Level III-IV Inferior Vena Caval Thrombectomy Without Cardiopulmonary Bypass: Long-Term Experience with Intrapericardial Control

Surgical Management and Oncologic Outcomes of Renal Cell Carcinoma and Inferior Vena Caval Thrombi With Aggressive Histologic Variants

OBJECTIVE

To characterize the surgical management, perioperative, and cancer-specific outcomes, and the influence of aggressive histologic variants (AHV) on operative management among patients with renal cell carcinoma (RCC) and inferior vena cava (IVC) thrombus. RCC with rhabdoid and/or sarcomatoid differentiation, which we defined as AHV, portends a worse prognosis. AHV can be associated with a desmoplastic reaction which may complicate resection.

METHODS

We reviewed patients undergoing radical nephrectomy and IVC thrombectomy between 1990 and 2020. Comparative statistics were employed as appropriate. Survival analysis was performed according to the Kaplan-Meier method, and intergroup analysis performed with log-rank statistics. Multivariable cox proportional hazards regression was used to assess the effect of AHV, age, thrombus level, vena cavectomy, metastases, and medical comorbidities on recurrence and overall survival (OS).

RESULTS

Ninety-four of 403 (23.3%) patients had AHV, including 43 (46%) rhabdoid, 39 (41%) sarcomatoid, and 12 (13%) with both. AHV were more likely to present with advanced disease; however, increased perioperative complications or decreased OS were not observed. Median (IQR) survival was 16.7 (4.8-47) months without AHV and 12.6 (4-29) months with AHV (P = .157). Sarcomatoid differentiation was independently associated with worse OS (HR = 2.016, CI 1.38-2.95, P <.001), whereas rhabdoid alone or with sarcomatoid demonstrated similar OS (P = 0.063).

CONCLUSION

RCC and IVC thrombus with AHV are more likely to present with metastatic disease, and sarcomatoid differentiation is associated with a worse OS. Resection of tumors with and without AHV have similar perioperative complications, suggesting that surgery can be safely accomplished in patients with RCC and IVC thrombus with AHV.

Patency outcomes of primary inferior vena cava repair in radical nephrectomy and tumor thrombectomy

OBJECTIVE

The reconstruction of inferior vena cava (IVC) during radical nephrectomy and venous tumor thrombectomy (RN-VTT) is mostly performed with primary repair or with a patch/graft. We sought to systematically evaluate the outcomes of IVC patency over short- to intermediate-term follow-up for patients undergoing primary repair of IVC and to assess the association with survival.

METHODS

A retrospective review of patients undergoing RN-VTT between January 2013 and August 2018 was conducted. Patients were followed until death, last available follow-up, or March 2022. The patency outcomes and IVC diameters were studied using follow-up cross-sectional imaging. The χ² test, Student t test, and Kaplan-Meier survival analysis were used.

RESULTS

Seventy-seven patients were included. The mean age was 59.2 ± 12.2 years and 45.4% had Mayo classification level III thrombus or higher. At a median follow-up of 36.5 months (13.3-60.7 months), the 3-year overall survival (OS) was 64%. Sixty patients underwent primary repair of the IVC and 48 of these patients were assessed for IVC patency. Ten patients (20.8%) developed caval occlusion, either from recurrent tumor (8.3%), new-onset bland thrombus (8.3%), or stenosis (4.2). The IVC patency seemed to be a significant predictor of OS (hazard ratio, 2.85; P = .021). Although the IVC diameters decreased significantly at the 3-month postoperative scan at the infrarenal (P = .019), renal (P < .001), and suprarenal (P < .001) levels, they did not decrease further on long-term follow-up imaging.

CONCLUSIONS

IVC reconstruction with primary repair results in an overall patency rate of 80.2% with only a 4.0% rate of stenosis. Recurrence of tumor thrombus (8.3%) or bland thrombus (8.3%) are the predominant reasons for IVC occlusion after RN-VTT, and this outcome is associated with poor OS.

Surgical treatment of renal cell carcinoma with inferior vena cava tumor thrombus

PURPOSE

The present report discusses the indications of cardiopulmonary bypass (CPB) in open nephrectomy and surgical outcomes of conventional and minimally invasive surgical techniques for treating advanced renal cell carcinoma with inferior vena cava tumor thrombus.

METHODS

The present study involved a comprehensive retrieval of pertinent literature from the most recent two decades.

RESULTS

Comparisons between radical nephrectomy procedures in terms of open, laparoscopic and robotic-assisted surgeries revealed that open surgery had more blood loss, a longer operation time and higher mortality rates than laparoscopic and robotic-assisted surgeries. Furthermore, surgery with CPB was associated with more blood loss than non-CPB surgery. Rates of early and late deaths were much higher in patients with CPB than in those without CPB.

CONCLUSIONS

Different surgical techniques had different indications in terms of levels of inferior vena cava tumor thrombus. The laparoscopic, robotic-assisted, open surgical techniques and CPB with deep hypothermic circulatory arrest were indicated for Levels I, II, III and III-IV inferior vena cava tumor thrombus, respectively. Laparoscopic and robotic-assisted surgeries cause less trauma than open surgery but require more complicated equipments to support the procedure. CPB should be avoided in radical nephrectomy whenever possible. The increased application of laparoscopic and robotic techniques in the future is anticipated.

Excision of Wilms' Tumor With Atrial Extension Under Moderate Hypothermia and Cerebral Perfusion

BACKGROUND

Wilms' tumor is the most common pediatric renal tumor. Almost half of all cases have involvement of the inferior vena cava, which must be addressed at the time of surgical excision. Further extension into the right atrium may pose an immediate vital risk and necessitates special operative techniques that employ cardiopulmonary bypass.

CASE REPORT

We report the case of a child with a left Wilms' tumor with inferior caval and right atrial involvement, which led to significant hemodynamic compromise and urgent surgery. A left nephrectomy and cavoatrial thrombectomy were performed via a sterno-laparotomy. Our strategy employed moderate hypothermic circulatory arrest at 26°C and antegrade cerebral perfusion in order to improve visualization and ensure complete thrombectomy and protection of the abdominal organs.

CONCLUSION

This case emphasizes the advantages of moderate hypothermic circulatory arrest compared to deep hypothermic circulatory arrest and normothemic cardiopulmonary bypass.

Surgical Tips for Inferior Vena Cava Thrombectomy

PURPOSE OF REVIEW

The aim of this review is to describe the preoperative evaluation, surgical techniques, and postoperative management of patients with renal cell carcinoma (RCC) undergoing radical nephrectomy (RN) and inferior vena cava (IVC) thrombectomy.

RECENT FINDINGS

RN and IVC thrombectomy remains the standard management option in non-metastatic RCC patients with IVC thrombus. A comprehensive preoperative workup, including high-quality imaging, blood works, and appropriate consultations are required for all patients. The aim of the surgery is complete resection of all tumor burden, which requires a skillful surgical team for such a challenging procedure and is inherently associated with a high rate of perioperative morbidity and mortality. Preoperative CT or MRI is essential for surgical planning. The surgical approach is mainly determined by the level of the tumor thrombus. The open approach has been the standard, though minimally invasive and robotic techniques are emerging in selected cases by experienced surgeons.

Removal of the Tumor Thrombus from the Right Atrium without Extracorporeal Circulation: Emphasis on the Displacement of the Tumor Apex

Objectives

To assess the outcomes of cavoatrial tumor thrombus removal using the liver transplantation technique for thrombectomy, a retrospective study was conducted.

Materials and Methods

Five patients with atrial tumor thrombi who underwent piggy-back mobilization of the liver, surgical access to the right atrium from the abdominal cavity, and external manual repositioning of the thrombus apex below the diaphragm (milking maneuver) were included into the study. Extracorporeal circulation was used in none of the cases. The average length of the atrial component of the tumor was 20.0 ± 11.7 mm (10 to 35 mm), and the width was 14.8 ± 8.5 mm (10 to 30 mm). In this work, the features of patients and surgical interventions as well as perioperative complications and mortality were analyzed.

Results

External manual repositioning of the tumor thrombus apex below the diaphragm was successfully performed in all patients. Tumor thrombi with the length of the atrial part up to 1.5 cm were removed through the extrapericardial approach. For evacuation of the thrombi with the large atrial part (3.0 cm or more), a transpericardial surgical approach was required. Specific complications associated with the access to the right atrium from the abdominal cavity (paresis of the right phrenic nerve, pneumothorax, and mediastinitis) were not detected in any case. The average clamping time of the supradiaphragmatic inferior vena cava (IVC) was 6.3 ± 4.6 min. The volume of intraoperative blood loss varied from 2500 to 5600 ml (an average of 3675 ± 1398.5 ml).

Conclusion

Our work represents the initial experience in the liver transplantation technique for thrombectomy in distinct and well-selected patients with atrial tumor thrombi. The effectiveness of this approach needs further study. The video presentation of our research took place in March 2019 at the 34th Annual EAU Congress in Barcelona.

A modified sequential vascular control strategy in robot-assisted level III-IV inferior vena cava thrombectomy: initial series mimicking the open 'milking' technique principle

OBJECTIVE

To introduce a modified sequential vascular control strategy, mimicking the open 'milking' technique principle, for the early release of the first porta hepatis (FPH) and to stop cardiopulmonary bypass (CPB) in level III-IV robot-assisted inferior vena cava (IVC) thrombectomy (RA-IVCTE).

PATIENTS AND METHODS

From November 2014 to June 2019, 27 patients with a level III-IV IVC tumour thrombus (IVCTT) underwent RA-IVCTE in our department. The modified sequential control strategy was used in 12 cases. Previously, we released the FPH after the thrombus was resected and the IVC was closed completely, and CPB was stopped at the end of surgery (15 patients). Presently, using our modified strategy, we place another tourniquet inferior to the second porta hepatis (SPH) once the proximal thrombus is removed from the IVC below the SPH. Then, we suture the right atrium and perform early release of the FPH, and stop CPB. Finally, tumour thrombectomy, vascular reconstruction, and radical nephrectomy are performed.

RESULTS

Compared with the previous strategy, the modified steps resulted in a shorter median FPH clamping (19 vs 47 min, P < 0.001) and CPB times (60 vs 87 min, P < 0.05); a lower rate of Grade II-IV perioperative complications (25% vs 60%, P < 0.05); and better postoperative hepatorenal and coagulation function, including better median serum alanine aminotransferase (172.7 vs 465.4 U/L, P < 0.001), aspartate aminotransferase (282.4 vs 759.8 U/L, P < 0.001), creatinine (113.4 vs 295 μmol/L, P < 0.01), blood urea nitrogen (7.3 vs 16.7 mmol/L, P < 0.01), and D-dimer (5.9 vs 20 mg/L, P < 0.001) levels.

CONCLUSION

With the early release of the FPH and stopping CPB, the modified sequential vascular control strategy in level III-IV RA-IVCTE reduced the perioperative risk for selected patients and improved the feasibility and safety of the surgery. We would recommend this approach to other centres that plan to develop robotic surgery for renal cell carcinoma with level III-IV IVCTT in the future.

Cumulative Sum Analysis of the Operator Learning Curve for Robot-Assisted Mayo Clinic Level I-IV Inferior Vena Cava Thrombectomy Associated with Renal Carcinoma: A Study of 120 Cases at a Single Center

Background

This study aimed to use cumulative sum analysis of the operator learning curve for robot-assisted Mayo Clinic level I–IV inferior vena cava (IVC) thrombectomy associated with renal carcinoma, and describes the development of an optimized operative procedure at a single center.

Material/Methods

A retrospective study included 120 patients with Mayo Clinic level I–IV IVC thrombus who underwent robotic surgery between 2013 and 2018. Points in the learning curve were identified using cumulative sum analysis, and their impact was assessed by multiple regression analysis. Perioperative indicators analyzed included operative time, estimated blood loss, early complications, and the 90-day progression rate.

Results

Cumulative sum analysis identified three phases in the learning curve of robot-assisted IVC thrombectomy. The median operative time decreased from 265 min (range, 212–401 min) to 207 min (range, 146–276 min) (p=0.003), the median estimated blood loss decreased from 775 ml (range, 413–1500 ml) to 300 ml (range, 163–813 ml) (p=0.006), and the early complication rate decreased from 52.5% to 15.0% (p<0.001). Multivariate analysis showed that for an initial 40 cases and a further 80 cases, the learning phase, the affected side, the Mayo Clinic level, and the surgical method were independent factors that affected operative time, estimated blood loss, and the rate of early complications.

Conclusions

Experience from an initial 40 cases and a further 80 cases of Mayo Clinic level I–IV IVC thrombectomy associated with renal carcinoma were found to provide acceptable surgical and clinical outcomes.

Association of an organ transplant-based approach with a dramatic reduction in postoperative complications following radical nephrectomy and tumor thrombectomy in renal cell carcinoma

OBJECTIVES

Our aim was to determine whether using an organ transplant-based(TB) approach reduces postoperative complications(PCs) following radical nephrectomy(RN) and tumor thrombectomy(TT) in renal cell carcinoma(RCC) patients with level II-IV thrombi.

METHODS

A total of 390(292 non-TB/98 TB) IRCC-VT Consortium patients who received no preoperative embolization/IVC filter were included. Stepwise linear/logistic regression analyses were performed to determine significant multivariable predictors of intraoperative estimated blood loss(IEBL), number blood transfusions received, and overall/major PC development within 30days following surgery. Propensity to receive the TB approach was controlled.

RESULTS

The TB approach was clearly superior in limiting IEBL, blood transfusions, and PC development, even after controlling for other significant prognosticators/propensity score(P < .000001 in each case). Median IEBL for non-TB/TB approaches was 1000 cc/300 cc and 1500 cc/500 cc for tumor thrombus Level II-III patients, respectively, with no notable differences for Level IV patients(2000 cc each). In comparing PC outcomes between non-TB/TB patients with a non-Right-Atrium Cranial Limit, the observed percentage developing a: i) PC was 65.8%(133/202) vs. 4.3%(3/69) for ECOG Performance Status(ECOG-PS) 0-1, and 84.8%(28/33) vs. 25.0%(4/16) for ECOG-PS 2-4, and ii) major PC was 16.8%(34/202) vs. 1.4%(1/69) for ECOG-PS 0-1, and 27.3%(9/33) vs. 12.5%(2/16) for ECOG-PS 2-4. Major study limitation was the fact that all TB patients were treated by a single, experienced, high volume surgeon from one center (non-TB patients were treated by various surgeons at 13 other centers).

CONCLUSIONS

Despite this major study limitation, the observed dramatic differences in PC outcomes suggest that the TB approach offers a major breakthrough in limiting operative morbidity in RCC patients receiving RN and TT.

Surgical management of renal cell carcinoma with associated tumor thrombus extending into the inferior vena cava: A 10-year single-center experience

OBJECTIVE

Renal cell carcinoma (RCC) is a tumor that has a tendency of vascular invasion by extending to the inferior vena cava (IVC) after the renal vein. The total resection of the renal tumor and tumor thrombus is considered the optimal treatment. In our study, we aimed to present the results related to 34 consecutive cases of RCC with tumor thrombus.

MATERIAL AND METHODS

Of the 442 patients diagnosed with renal tumors between January 2008 and January 2018, 34 (7.6%) had tumor thrombus over the renal vein extending to the IVC. The data of the 34 patients with tumor thrombus were retrospectively reviewed and included in the study. All the 34 patients underwent radical nephrectomy with tumor thrombectomy. The presence of thrombus was evaluated using contrast-enhanced abdominal tomography, magnetic resonance imaging, or color Doppler ultrasonography. The level of thrombus was classified using the Mayo Clinic tumor thrombus classification. Surgery was performed transperitoneally through a modified Chevron incision and mostly in collaboration with other clinics. Complications were classified according to the Clavien system.

RESULTS

Of the 34 patients, 22 were males and 12 were females. The mean follow-up period was 36±27.2 months in patients who had a mean age of 61±10.9 years. The mean tumor size was 10.5±3.3 cm. The number of patients according to the thrombus levels I, II, and III were 20, 9, and 5, respectively. The average blood loss was 744±285.4 mL. Radical surgery for all patients who had direct invasion to the vena cava wall and/or level II and III was performed by gastrointestinal and cardiothoracic surgeons. Cardiopulmonary bypass was not performed in any patient. Minor complications (Clavien grades 1-2) were seen in 8 (23.5%) patients, while 2 (5.8%) patients had major complications (Clavien grades 3-5). The mean follow-up period was 36 months (range, 6-72 months). The overall 5-year survival rate was 85.2%.

CONCLUSION

We think that radical nephrectomy and caval thrombectomy is a safe and effective method in patients with RCC without tumor exceeding the diaphragmatic level. We believe that the surgical success rate can be increased using a multidisciplinary approach in selected cases.

The value of a cross-discipline team-based approach for resection of renal cell carcinoma with IVC tumor thrombus: A report of a large, contemporary, single-institution experience

INTRODUCTION

We report the evolution of the largest, contemporary, single-institution experience with this complex procedure to highlight the value of a cross-discipline, team-based approach.

METHODS

Patients from a prospectively maintained database who underwent resection of renal cell carcinoma (RCC) with inferior vena cava (IVC) tumor thrombus from 2005 to 2016 at a single-institution were included for analysis.

RESULTS

Of 140 patients, 102 (73%) had tumor thrombus below the level of the hepatic vein confluence, and 96 (69%) were performed for curative-intent, while 43 (31%) were cytoreductive procedures for clinical trial consideration. Median overall survival (OS) of the entire cohort was 43.8 months (5-year OS:43%), and 73.6 months (5-year OS:59%) for those without metastatic disease. Fifty-one patients underwent resection from 2005 to 2010 and 89 from 2011 to 2016. All procedures since 2011 were performed by the same cross-discipline dedicated team of two surgeons, composed of a surgical and urological oncologist. When comparing the two time-periods, the team-approach after 2011 had shorter operative-times (5.3 vs 6.7 hours; P = 0.009), decreased ICU-utilization (25% vs 72%; P < 0.001), and decreased ICU length-of-stay (0.4 vs 2.2 days; P = 0.001). This group also trended towards less blood loss (1.2 vs 1.8 L), shorter average hospital length-of-stay (10 vs 11 days), and decreased 90-day mortality (6% vs 10%).

CONCLUSION

Resection of RCC with IVC tumor thrombus yields long-term survival. A dedicated, cross-discipline, and team-based approach optimizes patient outcomes and may improve value of care by reducing utilization of expensive hospital resources.

Indications, complications, and outcomes following surgical management of locally advanced and metastatic renal cell carcinoma

INTRODUCTION

Surgery may set the basis for a potential cure or would provide the best achievable quality of life in locally advanced or metastatic renal cell carcinoma (mRCC). However, survival extension with this approach would be scarce and not exempt from adverse events, thus preventing its recommendation in an already frail patient. An evidence based analysis on the role of surgery in each of the possible clinical scenarios involved under this heading may provide a clear picture on this issue and would be of value in the decision making process. Areas covered: Current literature was queried in PubMed/Medline in a systematic fashion. Manuscripts included were selected according to the quality of the data provided. A narrative review strategy was adopted to summarize the evidence acquired. Expert commentary: A surgery-based multimodal treatment approach should be strongly considered after adequate counseling in locally advanced and mRCC, since it may provide for additional benefits in terms of survival. However, a critical reevaluation of its adequacy, optimal timing, and selection of ideal candidates is currently ongoing.

Supradiaphragmatic Inferior Vena Caval Thrombectomy Without Cardiopulmonary Bypass: A Case Series at a Single Center

Introduction

Inferior vena cava tumor thrombectomy in renal cell carcinoma patients is a challenging procedure, frequently requiring the vascular bypass technique for high-level thrombi with additional complications. Adopting a technique such as intrapericardial control in selected cases will circumvent these problems. Here, we present the results of our intrapericardial control technique during supradiaphragmatic inferior vena caval tumor thrombectomy.

Case Presentation

The records of six patients with supradiaphragmatic tumor thrombi, who underwent radical nephrectomy and thrombectomy at our center with intrapericardial control between the years 2008 and 2015, were retrospectively reviewed. The patients’ characteristics, intra- and postoperative data, histology, and follow-up records were gathered and compared. There were no immediate or 30-day postoperative deaths. The mean age of the patients was 61.3 years (range 46 - 75). The total mean duration of surgery was 315 minutes and the mean amount of transfused red blood cells was 4.33 units during surgery and 0.8 units in the postoperative period. The average hospitalization duration was 8 days (range 5 - 17). Tumor stage was T3 in four patients and T4 in two, due to ipsilateral adrenal involvement. The mean duration of follow-up was 33.5 months. Only one of the patients developed recurrences, first in the tumor bed and then at the site of the skin incision; these were excised with no apparent complications.

Conclusions

Radical nephrectomy and tumor thrombectomy by intrapericardial control without cardiopulmonary bypass and hypothermic circulatory arrest is a safe and effective procedure that can avoid serious intra- and postoperative complications while providing acceptable cancer-control and mortality results.

Renal cell carcinoma with thrombus extending to the hepatic veins or right atrium: operative strategies based on 41 consecutive patients

OBJECTIVES

The natural history of renal cell carcinoma (RCC) with tumour thrombus extending at or above the hepatic veins is dismal. Different surgical approaches have been described including cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest. We here report our experience in terms of surgical techniques and outcomes on 41 consecutive patients presenting an RCC extending to the hepatic veins or the right atrium. A surgical decision-making algorithm is discussed.

METHODS

Retrospective review of 41 patients operated for RCC extending in the retrohepatic vena cava (extent level III-IV) between 2000 and 2015. Patients were operated by a dedicated urology/cardiac surgery team.

RESULTS

The mean age was 62.6 ± 10.4 years; 39% were female. Surgery was emergent in 7.3% of patients, 2.4% of patients had preoperative dialysis, 4.9% required a redo sternotomy and 19.5% had coronary artery disease. Tumour thrombus extended above the diaphragm in 23 patients (level IV) and to the level of hepatic veins (level III) in 18 patients. CPB was used in 38 patients. Arterial cannulation was in the aorta or femoral artery in 14 patients during the initial experience. In the current era, the axillary artery and the innominate artery were used in 12 patients each. Mean CPB, cross-clamp and circulatory arrest times were, respectively, 96.5 ± 42.9, 21.1 ± 16.4 and 10.2 ± 8.2 min (mean temperature of 25.7 ± 4.9°C). Hepatic exclusion without the use of CPB was performed to excise the thrombus in 3 patients. A right nephrectomy was performed in 25 patients, a left in 15 patients and a bilateral nephrectomy in 1 patient. Five patients had a partial inferior vena cava (IVC) resection, with 4 patients requiring a patch reconstruction of the IVC. Three patients had an infrarenal IVC ligation. One patient suffered a cerebrovascular accident in the postoperative period. One in-hospital death occurred (in-hospital mortality 2.4%). The mean follow-up was 1.9 ± 2.0 years. Twenty-three patients died during follow-up; 21 were disease-related. Three-year survival rate was 37.1%.

CONCLUSION

High-level RCC tumour thrombus is a rare clinical entity, the treatment of which is complex and requires dedicated operative teams. The operative technique should be tailored according to the level of extension and the extent of vena cava obstruction/occlusion of the tumour thrombus. Contemporary operative techniques may be conducted with excellent results. Mid-term survival is limited, supporting the necessity to pursue research efforts towards establishing effective adjunct therapies.

Modified technique of cavoatrial tumor thrombectomy without cardiopulmonary by-pass and hypothermic circulatory arrest: a preliminary report

Introduction

Traditionally, tumor thrombi extending into the right atrium have been managed by open surgery with sternotomy, cardiopulmonary bypass circulation and hypothermic circulatory arrest, and are associated with significant morbidity and mortality rates. Here, we evaluate the results of cavoatrial thrombectomy using our own, Foley catheter assisted-technique, obviating the need for thoracotomy, extracorporeal circulation, and/or hypothermic circulatory arrest.

Material and methods

Between June 2013 and January 2015, 4 consecutive patients underwent cavoatrial thrombectomy performed with our own, Foley catheter assisted technique, via Chevron incision, with no need for extracorporeal circulation or hypothermy for renal cell carcinoma with tumor thrombus extending into the right atrium. Analyses of patients’ data from a prospectively maintained database with respect to perioperative characteristics, morbidity and mortality were performed.

Results

The total mean duration of surgery was 255 minutes. The mean time of total IVC (inferior vena cava) occlusion was 90 seconds. The average blood loss volume, timed from the beginning of cavotomy incision until its closure, was 1200 ml. The total mean intraoperative blood loss was 3,150 ml. There was no perioperative death. Postoperative complications included one transient acute kidney injury requiring one-off hemodialysis and one re-operation due to bleeding. The follow-up time ranged between 12 to 17 months. None of the patients developed disease recurrence. All patients were still alive at the time of study completion.

Conclusions

Obtained results support the validity of our own, Foley catheter assisted technique, without cardiopulmonary bypass and hypothermic circulatory arrest for the treatment of renal cell carcinoma with tumor thrombus extending into the right atrium.

Robotic Level III Inferior Vena Cava Tumor Thrombectomy: Initial Series

PURPOSE

Level III inferior vena cava tumor thrombectomy for renal cancer is one of the most challenging open urologic oncology surgeries. We present the initial series of completely intracorporeal robotic level III inferior vena cava tumor thrombectomy.

MATERIALS AND METHODS

Nine patients underwent robotic level III inferior vena cava thrombectomy and 7 patients underwent level II thrombectomy. The entire operation (high intrahepatic inferior vena cava control, caval exclusion, tumor thrombectomy, inferior vena cava repair, radical nephrectomy, retroperitoneal lymphadenectomy) was performed exclusively robotically. To minimize the chances of intraoperative inferior vena cava thrombus embolization, an "inferior vena cava-first, kidney-last" robotic technique was developed. Data were accrued prospectively.

RESULTS

All 16 robotic procedures were successful, without open conversion or mortality. For level III cases (9), median primary kidney (right 6, left 3) cancer size was 8.5 cm (range 5.3 to 10.8) and inferior vena cava thrombus length was 5.7 cm (range 4 to 7). Median operative time was 4.9 hours (range 4.5 to 6.3), estimated blood loss was 375 cc (range 200 to 7,000) and hospital stay was 4.5 days. All surgical margins were negative. There were no intraoperative complications and 1 postoperative complication (Clavien 3b). At a median 7 months of followup (range 1 to 18) all patients are alive. Compared to level II thrombi the level III cohort trended toward greater inferior vena cava thrombus length (3.3 vs 5.7 cm), operative time (4.5 vs 4.9 hours) and blood loss (290 vs 375 cc).

CONCLUSIONS

With appropriate patient selection, surgical planning and robotic experience, completely intracorporeal robotic level III inferior vena cava thrombectomy is feasible and can be performed efficiently. Larger experience, longer followup and comparison with open surgery are needed to confirm these initial outcomes.

Management of inferior vena cava tumor thrombus in locally advanced renal cell carcinoma

The diagnosis of renal cell carcinoma is accompanied by intravascular tumor thrombus in up to 10% of cases, of which nearly one-third of patients also have concurrent metastatic disease. Surgical resection in the form of radical nephrectomy and caval thrombectomy represents the only option to obtain local control of the disease and is associated with durable oncologic control in approximately half of these patients. The objective of this clinical review is to outline the preoperative evaluation for, and operative management of patients with locally advanced renal cell carcinoma with venous tumor thrombi involving the inferior vena cava. Cornerstones of the management of these complex patients include obtaining high-quality imaging to characterize the renal mass and tumor thrombus preoperatively, with further intraoperative real-time evaluation using transesophageal echocardiography, careful surgical planning, and a multidisciplinary approach. Operative management of patients with high-level caval thrombi should be undertaken in high-volume centers by surgical teams with capacity for bypass and invasive intraoperative monitoring. In patients with metastatic disease at presentation, cytoreductive nephrectomy and tumor thrombectomy may be safely performed with simultaneous metastasectomy if possible. In the absence of level one evidence, neoadjuvant targeted therapy should continue to be viewed as experimental and should be employed under the auspices of a clinical trial. However, in patients with significant risk factors for postoperative complications and mortality, and especially in those with metastatic disease, consultation with medical oncology and frontline targeted therapy may be considered.

Cardiopulmonary Bypass has No Significant Impact on Survival in Patients Undergoing Nephrectomy and Level III-IV Inferior Vena Cava Thrombectomy: Multi-Institutional Analysis

PURPOSE

The impact of cardiopulmonary bypass in level III-IV tumor thrombectomy on surgical and oncologic outcomes is unknown. We determine the impact of cardiopulmonary bypass on overall and cancer specific survival, as well as surgical complication rates and immediate outcomes in patients undergoing nephrectomy and level III-IV tumor thrombectomy with or without cardiopulmonary bypass.

MATERIALS AND METHODS

We retrospectively analyzed 362 patients with renal cell cancer and with level III or IV tumor thrombus from 1992 to 2012 at 22 U.S. and European centers. Cox proportional hazards models were used to compare overall and cancer specific survival between patients with and without cardiopulmonary bypass. Perioperative mortality and complication rates were assessed using logistic regression analyses.

RESULTS

Median overall survival was 24.6 months in noncardiopulmonary bypass cases and 26.6 months in cardiopulmonary bypass cases. Overall survival and cancer specific survival did not differ significantly in both groups on univariate analysis or when adjusting for known risk factors. On multivariate analysis no significant differences were seen in hospital length of stay, Clavien 1-4 complication rate, intraoperative or 30-day mortality and cancer specific survival. Limitations include the retrospective nature of the study.

CONCLUSIONS

In our multi-institutional analysis the use of cardiopulmonary bypass did not significantly impact cancer specific survival or overall survival in patients undergoing nephrectomy and level III or IV tumor thrombectomy. Neither approach was independently associated with increased mortality on multivariate analysis. Greater surgical complications were not independently associated with the use of cardiopulmonary bypass.

Early occlusion control of the intrapericardial inferior vena cava under femoral-femoral extracorporeal circulation using a technique to prevent pulmonary embolism during nephrectomy for renal cell carcinoma with tumor thrombus: two case reports

Background

Renal cell carcinoma with tumor thrombus extension into the inferior vena cava occurs in approximately 5% of cases. Despite such situations, an aggressive surgical approach is recommended. However, intraoperative prevention of pulmonary embolism by a fragmended tumor thrombus is necessary. To prevent pulmonary embolism, placement of a temporary suprarenal filter has been attempted, however, the precise placement of a temporary filter between the level of the hepatic vein and right atrium is not always easy because of its migration, tilting, and strut fracture. Here we report a method for early occlusion control of the intrapericardial inferior vena cava to prevent pulmonary embolism during nephrectomy in level II or III renal cell carcinoma tumor thrombus.

Case presentation

Our first case was a 37-year-old Japanese man with left renal cell carcinoma extending into the inferior vena cava below the main hepatic vein (level II) and our second was a 75-year-old Japanese man with right renal cell carcinoma extending into the retrohepatic inferior vena cava at the main hepatic vein (level III). En block resection of the kidney and the tumor thrombus was performed with the aid of partial extracorporeal circulation; the postoperative course of both patients was uneventful.

Conclusion

Control of intrapericardial inferior vena cava is a feasible method to prevent pulmonary embolism.