Continuing Education
for Urology & GU Oncology Clinicians

Washington, DC ( One of the challenges of advanced renal cell carcinoma is its potential to literally cross boundaries between specialties, extending from the site of origin in the kidney via the vasculature into the realm of vascular, hepatic, and cardiac surgeons via the inferior vena cava and occasionally compromising the colon, spleen, and pancreas.

During the first session on renal cell carcinoma at the 20th Annual Meeting of Society for Urologic Oncology, Dr. Viraj Master from Emory University presented some data and some of his personal experience with improving performance in this complex surgery by establishing a consistent surgical team.

Dr. Master began with a brief review of the literature from outside of his institution. In a retrospective review focused on in-hospital mortality by Toren et al (Urology 2013),1 surgeon experience but not necessarily hospital volume seemed to be associated with lower in-hospital mortality, although this was not found to be statistically significant. (Age, cardiac bypass, and comorbidity were significantly predictive.) Interestingly, 75% of all deaths occurred within the urologic surgeon’s first 2 cases in practice.

In another retrospective series published by Gayed et al in 2016,2 surgeons from a single center noted subjectively that the most important modification they made to their technique was to establish a consistent surgical team with the same specialists present for each case.

In 2011, Dr. Master changed his own practice from working with a variety of non-urologic surgeons to working with a single hepatobiliary surgeon for all IVC thrombi greater than level II. With this change he noted a decrease in OR time by >1,5 hours, 3x decrease in ICU utilization, and decreases in estimated blood loss, length of stay, and 90-day mortality. These improvements are consistent with his subjective experience, as he found that repeated experience allowed him and his co-surgeon to learn and adapt to each-others desires and expectations over time leading to less intraoperative problem-solving. He also found that the trust developed during this partnership extended to other cases, improving cooperating during unplanned intraoperative consults and opening avenues to collaboration on unexpected cases, as when he was asked to assist with the removal of a retained IVC filter.

He noted that he did not see similar improvements when comparing patients from his practice across different time periods, which he posited made a simple learning curve effect less likely, but he did note that he made a number of other changes to his surgical practice around the same time as he was developing his surgical collaboration. These included: abandonment of a “Mercedes” incision in favor of a single midline, routine use of a general (rather than a cardiac) operating room, fluid restriction to decrease the turgidity of accessory vessels prior to thrombectomy, and avoidance of the use of transesophageal echocardiography intraoperatively. Some might see these as confounding the effect of the surgical collaboration, but Dr. Master noted that they are actually a result of the collaboration because their implementation depended on sharing of expertise and willingness to compromise on the part of the two surgeons.

Dr. Master concluded by noting that while there is much enthusiasm for emulating the aviation industry by treating individuals and interchangeable, it remains to be seen whether this is truly a beneficial model in surgery

Presented by: Viraj A Master, MD PhD, Professor, Director of Clinical Research, Department of Urology, Director of Integrative Oncology and Survivorship,  Winship Cancer Institute, Emory University, Atlanta, Georgia, USA.

Written by: Marshall Strother, MD, Society for Urologic Oncology Fellow, Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia PA @mcstroth at the 20th Annual Meeting of the Society of Urologic Oncology (SUO), December 4 - 6, 2019, Washington, DC  


1. Toren P, Abouassaly R, Timilshina N, Kulkarni G, Alibhai S, Finelli A. Results of a national population-based study of outcomes of surgery for renal tumors associated with inferior vena cava thrombus. Urology. 2013;82(3):572-7.

2. Gayed BA, Youssef R, Darwish O, et al. Multi-disciplinary surgical approach to the management of patients with renal cell carcinoma with venous tumor thrombus: 15 year experience and lessons learned. BMC Urol. 2016;16(1):43.