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Lardas M, Stewart F, Scrimgeour D, Hofmann F, Marconi L, Dabestani S, Bex A, Volpe A, Canfield SE, Staehler M, Hora M, Powles T, Merseburger AS, Kuczyk MA, Bensalah K, Mulders PFA, Ljungberg B, Lam TBL. Systematic Review of Surgical Management of Nonmetastatic Renal Cell Carcinoma with Vena Caval Thrombus. Eur Urol 2015; 70:265-80. [PMID: 26707869 DOI: 10.1016/j.eururo.2015.11.034] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 11/30/2015] [Indexed: 11/29/2022]
Abstract
CONTEXT Overall, 4-10% of patients with renal cell carcinoma (RCC) present with venous tumour thrombus. It is uncertain which surgical technique is best for these patients. Appraisal of outcomes with differing techniques would guide practice. OBJECTIVE To systematically review relevant literature comparing the outcomes of different surgical therapies and approaches in treating vena caval thrombus (VCT) from nonmetastatic RCC. EVIDENCE ACQUISITION Relevant databases (Medline, Embase, and the Cochrane Library) were searched to identify relevant comparative studies. Risk of bias and confounding assessments were performed. A narrative synthesis of the evidence was presented. EVIDENCE SYNTHESIS The literature search identified 824 articles. Fourteen studies reporting on 2262 patients were included. No distinct surgical method was superior for the excision of VCT, although the method appeared to be dependent on tumour thrombus level. Minimal access techniques appeared to have better perioperative and recovery outcomes than traditional median sternotomy, but the impact on oncologic outcomes is unknown. Preoperative renal artery embolisation did not offer any oncologic benefits and instead resulted in significantly worse perioperative and recovery outcomes, including possibly higher perioperative mortality. The comparison of cardiopulmonary bypass versus no cardiopulmonary bypass showed no differences in oncologic outcomes. Overall, there were high risks of bias and confounding. CONCLUSIONS The evidence base, although derived from retrospective case series and complemented by expert opinion, suggests that patients with nonmetastatic RCC and VCT and acceptable performance status should be considered for surgical intervention. Despite a robust review, the findings were associated with uncertainty due to the poor quality of primary studies available. The most efficacious surgical technique remains unclear. PATIENT SUMMARY We examined the literature on the benefits of surgery to remove kidney cancers that have spread to neighbouring veins. The results suggest such surgery, although challenging and associated with high risk of complications, appears to be feasible and effective and should be contemplated for suitable patients if possible; however, many uncertainties remain due to the poor quality of the data.
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Affiliation(s)
- Michael Lardas
- Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Fiona Stewart
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | | | - Fabian Hofmann
- Department of Urology, Sunderby Hospital, Sunderby, Sweden
| | - Lorenzo Marconi
- Department of Urology, Coimbra University Hospital, Coimbra, Portugal
| | - Saeed Dabestani
- Department of Urology, Skåne University Hospital, Malmö, Sweden
| | - Axel Bex
- Department of Urology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Alessandro Volpe
- Division of Urology, Maggiore della Carita' Hospital, University of Eastern Piedmont, Novara, Italy
| | - Steven E Canfield
- Division of Urology, University of Texas Medical School at Houston, Houston, TX, USA
| | - Michael Staehler
- Department of Urology, Ludwig-Maximilians University, Munich, Germany
| | - Milan Hora
- Department of Urology, Faculty Hospital and Faculty of Medicine in Pilsen, Charles University in Prague, Prague, Czech Republic
| | - Thomas Powles
- The Royal Free NHS Trust and Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Axel S Merseburger
- Department of Urology, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Markus A Kuczyk
- Department of Urology and Urologic Oncology, Hannover Medical School, Hannover, Germany
| | - Karim Bensalah
- Department of Urology, University of Rennes, Rennes, France
| | - Peter F A Mulders
- Department of Urology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Börje Ljungberg
- Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå University, Umeå, Sweden
| | - Thomas B L Lam
- Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK; Academic Urology Unit, University of Aberdeen, Aberdeen, UK.
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