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| The impact of intra-operative cell salvage during open nephrectomy |
Ned Kinneara,*( ),Lina Huaa,Bridget Heijkoopa,Derek Hennesseyb,Daniel Spernata
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a Department of Urology, The Queen Elizabeth Hospital, Adelaide, Australia
b Department of Urology, Craigavon Area Hospital, Portadown, UK |
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Abstract Objective:To assess the impact of intra-operative cell salvage on outcomes in open nephrectomy. Methods: A retrospective cohort study was performed of all patients undergoing open nephrectomy for suspected malignancy from 1 October 2013 to 1 October 2017. Patients were grouped and compared based on whether they received intra-operative cell salvage (ICS). Primary outcomes were allogeneic transfusion rates (ATRs), and if histology confirmed cancer, disease recurrence. Secondary outcomes were complications and transfusion-related cost. Results: Forty patients underwent open nephrectomy for suspected malignancy during the enrolment period. Sixteen patients received ICS while 24 did not (standard group). Compared with the standard group, ICS patients had similar median age (63.5 vs. 61.0 years; p = 0.83) but fewer females (19% vs. 58%; p = 0.013). The groups were similar in pre-operative and discharge haemoglobin, Charlson Comorbidity Index, length of hospital stay and proportion with thoracoabdominal surgical approach. The ICS group had a smaller proportion undergoing partial nephrectomy (19% vs. 54%; p = 0.025) and shorter median follow-up (278 vs. 827 days; p = 0.0005). Histology was malignant for 14 ICS and 15 standard patients. The ICS group had more frequent ≥T2 disease (79% vs. 27%; p = 0.005). There were no positive margins. Both groups had similar ATRs (6% vs. 4%; p = 0.96), complication rates (19% vs. 29%; p = 0.46) and recurrence rates (18% vs. 7%; p = 0.40). Transfusion costs were higher amongst ICS patients (AUD $878.18 vs. $49.65 per patient). Conclusion: ICS appears safe, with low rates of recurrence and complication. Both groups had low ATRs, and therefore cost benefit for ICS was not seen.
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Received: 24 December 2017
Available online: 27 June 2018
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Corresponding Authors:
Ned Kinnear
E-mail: ned.kinnear@gmail.com
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| Cost ($) | Item | | 0.98 | Separate Yanker sucker | | 27.50 | Dual lumen sucker line | | 12.64 | Anticoagulant; 2 ampoules of 25 000 units/5 mL heparin | | 2.13 | ICS machine tubing | | 1.10 | 1 × 1000 mL 0.9% normal saline | | 72.50 | ICS reservoir | | 4.54 | Bacterial filter | | 488.46 | Anaesthetic nurse wages per case | | 609.85 | Sub-total, ICS setup cost | | 56.00 | Leucocyte depletion filter; Haemonectics? RS1VAE | | 280.00 | ICS processor set | | 35.00 | Reinfusion bag | | 11.00 | 10 × 1000 mL 0.9% normal saline per 500 mL reinfused @$1.10/bag | | 382.00 | Sub-total, ICS reinfusion cost |
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The cost of ICS set-up and reinfusion in Australian dollars, as of 30 June 2017.
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| Index | ICS | Standard | p-Value | | Demographics | | Patients (n) | 16 | 24 | | | Age (year), median (IQR) | 63.5 (56-70) | 61 (51-71) | 0.83 | | Female, n (%) | 3 (19%) | 14 (58%) | 0.013 | | Pre-operative haemoglobin (g/L), median (IQR) | 144 (114-152) | 139 (133-149) | 0.99 | | Post-operative haemoglobin (g/L), median (IQR) | 120 (95-127) | 112 (101-125) | 0.86 | | Charlson Comorbidity Index, median (IQR) | 4 (2-5) | 3 (2-5) | 0.35 | | Length of stay (day), median (IQR) | 7 (5-7) | 7 (6-9) | 0.42 | | Follow-up (day), median (IQR) | 278 (130-554) | 827 (549-1319) | 0.0005 | | Approach | | Thoracoabdominal, n (%) | 14 (88%) | 19 (79%) | 0.50 | | Left-sided tumour, n (%) | 7 (44%) | 10 (42%) | 0.90 | | Radical, n (%) | 13 (81%) | 11 (46%) | 0.025 |
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Patient demographics and surgical approach.
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| Index | ICS (n = 16) | Standard (n = 24) | p-Value | | Histology a | | Malignant | 14 | 15 | | | Renal cell carcinoma, n (%) | 12 (86) | 11 (73) | N/A | | Size (mm), median (IQR) | 63 (31-111) | 27 (22-69) | 0.11 | | Margin positive, n (%) | 0 (0) | 0 (0) | N/A | | Tumour stage ≥T2, n (%) | 11 (79) | 4 (27) | 0.005 | | Nodal stage N1, n (%) | 1 (7) | 1 (7) | 1 | | Metastasis stage M1, n (%) | 3 (21) | 1 (7) | 0.25 | | Outcomes a | | Patients with allogeneic transfusion, n (%) | 1/16 (6) | 1/24 (4) | 0.96 | | Malignant and M0, disease recurrence, n (%) | 2/11 (18) | 1/14 (7) | 0.40 | | Complications, n (%) | 3/16 (19) | 7/24 (29) | 0.46 | | Transfusion-related cost (AUD, $) | 878.18 | 49.65 | N/A |
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Histopathology and outcomes.
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| C-D grade | Patients and histology details | | Intra-operative cell salvage group | | Self-limiting asymptomatic fever | 1 | 62yr M CCI 4, 15 mm T1N0M0 | | Self-limiting asymptomatic hyperkalaemia | 1 | 74yr M CCI 7, 60 mm T3N0M0 | | Persistent high drain outputs. Drain left in-situ on discharge and removed subsequently in outpatients | 3a | 74yr M CCI 9, 70 mm T3N0M1 | | Standard group | | Self-limiting asymptomatic fever | 1 | 51yr M CCI 3, 70 mm T3N0M0 | | Self-limiting asymptomatic hypoxia | 1 | 84yr F CCI 8, 85 mm T3N1M1 | | Post-operative ileus, resolved without nasogastric tube | 1 | 69yr M CCI 4, 15 mm oncocytoma | | Hospital acquired pneumonia + rotavirus-positive diarrhea, treated with antibiotics and supported therapy | 2 | 66yr M CCI 3, 28 mm oncocytoma | | Angina pectoris with normal investigations | 2 | 70yr F CCI 5, 37 mm T1N0M0 | | Small pneumothorax post-underwater sealed drain removal; resolved with conservative management | 3a | 88yr F, CCI 5, benign atrophic kidney | | Intra-operative laceration to proximal ureter anterior wall during partial nephrectomy, managed with ureteric stent for 6 weeks | 3a | 71yr M CCI 3, 22 mm T1N0M0 |
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Complications.
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