Optimal management of abdominal aortic aneurysms and urologic malignancies: Benefits of simultaneous surgical treatment

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 develo p guidelines for evaluation and management. Clinical data of all patients d iagnosed between 1980 and 1998 with both AAA and UM, who also had staged or simultaneous surgical treatment were reviewed. Four thousand forty-seven p atients 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, rang e: 61 to 92) had UM. UM was discovered incidentally in nine patients with A AA with computed tomography (CT) scan (7) and ultrasonography (2). In one p atient 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 3 3% were asymptomatic. The AAA was symptomatic at first examination in three (17%) patients, 14 (78%) patients had hypertension, and two (11%) had rena l insufficiency (overall mean serum creatinine: 1.6, range: 0.8 to 3.7). Me an AAA. diameter was 5.8 rm (range: 3.8 to 8 cm). Aortography documented si gnificant contralateral renal artery disease in two patients. Twelve patien ts underwent simultaneous AAA repair and resection of UM; the operations we re staged in six (AAA repair first in 2, nephrectomy first in 4). One patie nt required emergent repair of a ruptured AAA three days after nephrectomy. UM was treated with nephrectomy in 17 patients, and with bilateral uretere ctomy and cystectomy in one. A straight aortic graft was implanted in seven patients, a bifurcated graft in ten, and one had extra-anatomic reconstruc tion. Two patients required reconstruction of the contralateral renal arter y. 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 diff erence was not significant (p=>0.1). Two patients developed postoperative r enal 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 UNI have satisfactory long-term survival, which ju stifies aggressive treatment of concomitant: AAA, Aortography in these pati ents is suggested to exclude contralateral renal artery disease. Complicati ons were frequent, but: simultaneous repair did not increase morbidity or m ortality 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 si multaneous treatment: of AAA and UM.