.2013.412A1002
Open Access IJCM
5
Partial Nephrectomy for Renal Cell Carcinoma: Risk
Factors for Acute Post-Operative Hemorrhage and Impact
on Subsequent Hospital Course and Complete
Nephrectomy Rate. An Analysis of 200 Consecutive Cases
James Cavalcante, Alan Perrotti, Philip Rabadi, Alicia McCarthy, Michael Perrotti*
Urologic Oncology Service, Saint Peter’s Hospital Cancer Care Center, Saint Peter’s Health Partners, Albany, New York, USA.
Received October 29th, 2013; revised November 25th, 2013; accepted December 10th, 2013
Copyright © 2013 James Cavalcante et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In accor-
dance of the Creative Commons Attribution License all Copyrights © 2013 are reserved for SCIRP and the owner of the intellectual
property James Cavalcante et al. All Copyright © 2013 are guarded by law and by SCIRP as a guardian.
ABSTRACT
Purpose: Clinical guidelines recommend partial nephrectomy (PN) as the preferred method of surgical excision of the
small renal tumor whenever feasible. PN has comparable cancer cure rates to that of radical nephrectomy in this setting,
and decreased risk of chronic kidney disease. A recognized devastating complication following partial nephrectomy is
acute post-operative hemorrhage (APOH) from the reconstructed kidney. Risk factors for hemorrhage following partial
nephrectomy remain poorly elucidated, as does the impact of hemorrhage on subsequent hospital stay. Identification of
risk factors for hemorrhage may lead to a better understanding of and reduction of this complication. Material and
Methods: We utilized a prospectively managed database comprised of patients undergoing open partial nephrectomy at
our institution by the same surgical team from January 2006 to July 2012. Clinicopathologic factors assessed APOH for
their relationships, including patient age, gender, diabetes, smoking, hypertension, coronary artery disease, American
Society of Anesthesia Score (ASA), tumor size, RENAL nephrotomy score, pathologic result, cancer margin status,
operative time, and intra-operative blood loss. The impact of APOH on subsequent hospital course was evaluated and
compared with the entire cohort. Results: Data were analyzed from 200 consecutive patients. We identified 7 patients
(3.5%) who experienced APOH. Compared with the entire cohort, APOH resulted in an increased hospital length of
stay (median, 5 days; range, 2 - 11 days, p = 0.001), an increased transfusion requirement (median, 6 units; range, 1 - 16
units. p = 0.001), a greater risk of selective angiographic embolization (median, 2 procedures; range, 0 - 3, p = 0.001),
and completion nephrectomy (n = 2, p = 0.001). One patient in the APOH group experienced cardiac arrest and was
resuscitated. Clinicopathologic factors associated with the increased risk of APOH in the present cohort were male gen-
der (p = 0.03) and hypertension (p = 0.006). Conclusion: In the present analysis, APOH was associated with extended
hospitalization, the increased transfusion requirement and the need for more ancillary procedures. APOH patients were
at significantly increased risk of renal loss. Male gender and hypertension were associated with increased risk for
APOH. We have incorporated this information into an APOH risk reduction program at our institution.
Keywords: Kidney Neoplasms; Partial Nephrectomy; Renal Cell Carcinoma
1. Introduction
Clinical guidelines recommend partial nephrectomy (PN)
as the preferred method of surgical excision of the small
renal tumor whenever feasible [1]. PN has comparable
cancer cure rates to that of radical nephrectomy in this
setting [2], and decreased risk of chronic kidney disease
[3]. A recognized devastating complication following
partial nephrectomy is acute post-operative hemorrhage
(APOH) from the reconstructed kidney. Risk factors for
hemorrhage following partial nephrectomy remain poorly
elucidated, as does the impact of hemorrhage on subse-
quent hospital stay. Identification of risk factors for he-
*Corresponding author.

Partial Nephrectomy for Renal Cell Carcinoma: Risk Factors for Acute Post-Operative Hemorrhage
and Impact on Subsequent Hospital Course and Complete Nephrectomy Rate.
6
An Analysis of 200 Consecutive Cases
morrhage may lead to a better understanding of and re-
duction of this complication. In the present investigation,
we sought to determine risk factors for acute post-opera-
tive hemorrhage after partial nephrectomy utilizing a
prospectively managed patient database. We also evalu-
ated the impact of APOH on subsequent hospital stay.
2. Material and Methods
A prospectively managed database was utilized com-
prised of patients undergoing open partial nephrectomy
at our institution. The current investigation includes all
patients operated from January 2006 to July 2012 by a
single surgical team. Clinicopathologic factors assessed
for their relationship to APOH included patient age,
gender, diabetes, smoking, hypertension, coronary artery
disease, American Society of Anesthesia Score (ASA),
R.E.N.A.L. nephrotomy score [4], tumor size, pathologic
result, cancer margin status, operative time, and intra-
operative blood loss. The impact of APOH on subsequent
hospital course was evaluated and compared to the entire
cohort.
We identified patients with and without APOH. For
the purposes of this investigation, APOH was defined as
acute post-operative drop in hemoglobin (<8 mg/dl) and
radiographic CT scan evidence of either peri-nephric
retroperitoneal hematoma or blood within the renal col-
lecting system of the operated kidney. APOH could be
associated with acute hypotension (i.e., systolic BP < 100
mmHg), gross hematuria and increasing flank pain, but
this was not required for the diagnosis of APOH. Evalu-
ated subsequent hospital course outcome measures in-
cluded blood transfusion, renal angiography procedure
with or without selective renal embolization, and com-
pletion nephrectomy.
Univariate statistical analysis was performed using the
X2 test and Fisher’s exact test as appropriate for cate-
gorical data [5]. These included gender, hypertension,
smoking, diabetes, coronary artery disease, American
Society of Anesthesiologists (ASA) score (dichotomized
as 1 and 2 versus 3, 4 and 5), tumor laterality, pathologic
result (cancer versus benign), surgical margin status (i.e.,
cancer at margin versus not). The Mann-Whitney test [5]
was utilized for continuous data including age, tumor
size, R.E.N.A.L. nephrotomy score, operative time, renal
artery clamp time, and intra-operative blood loss.
In assessing the impact of APOH on subsequent hos-
pital course, measured variables were dichotomized as
length of stay (LOS) ≤3 days versus >3 days; transfusion
as none versus ≥1 unit of packed red blood cell (PRBC);
no angiographic embolization versus angiographic em-
bolization regardless of number of procedures performed
for each patient; completion nephrectomy as either per-
formed or not performed.
3. Results
Data were analyzed from 200 consecutive patients oper-
ated from January 1st, 2006 to July 30th 2012. Table 1
presents the clinicopathologic features for the APOH
cohort and the non-APOH cohort.
APOH was identified in 7 patients. The only clinico-
pathologic factor associated with increased risk of APOH
in the present cohort were male gender (p = 0.03) and
hypertension (p = 0.006). This data is shown in Table 1.
Only a subset of the current cohort had calculation of
R.E.N.A.L. nephrotomy score following its description in
2009. In the present investigation, R.E.N.A.L. nephro-
tomy score did not correlate with APOH in the subset
evaluated. Age, diabetes, smoking, coronary artery dis-
ease, American Society of Anesthesia Score (ASA), tu-
mor size, pathologic result, cancer margin status, opera-
tive time, and intra-operative blood loss did not correlate
with APOH.
Table 2 illustrates the impact of APOH on subsequent
hospital course. Compared to the entire cohort, APOH
resulted an increased hospital length of stay (median, 5
days; range, 2 - 11 days, p = 0.001), increased transfu-
sion requirement (median 6 units; range, 1 - 16 units, p =
0.001), greater risk of selective angiographic emboliza-
tion (median, 2 procedures; range, 0 - 3, p = 0.001), and
greater risk of completion nephrectomy (n = 2, p =
0.001). One patient in the APOH group experienced car-
diac arrest and was resuscitated. There were no deaths in
either cohort.
4. Discussion
It is estimated that there will be 65,140 new cases of
kidney cancer in the United States in 2013, and the inci-
dence is increasing [6,7]. Greater than 70% of newly
detected renal tumors are incidentally detected, often less
than 4 cm [8], and potentially amenable to either surveil-
lance (lesions ≤ 2 cm), emerging percutaneous treatments
(i.e., radiofrequency ablation; cryosurgery), compete
nephrectomy and partial nephrectomy [9]. For those pa-
tients felt best to be managed with surgical excision,
clinical guidelines recommend partial nephrectomy (PN)
as the preferred method of surgical excision of the small
renal tumor whenever feasible [1]. PN has comparable
cancer cure rates to that of radical nephrectomy in this
setting [2], and decreased risk of chronic kidney disease
[3]. Despite this, investigators have reported that PN ap-
pears to be underutilized in the United States, even in
Open Access IJCM

Partial Nephrectomy for Renal Cell Carcinoma: Risk Factors for Acute Post-Operative Hemorrhage
and Impact on Subsequent Hospital Course and Complete Nephrectomy Rate.
An Analysis of 200 Consecutive Cases
Open Access IJCM
7
Table 1. Clinical features of patient with and without acute post-operative hemorrhage.
APOH Cohort Non-APOH Cohort
Pt. No. 7 193
Age (years) 60 (54 - 73) 58 (28 - 84) p = NS
Tumor Size (cm) 3.1 (2.2 - 7.5) 2.8 (0.6 - 11) p = NS
Gender p = 0.03
Male 7 (100%) 115 (59%)
Female - 78 (41%)
Tumor Side p = NS
Left 3 (42%) 92 (48%)
Right 4 (57%) 101 (52%)
Hypertension 7 (100%) 96 (49%) p = 0.006
Diabetes 1 (14%) 23 (12%) p = NS
Smoking 3 (42%) 84 (43%) p = NS
CAD 1 (14%) 22 (11%) p = NS
ASA 2 (2 - 3) 2 (2 - 3) p = NS
APOH = acute post-operative hemorrhage; Pt. No. = patient number; ASA = American Society of Anesthesiology score; age, tumor size and ASA are expressed
as the median and range; NS = statistically not significantly different.
Table 2. Impact of acute post-operative hemorrhage on subsequent hospital course.
APOH Cohort Non-APOH Cohort
Length of Stay p = 0.001
≤3 days 1 (14%) 140 (72%)
>3 day 6 (85%) 53 (27%)
Transfusion p = 0.001
none 1 (14%) 184 (95%)
≥1 unit PRBC 6 (85%) 9 (5%)
Renal Angiography p = 0.001
none 2 (28%) -
≥1 procedure 5 (72%) 193 (100%)
Completion Nephrectomy p = 0.001
yes 2 (28%) 4 (2%)
no 5 (72%) 189 (98%)
APOH = acute post-operative hemorrhage; PRBC = packed red blood cells; renal angiography denotes angiogram of the bleeding kidney with or without at-
tempted embolization.
patients with pre-existing renal insufficiency who may
benefit most from PN [9]. Investigators utilizing the Na-
tional Cancer Database recently reported a decrease in
the median tumor size of stage 1 tumors from 4.1 to 3.6
cm between 1993 and 2004 [10], indicating that many of
these tumors may be amenable to partial nephrectomy.

Partial Nephrectomy for Renal Cell Carcinoma: Risk Factors for Acute Post-Operative Hemorrhage
and Impact on Subsequent Hospital Course and Complete Nephrectomy Rate.
8
An Analysis of 200 Consecutive Cases
However, a recent analysis utilizing the Surveillance,
Epidemiology ad End Results program during that same
time period showed that in the US only 35.2% of patients
with T1a (≤4 cm) renal masses received partial nephrec-
tomy between 1999 and 2006 [11]. That same study re-
vealed that only 50% of tumors <2 cm were treated with
partial nephrectomy, and 48% of tumors between 2 and 4
cm were treated with partial nephrectomy [12].
There is increasing evidence that surgically induced
chronic kidney disease [13,14] following complete neph-
rectomy is associated with increased risk of cardiovascu-
lar disease including death [15,16] and metabolic adverse
consequences including anemia, acidosis, and osteoporo-
sis [17,18] and associated significant adverse health con-
sequences.
The reason for underutilization of partial nephrectomy
compared to radical nephrectomy for management of the
T1a (<4 cm) and select T1b 4 - 7 cm) renal mass is un-
clear, and is beyond the scope of the current investigation.
Investigators have suggested that the explanation may be
multifactorial, including physician and patient factors,
and that the decision making requires complex multi
perspective reasoning [19]. It is generally recognized that
partial nephrectomy is a complex procedure requiring
surgical expertise, a dedicated operating room team and
advanced surgical technology, and that partial nephrec-
tomy is associated with increased surgical risk both in-
tra-operative and post-operative, the most devastating
being post-operative hemorrhage. The present study
sought to identify risk factors for APOH after partial
nephrectomy. Though a rare event, APOH increased the
hospital length of stay, the transfusion rate, the need for
ancillary procedures and most importantly, the complete
nephrectomy rate which was 29% in the APOH cohort
compared to 2% in the non-APOH group. Furthermore,
we sought to identify risk factors associated with APOH.
So that such knowledge may allow preemptive risk re-
duction. At our institution all hypertensive males are
treated under the care of a cardiologist to maximize hy-
pertension management for at least 1 month prior to par-
tial nephrectomy. In addition, we have instituted a
peri-operative protocol to maintain normotensive status
throughout the intra-operative and post-operative period.
Whereas in the past all patients received PRN supple-
mental meds for hypertension, now our protocol admin-
isters that medication (usually beta-blockade) as standing
order with hold parameter (i.e. Systolic BP < 100 mmHg
or HR < 60 bpm). We attempt to maintain a mean arterial
pressure of 70 - 80. Since the institution of this protocol
in October 2011 we have not experienced an APOH.
During this period, our patient criteria, volume, surgical
technique and post-operative pathway [20] remain con-
stant.
5. Conclusion
In the present analysis, APOH was associated with ex-
tended hospitalization, the increased transfusion require-
ment and the need for more ancillary procedures. APOH
patients were at significantly increased risk of renal loss.
Male gender and hypertension were associated with in-
creased risk for APOH. We have incorporated this in-
formation into an APOH risk reduction program at our
institution.
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and Impact on Subsequent Hospital Course and Complete Nephrectomy Rate.
An Analysis of 200 Consecutive Cases
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