Optimal Management of Abdominal Aortic Aneurysms and Urologic Malignancies: Benefits of Simultaneous Surgical Treatment

Abstract

The coexistence of urologic malignancy (UM) and abdominal aortic aneurysm (AAA) is rare. Simultaneous treatment may increase morbidity, whereas staged operations delay necessary treatment. We reviewed our experience to develop guidelines for evaluation and management. Clinical data of all patients diagnosed between 1980 and 1998 with both AAA and UM, who also had staged or simultaneous surgical treatment were reviewed. Four thousand forty-seven patients underwent AAA repair during the study period at our institution. Of these, 18 (0.44%) patients, 16 men and two women (mean age: 74 years, range: 61 to 92) had UM. UM was discovered incidentally in nine patients with AAA with computed tomography (CT) scan (7) and ultrasonography (2). In one patient with AAA, hematuria raised the suspicion of UM. Eight patients were diagnosed with AAA during evaluation of UM by CT scan or ultrasound (7) or during laparotomy (1). Initial signs and symptoms included abdominal pain (33%), gross hematuria (33%), and urinary tract infections (17%), although 33% were asymptomatic. The AAA was symptomatic at first examination in three (17%) patients, 14 (78%) patients had hypertension, and two (11%) had renal insufficiency (overall mean serum creatinine: 1.6, range: 0.8 to 3.7). Mean AAA diameter was 5.8 cm (range: 3.8 to 8 cm). Aortography documented significant contralateral renal artery disease in two patients. Twelve patients underwent simultaneous AAA repair and resection of UM; the operations were staged in six (AAA repair first in 2, nephrectomy first in 4). One patient required emergent repair of a ruptured AAA three days after nephrectomy. UM was treated with nephrectomy in 17 patients, and with bilateral ureterectomy and cystectomy in one. A straight aortic graft was implanted in seven patients, a bifurcated graft in ten, and one had extra-anatomic reconstruction. Two patients required reconstruction of the contralateral renal artery. The 30-day mortality rate was 0% after staged and 6% after simultaneous repair (p= >0.1). Major perioperative complications occurred more frequently after simultaneous (42%) than after staged repair (33%), although the difference was not significant (p= >0.1). Two patients developed postoperative renal failure. Seventeen patients were followed for an average of 3.9 years (14 days to 10.8 years). Three (17%) patients died of recurrent cancer at 1, 10.7, and 10.8 years after surgery.

Patients with resectable UM have satisfactory long-term survival, which justifies aggressive treatment of concomitant AAA. Aortography in these patients is suggested to exclude contralateral renal artery disease. Complications were frequent, but simultaneous repair did not increase morbidity or mortality significantly. The risk of AAA rupture after nephrectomy, need to correct contralateral renal artery disease at the time of nephrectomy, and disadvantage of delaying treatment of UM are compelling reasons to favor simultaneous treatment of AAA and UM.

Get full access to this article

View all access options for this article.

References

1. Bickerstaff LK , Hollier LH , Van Peenen HJ , et al: Abdominal aortic aneurysm repair combined with a second surgical procedure-morbidity and mortality. Surgery 95:487-491, 1984.

2. Ginsberg DA , Modrall JG , Esrig D , et al: Concurrent abdominal aortic aneurysm and urologic neoplasm: an argument for simultaneous intervention. Ann Vasc Surg 9:428-433, 1995.

3. Galt SW , McCarthy WJ , Pearce WH , et al: Simultaneous abdominal aortic aneurysm repair and nephrectomy for neoplasm. Am J Surg 170:227-230, 1995.

4. DeMasi RJ , Gregory RT , Snyder SO , et al: Coexistent abdominal aortic aneurysm and renal carcinoma: management options. Am Surg 60:961-966, 1994.

5. Howe SF , Taylor RJ , Halloran BG , et al: Management of synchronous renal cell carcinoma and aortic disease. Am J Surg 170:231-234, 1995.

6. Szilagyi DE , Elliott JP , Berguer R : Coincidental malignancy and abdominal aortic aneurysm. Problems of management. Arch Surg 95:402-412, 1967.

7. Nora JD , Pairolero PC , Nivatvongs S , et al: Concomitant abdominal aortic aneurysm and colorectal carcinoma: priority of resection. J Vasc Surg 9:630-635, 1989.

8. Bernhard VM . Management of graft infections following abdominal aortic aneurysm replacement. World J Surg 4:679-686, 1980.

9. Ouriel K , Ricotta JJ , Adams JT , et al: Management of cholelithiasis in patients with abdominal aortic aneurysm. Ann Surg 198:717-719, 1983.

10.

10. Konety BR , Shuman B , Webster M , et al: Simultaneous radical nephrectomy and repair of abdominal aortic aneurysm. Urology 47:813-818, 1996.

11.

11. Swanson RJ , Littooy FN , Hunt TK , et al: Laparotomy as a precipitating factor in the rupture of intraabdominal aneurysms. Arch Surg 115:299-304, 1980.

12.

12. Trueblood HW , Williams DK , Gustafson JR . Aneurysmal rupture following resection of abdominal malignancy. Am Surg 42:535-537, 1976.

13.

13. Cohen JR , Perry MO , Hariri R , et al: Aortic collagenase activity as affected by laparotomy, cecal resection, aortic mobilization, and aortotomy in rats. J Vasc Surg 1:562-565, 1984.