Myocardial Injury After Radical Nephrectomy

Patients undergoing nephrectomy have a greater risk of cardiac events requiring admission compared to the general population. For example, registry data report 21% of patients over 65 undergoing nephrectomy have at least one cardiovascular event after surgery. Myocardial injury after non-cardiac surgery (MINS) is a condition which is associated with increased mortality and a higher rate of major adverse cardiac events (MACE), in both the immediate perioperative period and within 1-year post-surgery. Diagnosis is via the presence of elevated troponin levels in the first 3 days post-surgery, in the absence of ischaemic symptoms and ECG changes.

The occurrence of MINS following nephrectomy for renal cell carcinoma has not yet been explored. Risk factors for MINS include increasing age and post-operative acute kidney injury. Results from the British Association of Urological Surgeons (BAUS) Nephrectomy audit demonstrate that most patients undergoing nephrectomy are over 60 and that increasing age is associated with lower eGFR pre-operatively. The accepted further reduction in post-operative GFR with nephrectomy makes these patients at high risk of MINS.

The BAUS Nephrectomy audit also demonstrates that elderly patients undergoing nephrectomy are likely to be anaemic preoperatively. In at-risk patients, any intraoperative haemodynamic instability may progress to myocardial injury and cardiac related complications due to a change in myocardial oxygen demand.

Most radical nephrectomies are now performed using robotic or laparoscopic approaches. Current evidence from retrospective studies and a small prospective study suggests that there is no difference in perioperative nor oncological outcomes between laparoscopic and robotic radical nephrectomy, including blood loss. However, no studies to date have looked at MINS and large-scale prospective studies comparing the haemodynamic effects of laparoscopic vs robotic nephrectomy are needed.

Understanding the spectrum of MINS and its potential impact on patients undergoing nephrectomy is pivotal. This could lead to better patient selection and stratified care to improve outcomes. Advances in systemic therapy for metastatic disease mean nephrectomy may become more prevalent in persons on multiple therapies. As patients undergoing nephrectomy are at high risk of MINS, it is vital to have a greater understanding of this potential complication. This aligns with the James Lind Alliance Priority Setting Partnership in perioperative care which highlights the importance of research into post-operative complications. Furthermore, this group also underlines the importance of adequate preoperative discussions with patients, which would include the risk of postoperative complications such as MINS.