Adjuvant instant preoperative renal artery embolization facilitates the radical nephrectomy and thrombectomy in locally advanced renal cancer with venous thrombus: a retrospective study of 54 cases

Survival benefits after radical nephrectomy and IVC thrombectomy of renal cell carcinoma patients with inferior vena cava thrombus

Objective

The role of tumor thrombus as a predictor of survival in patients with renal cell carcinoma (RCC) is controversial. This study aims to evaluate surgical and oncological outcomes after surgery in RCC with inferior vena cava (IVC) tumor thrombus patients.

Materials and methods

A total of 58 patients (2002-2019) underwent radical nephrectomy and IVC thrombectomy at our institute, were retrospectively reviewed. Kaplan-Meier analysis was utilized to compare survival benefits between cohorts and Cox-regression to evaluate potential predictors of patient survival.

Results

There were 5(8.6%), 21(36.2%), 23(39.7%) and 9 (15.5%) patients with tumor thrombus level I, II, III and IV respectively. The major complications (Clavien 3-5) were observed in 15 patients (25.8%) and 12 patients (80%) were patients with high thrombus level (III-IV). There was 9%mortality (5patients): 2 intraoperatively and 3 postoperatively. Median follow-up was 15 months (IQR:5-41). Two-year overall survival (OS) was 80% and 75% in all patients and pN0M0 cohort, respectively. There was significant difference in OS among each IVC thrombus level cohort (p < 0.02). Two-year OS of metastatic RCC patients was 67% and not significantly different when compared to non-metastatic cohort (p = 0.12). On multivariate analysis, only sarcomatoid dedifferentiation was associated with OS(p = 0.04). Disease-free survival was not significantly different among thrombus-level cohorts (p = 0.65).

Conclusions

Our study suggested that surgical treatment for RCC with IVC thrombus provided substantial OS outcomes. Although survival was significantly reduced with higher IVC thrombus level cohort, the level of thrombus itself was not an independent factor. Only sarcomatoid dedifferentiation was a predictor for reduced OS after radical nephrectomy and tumor thrombectomy. Meticulous patient selection and prompt counselling are substantial step for the operation.

A Narrative Review on Robotic Surgery as Treatment for Renal Cell Carcinoma with Inferior Vena Cava Thrombus

Renal cell carcinoma (RCC) is a common diagnosis, of which a notable portion of patients present with an extension into the venous circulation causing an inferior vena cava (IVC) tumor thrombus. Venous extension has significant implications for staging and subsequent treatment planning, with recommendations for more aggressive surgical removal, although associated surgical morbidity and mortality is relatively increased. The methods for surgical removal of RCC with IVC thrombus remain complex, particularly surrounding the use of robot-assisted surgery. Robot assistance for radical nephrectomy in this context is recently emerging. Thrombus level has important implications for surgical technique and prognosis. Other preoperative considerations may include location, laterality, size, and wall invasion. The urology literature on treatment of such tumors is largely limited to case series and institutional studies that describe the feasibility of various surgical options for these complex tumors. Further understanding of the outcomes and patient-specific risk factors would shed increased light on the optimal treatment for such cases. This narrative review provides a thorough overview on the previously reported use of robot-assisted nephrectomy in RCC with IVC thrombus to inform further studies which may optimize outcomes and guide shared decision-making.

A systematic review and meta-analysis on the efficacy of preoperative renal artery embolization prior to radical nephrectomy for renal cell carcinoma: Is it necessary?

INTRODUCTION

Radical nephrectomy for Renal Cell Carcinoma (RCC) is still the treatment of choice for all stages except for stage I and IV, which need patient selectivity. The purpose of Renal Artery Embolization (RAE) pre-operative before radical nephrectomy is to facilitate resection, reduce bleeding, and reduce the time to surgery, but the necessity of this procedure is still debatable. This study investigates the efficacy of pre-operative Renal Artery Embolization (PRAE) before radical nephrectomy for RCC patients.

METHODS

The systematic searches based on PRISMA guidelines were conducted in Pubmed, Scopus, Web of Science, Medrxiv, and ScienceDirect databases with pre-defined keywords. Both analyses, quantitative and qualitative, were performed to assess blood loss, transfusion rate, surgical time, Intensive Care Unit (ICU) stay, and hospital stay.

RESULTS

A total of 921 patients from 8 eligible studies were included. The blood loss was significantly lower in the PRAE group compared to the control group (p = < 0.00001; SMD -20 mL; 95%CI -0.29, -0.12). There is no statistically significant difference between RAE and without RAE in the transfusion rate nephrectomy (p = 0.53, OR 0.65; 95% CI 0.16, 2.57), mean operative time (p = 0.69; SMD 5.91; 95% CI -23.25, 35.07), mean length of hospital stay (p = 0.05; SMD 0.56; 95% CI 0.00, 1.12), and mean length of stay in the ICU (p = 0.45; SMD 11.61; 95% CI -18.35, 41.57) Conclusions: PRAE before radical nephrectomy significantly reduces blood loss in RCC patients but is similar in the surgical time, transfusion rate, and length of hospital stay and ICU stay.

Succinate Dehydrogenase Defects Giant Renal Cell Carcinoma

Succinate dehydrogenase (SDH)-deficient renal cell carcinoma (RCC) is a new subtype of RCC included in the 2016 edition of the WHO classification in RCC. SDH-defective RCC accounts for 0.05-0.2%, and preoperative diagnosis is difficult. We report a severe adherent RCC of inferior vena cava that underwent open radical nephrectomy after preoperative renal artery embolization. Postoperative histopathological examination diagnosed SDH-defective RCC; the clinicopathological stage was pT2b. After 10 months of follow-up, the patient had no evidence of disease recurrence. For patients with large RCC, interventional embolization can be selected to reduce intraoperative bleeding and blood transfusion, and it is recommended to complete interventional surgery within 3-4 h before surgery. SDH-deficient RCC is difficult to distinguish from other renal tumors in imaging, so immunohistochemical examination of SDHB is recommended for young and middle-aged patients, especially those under 45.

Renal cell carcinoma with tumor thrombus: A review of relevant anatomy and surgical techniques for the general urologist

Renal cell carcinoma (RCC) is estimated to account for 4.1% of all new cancer diagnoses and 2.4% of all cancer deaths in 2020 according to the National Cancer Institute SEER database. This will likely total 73,000 new cases and 15,000 deaths. RCC is one of the most lethal of the common cancers urologists will encounter with a 5-year relative survival of 75.2%. Renal cell carcinoma is one of a small subset of malignancies that are associated with tumor thrombus formation, which is tumor extension into a blood vessel. An estimated 4% to 10% of patients with RCC will have some degree of tumor thrombus extending into the renal vein or inferior vena cava at the time of diagnosis. Tumor thrombi change the staging of RCC and therefore are an important part of initial patient workup. It is known that such tumors are more aggressive with higher Fuhrman grades, N+ or M+ at time of surgery and have higher probability of recurrence with lower cancer-specific survival. Aggressive surgical intervention with radical nephrectomy and thrombectomy can be performed with survival benefits. Classifying the level of the tumor thrombus becomes vitally important in surgical planning as it will dictate the surgical approach. Level 0 thrombi may be amenable to simple renal vein ligation while level 4 can require thoracotomy and possible open-heart surgery with coordination of many surgical teams. Here we will review the anatomy associated with each level of tumor thrombus and attempt to construct an outline for surgical techniques that may be used. We aim to give a concise overview so that general urologists may use it to understand these potentially complicated cases.

Utility of preoperative vascular embolization of renal tumors with left renal vein tumor thrombus

INTRODUCTION AND OBJECTIVES

Preoperative renal artery embolization (PRAE) for large renal masses may be performed prior to nephrectomy in order to simplify the procedure and reduce intraoperative bleeding. The objective of this work is to determine the role of PRAE on intraoperative bleeding and postoperative complications in left renal tumors with tumor thrombus limited to the left renal vein (level 0).

MATERIAL AND METHODS

Retrospective analysis to evaluate 46 patients who underwent left radical nephrectomy and thrombectomy for the treatment of renal cell carcinoma with level 0 tumor thrombus during the period 1990-2020. PRAE was limited to those cases in which surgical access to the main renal artery was presumed a priori difficult in the preoperative imaging study (n = 9; 19.6%). Intraoperative bleeding was estimated based on the perioperative transfusion rate, and postoperative complications were categorized according to the Clavien-Dindo classification. The Chi-squared test was used for comparisons. A multivariate analysis was performed to identify predictors of transfusion and complications.

RESULTS

There were no significant differences in the overall complication rate (11.1% vs. 32.4%, p = 0.19), major complication rate (0% vs. 8.1%, p = 0.51), or transfusion rate (11.1% vs. 19%, p = 0.49) between both groups (PRAE vs. non-PRAE). In the multivariate analysis, PRAE did not behave as a predictor of complications (OR: 0.11, 95%CI 0.01-2.86; p = 0.18) nor transfusion (OR: 0.46, 95%CI 0.02-7.38; p = 0.58).

CONCLUSIONS

In our study on left RCC with level 0 tumor thrombus and difficult access to the main renal artery, PRAE was not associated with increased bleeding or postoperative complications, and it did not behave as an independent predictor of these variables. Therefore, it could be used as a preoperative maneuver to facilitate vascular management in selected cases.

Utility of preoperative vascular embolization of renal tumors with left renal vein tumor thrombus

INTRODUCTION AND OBJECTIVES

Preoperative renal artery embolization (PRAE) for large renal masses may be performed prior to nephrectomy in order to simplify the procedure and reduce intraoperative bleeding. The objective of this work is to determine the role of PRAE on intraoperative bleeding and postoperative complications in left renal tumors with tumor thrombus limited to the left renal vein (level 0).

MATERIAL AND METHODS

Retrospective analysis to evaluate 46 patients who underwent left radical nephrectomy and thrombectomy for the treatment of renal cell carcinoma with level 0 tumor thrombus during the period 1990-2020. PRAE was limited to those cases in which surgical access to the main renal artery was presumed a priori difficult in the preoperative imaging study (n=9; 19.6%). Intraoperative bleeding was estimated based on the perioperative transfusion rate, and postoperative complications were categorized according to the Clavien-Dindo classification. The Chi-squared test was used for comparisons. A multivariate analysis was performed to identify predictors of transfusion and complications.

RESULTS

There were no significant differences in the overall complication rate (11.1% vs. 32.4%, P=.19), major complication rate (0% vs.8.1%, P=.51), or transfusion rate (11.1% vs. 19%, P=.49) between both groups (PRAE vs. non-PRAE). In the multivariate analysis, PRAE did not behave as a predictor of complications (OR:0.11, 95%CI 0.01-2.86; P=.18) nor transfusion (OR:0.46, 95%CI 0.02-7.38;P=.58).

CONCLUSIONS

In our study on left renal cell carcinomas with level 0 tumor thrombus and difficult access to the main renal artery, PRAE was not associated with increased bleeding or postoperative complications, and it did not behave as an independent predictor of these variables. Therefore, it could be used as a preoperative maneuver to facilitate vascular management in selected cases.