The surgical management and prognosis of renal cell cancer with IVC tumor thrombus: 15-Years of experience using a multi-specialty approach at a single UK referral center

Case report: Anesthetic management for removal of tumor thrombus in the inferior vena cava and pulmonary artery in renal cell carcinoma

Anesthetic management of patients with renal cell carcinoma with tumor thrombus in the inferior vena cava (IVC) is challenging. This paper reports the experience of anesthesia management in a patient with advanced renal cell carcinoma with thrombus accumulation in the IVC, right atrium, and pulmonary artery who underwent radical nephrectomy and tumor thrombus removal assisted by cardiopulmonary bypass. The emboli, measuring approximately 3 × 6 cm in the left inferior pulmonary artery and 4 × 13 cm in the right main pulmonary artery, were removed completely. During incision of the IVC under systemic heparinization, significant blood loss occurred in the surgical field. The surgery took 724 min, and cardiopulmonary bypass took 396 min. Intraoperative blood loss was 22,000 ml. The patient was extubated 39 hours after surgery and stayed in intensive care unit for 3 days. At 1 year follow-up, the patient was in good health and leading a normal life.

Simultaneous surgical management of renal cancer with atrial thrombotic extension and severe chronic coronary artery disease: a case report

BACKGROUND

Renal cell carcinoma accounts for 2-3% of all malignant cancers in adults and is characterized by the potential development of venous tumor thrombus.

CASE PRESENTATION

We present a rare case of a 62-year-old Caucasian man who arrived in the emergency department for monosymptomatic hematuria. Further investigation revealed a right renal cell carcinoma with 16 cm intravascular extension through the renal vein into the inferior vena cava and right atrium associated with significant coronary artery disease based on the computed tomography scan and coronary angiography. To the best of our knowledge, after an extensive literature review, only one similar case has been reported with involvement of the contralateral kidney. Therefore, there are no applicable management recommendations. After performing coronary artery bypass graft surgery, we proceeded with an open right radical nephrectomy and inferior vena cava and right atrium thrombectomy under cardiopulmonary bypass and while the patient's heart was still beating. The postoperative course went without complications, and the patient was discharged from the hospital on the 10th postoperative day.

CONCLUSIONS

Radical nephrectomy and thrombectomy with reconstruction of the inferior vena cava combined with coronary artery bypass graft can be performed safely and effectively in selected patients with renal cell carcinoma and significant coronary artery disease. Multidisciplinary teamwork and careful patient selection are essential for optimal outcomes.

Cavoatrial hypernephroma resection on cardiopulmonary bypass: Mild/normo-versus moderate hypothermia

INTRODUCION

Renal cell carcinoma (RCC) is one of the most prevalent malignant tumors. It extends up into the systemic veins and right atrium. Surgical extraction of such extensions is usually carried out using cardiopulmonary bypass (CPB) with moderate hypothermic (MH) being frequently applied in order to obtain a clear surgical field. However, due to obvious disadvantages of hypothermia, approaches with mild/normothermia (NT) during CPB have also been established. The current study aims to compare the outcomes of patients undergoing RCC tumor and extensions resection using MH versus NT.

MATERIAL AND METHODS

This is a retrospective, non-randomized study. All patients who underwent RCC tumor and extensions resection for stage III or IV (Staehler) RCC in a single center between 2006 and 2020 were included. During surgery, MH or NT were applied. CPB was realized using aortic and bicaval cannulation. We compared the procedural times, transfusion requirements and postoperative outcomes, respectively between the MH and NT groups.

RESULTS

A total of 24 consecutive patients (n(NT) = 12, n(MH) = 12) were included in the study (median age NT 68.5 and MH 66.5). The study only showed a significant difference in heart-lung machine times (median CPB time NT 45.5 min and MH 110.0 min, p = 0.004). All other results, loss of drainage, administration of blood products, as well as the postoperative course and mortality were comparable in both groups.

CONCLUSION

The results showed a high perioperative and long-term mortality. The perioperative course was similar after surgery with NT or MH. Therefore, NT which minimizes potential complications of MH should be preferred.

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.

Prevalence and risk factors of myocardial and acute kidney injury following radical nephrectomy with vena cava thrombectomy: a retrospective cohort study

BACKGROUND

Radical nephrectomy with thrombectomy is the mainstay treatment for patients with renal cell carcinoma with vena cava thrombus. But the procedure is full of challenge, with high incidence of major complications and mortality. Herein, we investigated the incidence and predictors of myocardial injury and acute kidney injury (AKI) in patients following radical nephrectomy with inferior vena cava thrombectomy.

METHODS

Patients who underwent nephrectomy with thrombectomy between January 2012 and June 2020 were retrospectively reviewed. Myocardial injury was diagnosed when peak cardiac troponin I was higher than 0.03 ng/ml. AKI was diagnosed according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Multivariable logistic regression models were used to identify predictors of myocardial injury or AKI after surgery.

RESULTS

A total of 143 patients were included in the final analysis. Myocardial injury and AKI occurred in 37.8 and 42.7% of patients after this surgery, respectively. Male sex (odds ratio [OR] 0.27, 95% confidence interval [CI] 0.10-0.71; P = 0.008) was associated with a lower risk, whereas high level Mayo classification (compared with Mayo level I + II, Mayo level III + IV: OR 4.21, 95% CI 1.42-12.4; P = 0.009), acute normovolemic hemodilution before surgery (OR 2.66, 95% CI 1.10-6.41; P = 0.029), long duration of intraoperative tachycardia (per 20 min: OR 1.49, 95% CI 1.10-2.16; P = 0.036), and long duration of surgery (per 1 h, OR 1.48, 95% CI 1.03-2.16, P = 0.009) were associated with a higher risk of myocardial injury. High body mass index (OR 1.18, 95% CI 1.06-1.33; P = 0.004) and long duration of intraoperative hypotension (per 20 min: OR 1.30, 95% CI 1.04-1.64; P = 0.024) were associated with a higher risk, whereas selective renal artery embolism before surgery (OR 0.20, 95% CI 0.07-0.59, P = 0.004) was associated with a lower risk of AKI.

CONCLUSION

Myocardial injury and AKI were common in patients recovering from radical nephrectomy with inferior vena cava thrombectomy. Whether interventions targeting the above modifiable factors can improve outcomes require further studies.

Case reports of robot-assisted laparoscopic radical nephrectomy and inferior vena cava tumor thrombectomy: A retrospective analysis

Renal cell carcinoma is one common type of urologic cancers. It has tendencies to invade into the inferior vena cava (IVC) and usually requires an open surgery procedure. High rates of operative complications and mortality are usually associated with an open surgery procedure. The recently emerged robot-assisted laparoscopic radical nephrectomy (RAL-RN) and IVC tumor thrombectomy have shown to reduce operative related complications in patients with renal cell carcinoma.This case series study aimed to summarize technical utilization, perioperative outcomes, and efficacies of RAL-RN and IVC tumor thrombectomy in our hospital. A retrospective analysis was performed on clinical data from 20 patients who underwent RAL-RN and IVC tumor thrombectomy from January 2017 to December 2019 in our department.Patients had a median age of 59 years (interquartile range [IQR], 46-68). Four patients had renal neoplasm on left side and 16 on right side. Nineteen patients underwent RAL-RN (level 0: n = 2) or RAL-RN with IVC thrombectomy (n = 17) (level I: n = 3; level II: n = 12; and level III: n = 3) and 1 patient was converted into an open surgery. The median operative time was 328 minutes (IQR, 221-453). The estimated median blood loss was 500 mL (IQR, 200-1200). The median size of removed renal carcinoma was 67 cm2 (IQR, 40-91); the length of IVC tumor thrombus was 5 cm (IQR, 3-7). The postsurgery hospital length of stay was 6 days (IQR, 5-7). The complications included intestinal obstruction (n = 1), lymphatic fistula (n = 1), heart failure (n = 1), and low hemoglobin level (n = 1). The outcomes for patients after 16 months (IQR, 11-21) follow-up were tumor-free (n = 10), tumor progression (n = 4), loss of contact (n = 1), and death (n = 5).We concluded that RAL-RN and IVC thrombectomy renders good safety profiles including minimal invasiveness, low estimated median blood loss, short hospitalization, low morbidity, and quick renal function recovery. The long-term efficacy needs a further investigation.

A cut above? Inferior vena cava resection without reconstruction: a dual-centre experience

Objectives:

To evaluate outcomes in our patients undergoing inferior vena cava (IVC) resection without reconstruction, as part of an adrenal/renal cell cancer (RCC) operation.

Methods:

British Association of Urological Surgeons (BAUS) Data and Audit System records were obtained for two operating surgeons, each at geographically separate urological cancer centres. Retrospectively reviewed case notes of patients who had undergone IVC resection without reconstruction as part of an adrenal/RCC operation, assessing operative parameters, length of stay, complications and follow-up status.

Results:

A total of Twenty-eight patients (20 right-sided tumours, 8 left sided) underwent IVC resection without reconstruction in May 2013–February 2017. No perioperative or early deaths occurred. Fourteen patients (50%) had complications: sepsis; pneumonia; congestive cardiac failure; acute kidney injury; symptomatic peripheral deep venous thrombosis; splenectomy; and significant chyle leak. At a median follow-up of 21 months (range 1–55 months) six patients (21.4%) have died and two patients (7.1%) progressed to metastatic disease, giving a 71.4% progression-free survival in this series.

Conclusions:

This case series illustrates our experience of IVC resection without reconstruction as an acceptably safe procedure. This should be considered as an alternative to graft reconstruction, particularly as minimal invasive approaches are being adopted.

Level of Evidence:

3

Transabdominal approach for renal cell carcinoma with supradiaphragmatic tumor thrombus: description of a modified technique and indications for treatment

Objective

We investigated the safety and effectiveness of a modified transabdominal approach for renal cell carcinoma (RCC) with a supradiaphragmatic inferior vena cava (IVC) tumor thrombus (TT).

Methods

Eight patients underwent radical nephrectomy with removal of a supradiaphragmatic IVC-TT through an abdominal incision using a transdiaphragmatic approach in Peking University Third Hospital from April 2015 to January 2018. We modified this technique using a Foley catheter balloon to avoid piggyback liver mobilization.

Results

All patients underwent successful operations. The median operative time was 7 hours 23 minutes. The median estimated blood loss was 2963 mL. All patients received a blood transfusion with a median blood infusion volume of 2162 mL. Two patients with Budd–Chiari syndrome developed postoperative ascites and hydrothorax due to non-watertight repair of the diaphragm. During a follow-up of 11 to 44 months, only one patient died of liver metastasis and four patients developed distant metastasis without recurrence in the IVC.

Conclusions

The modified transabdominal approach described herein has an encouraging safety profile and provides a surgical option for treatment of RCC with a supradiaphragmatic IVC-TT. More evidence concerning the beneficial role of this procedure will be elucidated in further studies.

Robotic retroperitoneal versus transperitoneal inferior vena cava thrombectomy: right-sided cases with level I-II tumor thrombus

OBJECTIVES

To compare the perioperative hemodynamic consequences and oncology outcomes of robotic retroperitoneal versus transperitoneal inferior vena cava(IVC) thrombectomy(IVCT) for right renal cell carcinoma(RCC) with IVC tumor thrombus(IVCTT) that located below the first porta hepatis.

PATIENTS AND METHODS

Between January 2018 and June 2019, 35 patients of right RCC with IVCTT that located below the first porta hepatis underwent robotic retroperitoneal IVCT(16 patients) or transperitoneal IVCT(19 patients). We have described the procedures of transperitoneal IVCT earlier. The main procedure of robotic retroperitoneal IVCT include circumferential dissection of the IVC, sequentially clamping subhepatic IVC, the left renal vein and the caudal IVC with vessel loops, IVCT, IVC repair, radical nephrectomy(RN). The following parameters were compared between the two groups: baselines characteristic, perioperative consequences and hemodynamic changes.

RESULTS

Retroperitoneal and transperitoneal cohorts were comparable in terms of IVC thrombus length(3.2 vs 4.0 cm), IVC block time (18 vs 16 min, p=0.64), postoperative hospital stay (6 vs 6 days, p= 0.67), postoperative complications (0 vs 0), and recurrence or metastasis rate(0 vs 0) for patients with similar baseline characteristic. The retroperitoneal cohort tended to less blood loss (160 vs 240ml,p=0.024), shorter operative time(130 vs 145min,p=0.003), lower central venous pressure(p＜0.05) and smaller diameter of IVC (p＜0.05).

CONCLUSIONS

Robotic retroperitoneal RN and IVCT is feasible for patients of right RCC with IVCTT located below the first porta hepatis and is superior to transperitoneal IVCT in terms of bleeding control and operation time for skilled surgeons.

The role of open radical nephrectomy in contemporary management of renal cell carcinoma

Radical nephrectomy (RN) remains a cornerstone of the management of localised renal cell carcinoma (RCC). RN involves the en bloc removal of the kidney along with perinephric fat enclosed within Gerota's fascia. Key principles of open RN include appropriate incision for adequate exposure, dissection and visualisation of the renal hilum, and early ligation of the renal artery and subsequently renal vein. Regional lymph node dissection (LND) facilitates local staging but its therapeutic role remains controversial. LND is recommended in patients with high risk clinically localised disease, but its benefit in low risk node-negative and clinically node-positive patients is unclear. Concomitant adrenalectomy should be reserved for patients with large tumours with radiographic evidence of adrenal involvement. Despite a recent downtrend in utilisation of open RN due to nephron-sparing and minimally invasive alternatives, there remains a vital role for open RN in the management of RCC in three domains. Firstly, open RN is important to the management of large, complex tumours which would be at high risk of complications if treated with partial nephrectomy (PN). Secondly, open RN plays a crucial role in cytoreductive nephrectomy (CN) for metastatic RCC, in which the laparoscopic approach achieves similar results but is associated with a high reoperation rate. Finally, open RN is the current standard of care in the management of inferior vena caval (IVC) tumour thrombus. Management of tumour thrombus requires a multidisciplinary approach and varies with cranial extent of thrombus. Higher level thrombus may require hepatic mobilisation and circulatory support, whilst the presence of bland thrombus may warrant post-operative filter insertion or ligation of the IVC.

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

Background

The role of renal artery embolization (RAE) in the therapeutic armamentarium is always controversial. The present study aimed to assess the safety and the surgical outcomes of the instant renal artery embolization (I-RAE) prior to nephrectomy and thrombectomy in patients with locally advanced renal cell carcinoma (RCC) with venous thrombus.

Methods

We performed a retrospective analysis of 54 patients treated with nephrectomy and thrombectomy between January 2012 and January 2019. Twenty-four patients were treated with I-RAE before surgery. Thirty patients received surgery alone (non-RAE group). The patient demographics, operation time, blood loss, transfusion requirements, complications, and other surgical parameters were analyzed between the two groups.

Results

The mean tumor size in the I-RAE group was significantly larger than that in the non-RAE group (11.1 cm versus 7.9 cm; p = .001). The mean estimated blood loss was significantly lower in the I-RAE group compared to that in the non-RAE group (596 ml versus 827 ml; p = .015), and the patients in the non-RAE group were more likely to receive blood transfusion (red blood cell, RBC units, 4 U versus 6 U, p = .025; plasma volume, 200 ml versus 400 ml, p = .01). No differences were found in operative duration, ICU stay, perioperative complications, and length of postoperative hospitalization.

Conclusions

Instant preoperative adjuvant renal artery embolization (I-RAE) is a safe technique. It facilitates nephrectomy and thrombectomy by reducing blood loss, transfusion requirements, and complications of delayed operations, providing urologists with a reliable option for treatment of locally advanced RCC with tumor thrombus.

The influence of venous tumor thrombus combined with bland thrombus on the surgical treatment and prognosis of renal cell carcinoma patients

Objective

To describe the clinical characteristics of renal cell carcinoma (RCC) with venous tumor thrombus (VTT) and bland thrombus (BT), and to evaluate the influence of BT on surgical treatment and cancer‐specific survival (CSS) of RCC with VTT.

Methods

We retrospectively reviewed clinical data of 123 patients with RCC and VTT, who underwent surgical treatment in our center between February 2015 and May 2018. Patients were divided into the BT group (21 patients) and non‐BT group (102 patients). Chi‐square and Mann‐Whitney U test were used for categorical and continuous variables respectively. Univariable log‐rank tests and multivariable Cox regressions were conducted to evaluate the prognostic significance of each variable. Kaplan‐Meier plots were performed to evaluate the influence of BT.

Results

In the delayed phase of enhanced magnetic resonance imaging (MRI), BT and VTT had difference. Patients were divided according to the relative position of BT: proximal end BT (one patients), contralateral renal vein BT (two patients), distal end BT (12 patients), and multiple BT (six patients). The average length of BT was 8.4 ± 5.8 cm (range: 0.6‐20.0 cm). Patients with BT had longer operative time (P = .001), more surgical blood loss (P = .004), higher proportion of open surgery (P = .006), more postoperative complications (P = .011). BT (hazard ratio [HR] = 3.323, P = .007) were independent risk factors for poor prognosis.

Conclusions

In the delayed phase of enhanced MRI, BT showed no obvious enhancement, while VTT usually showed enhancement. This was an important basis for preoperative imaging diagnosis of BT. The presence of BT increases the difficulty of surgery, and is correlated with adverse survival outcomes in patients with RCC and VTT.

Anesthetic management of radical nephrectomy in patients with renal cell carcinoma involving renal vein or inferior vena cava

OBJECTIVE

To investigate the perioperative anesthetic management of patients diagnosed with renal cell carcinoma (RCC) metastasized into the renal vein or inferior vena cava (IVC) after undergoing radical nephrectomy to provide clinical evidence for rational anesthetic interventions.

METHODS

A total of 81 patients with RCC extending into the renal vein or IVC, aged 17-73 years, undergoing radical nephrectomy were recruited. Preoperative status, intraoperative management, average operation time, average estimated blood loss, postanesthesia outcomes, and postoperative complications were retrospectively analyzed.

RESULTS

The mean operation time was 288 minutes (range 146-825 minutes). The mean estimated blood loss was recorded as 1905 mL (range 200-7000 mL). Among 81 cases, 9 patients (11.1%, 1 level II, 3 level III, and 5 level IV) were switched to undergo cardiopulmonary bypass. Significant hemodynamic fluctuations were observed in 39 patients who presented with level II-IV of tumor thrombus. One patient had pulmonary embolism and died of active cardiopulmonary resuscitation. The mean postoperative hospital stay was 12.8 days. Twenty-five cases with level III-IV tumor thrombus were transferred to the intensive care unit with endotracheal intubation due to massive intraoperative blood loss. The remaining 55 cases were transferred to the postanesthesia care unit 2 hours before being transferred to the ward. One patient had postoperative acute coronary syndrome and was discharged after effective interventions.

CONCLUSION

Anesthetic management and intensive postoperative care play a pivotal role in the success of complete resection of RCC that metastasize into the IVC.

Foley catheter-assisted six-step thrombectomy technique in the surgical management of renal cell carcinoma with Mayo level II to IV tumor thrombus

OBJECTIVE

To simplify Foley catheter-assisted thrombectomy to a six-step approach and determine the feasibility and results of this technique for renal cell carcinoma (RCC) with a Mayo level II to IV tumor thrombus (TT).

METHODS

The surgical records of patients with RCC with a Mayo level II to IV TT treated in our hospital were retrospectively reviewed. Fifteen patients who underwent radical nephrectomy and thrombectomy with a Foley catheter-assisted procedure were included. Epidemiological and clinicopathological features, operation-related variables, and outcomes were evaluated.

RESULTS

The TTs in all 15 patients were successfully retracted by the Foley catheter. The mean operation time was 420.1 ± 108.9 minutes. The mean intraoperative blood loss and perioperative red blood cell transfusion volumes were 1846.7 ± 1467.8 and 1288.7 ± 1060.6 mL, respectively. Five patients had perioperative complications. The median follow-up time was 9 (range, 0-34) months, and four patients died of the disease.

CONCLUSIONS

Simplification of Foley catheter-assisted thrombectomy to a six-step approach results in the probability of avoiding thoracotomy or cardiopulmonary bypass to a certain degree and is associated with fewer complications, less blood loss, and less perioperative red blood cell transfusion. However, experienced surgeons and multidisciplinary cooperation are still needed.

Postsurgical complications in patients with renal tumours with venous thrombosis treated with surgery

BACKGROUND AND OBJECTIVE

Surgery on renal tumours with venous thrombosis suffers a high rate of complications and non-negligible perioperative mortality. Our objective was to analyse the postoperative complications, their relationship with the level of the thrombus and its potential predisposing factors.

MATERIALS AND METHODS

A retrospective analysis was conducted of 101 patients with renal tumours with venous thrombosis operated on between 1988 and 2017. Two patients were excluded because of intraoperative pulmonary thromboembolism and exitus (2%). The postsurgical complications were classified according to Clavien-Dindo. To compare the qualitative variables, we employed the chi-squared test. We performed a multivariate analysis using binary logistic regression to identify the independent predictors.

RESULTS

Some type of postsurgical complication occurred in 34 (34.3%) patients, 11 (11.1%) of which were severe (Clavien III-V). There were significant differences in the total complications (P=.003) and severe complications (Clavien≥III; P=.03) depending on the level of the tumour thrombus.

A rare case report of one stage surgical treatment for left renal cell carcinoma with level IV intravenous tumor thrombus combined with severe coronary artery stenosis

RATIONALE

Renal cell carcinoma (RCC) exhibits a natural tendency to extend from the kidney into inferior vena cava (IVC) and growing into the right atrium is a rare complication. We report a 65-year-old patient with an RCC with intravascular extension through renal vein into the IVC and right atrial combined with severe coronary artery disease. This case has not been described in the literature and there is no treatment guideline for it.

PATIENT CONCERNS

A 65-year-old patient was admitted to our clinic with complaints of edema of both lower extremities.

DIAGNOSES

On the basis of the magnetic resonance imaging scan and coronary angiography, we strongly suspected an RCC with intravascular extension through renal vein into the IVC and right atrial combined with severe coronary artery disease.

INTERVENTIONS

We performed open left radical nephrectomy, IVC, and right atrium thrombectomy under cardiopulmonary bypass and coronary artery bypass grafting on beating heart.

OUTCOMES

The postoperative course was uneventful. The patient has been discharged from hospital.

LESSONS

Coexistence of severe coronary artery disease and RCC infiltrating inferior vena cava and right atrium rendered this operation as very high-risk procedure. We hope that our operational manners can prove the possibility of simultaneous difficult cardiac and urologic operation. The basic point of our report concerns the fact that the oncologic treatment was not delayed despite severe heart disease.

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.

Frontiers in robot-assisted retroperitoneal oncological surgery

Robot assistance has been rapidly adopted by urological surgeons and has become particularly popular for oncological procedures involving the retroperitoneal space. The wide dissemination of robot assistance probably reflects the limited amount of operating space available within the retroperitoneum and the advantages provided by robot-assisted approaches, including 3D imaging, wristed instrumentation and the shorter learning curve compared with that associated with the equivalent laparoscopic techniques. Surgical procedures that have traditionally been performed using an open or laparoscopic approach, such as partial nephrectomy, radical nephrectomy, retroperitoneal lymph node dissection, nephroureterectomy and adrenalectomy, are now often being performed using robot assistance. The frontiers of robot-assisted retroperitoneal oncological surgery are constantly expanding, with an emphasis on maintaining oncological and functional outcomes, while minimizing the level of surgical invasiveness.

Xeno-pericardial patch repair of the inferior vena cava for radical resection of renal cell carcinoma with tumor thrombus

Background and Objectives

For tumor thrombus in the inferior vena cava (IVC) complicated with kidney cancer, we built a surgical team to achieve (1) en bloc tumor resection; (2) xeno‐pericardial patch IVC repair; and (3) minimum organ damages. We reviewed outcome of the case series to verify rationale of this approach.

Methods

A consecutive series of 12 patients having the IVC tumor thrombus by renal cell carcinoma in the last 3 years was enrolled. Minimum kidney ischemia was induced in five cases (Procedure I), whereas liver and kidney ischemia was induced in five cases (Procedure II). Mild hypothermic extracorporeal circulation was used in two cases (Procedure III).

Results

There was no mortality or severe morbidities related to the surgery. Postoperative recovery was most prompt by the Procedure I. Liver and kidney ischemic time was longer in the Procedure III than the Procedure II, whereas organ function was not substantially impaired in either series. The resected IVC margin was free from the cancer in all cases, while local recurrence was not seen in any cases.

Conclusions

En bloc resection with xeno‐pericardial patch repair of the IVC was successfully performed in the tumor thrombus complicated with kidney cancer with minimum organ damage.

The enduring patency of primary inferior vena cava repair

BACKGROUND

Inferior vena cava repair after planned and unplanned venotomy is performed by either interposition bypass, patch venopasty, or lateral venorrhaphy and primary repair. Primary repair of the inferior vena cava avoids the use of foreign material and allows an all-autologous repair in an expeditious fashion. The purpose of this study was to demonstrate the utility of inferior vena cava repair, determine the degree of inferior vena cava stenosis, and examine clinical outcomes after primary repair.

METHODS

We conducted a single-center retrospective review of patients who underwent primary inferior vena cava repairs between January 2002 and January 2014 at a tertiary care center. Primary repair followed lateral venorrhaphy for tumor extraction or for repair of an iatrogenic inferior vena cava injury. Patient demographics, cross-sectional vena cava dimensions, and patient outcomes were tabulated.

RESULTS

In total, 47 (30 men and 17 women) patients underwent primary inferior vena cava repair (median age 58 years, range 31-83 years). Twenty-six patients (15 men and 11 women) underwent en bloc radical nephrectomy, inferior vena cava tumor thrombus extraction, and primary lateral venorrhaphy (median age 61 years, range 39-83 years). The majority, 92% of these patients, had renal cell carcinoma on final pathology, with a median follow-up period of 39 months (range 1-108 months). Twenty-one patients (15 men and 6 women) underwent primary repair for iatrogenic inferior vena cava injury (median age 54 years, range 31-82 years). The median follow-up period was 18.5 months (3-110 months). Clinic follow-up with postoperative imaging was obtained in 76.9% of those undergoing tumor thrombus extraction (n = 20) and 76.2% of those undergoing repair of an iatrogenic injury (n = 16). Overall, there was a 13% infrarenal inferior vena cava diameter loss, 17% inferior vena cava diameter loss at the level of the renal veins, and 10% suprarenal inferior vena cava diameter loss when comparing postoperative with preoperative imaging. All patients remained asymptomatic; therefore, inferior vena cava narrowing associated with primary repair was clinically insignificant.

CONCLUSION

Primary inferior vena cava repair is associated with less than 20% inferior vena cava diameter loss and does not compromise venous outflow from the extremities. Primary inferior vena cava repair is a safe and expeditious technique that provides excellent clinical outcomes and long-term patency.

Combined Aortic Valve Replacement and Renal Cell Carcinoma Thrombectomy

Although nephrectomy for renal cell carcinoma with inferior vena cava invasion is a common procedure, it is rare to have level IV invasion necessitating cardiopulmonary bypass (CPB). Furthermore, it is exceptionally rare to perform cardiac surgery concomitantly with this resection. We report a case in which an aortic valve replacement was done in the same surgical setting as a level IV thrombectomy. We have demonstrated that although it can be difficult to manage the coagulopathy post-CPB, this can be successfully accomplished with adequate prior preparation and a coordinated team effort.

Multi-disciplinary surgical approach to the management of patients with renal cell carcinoma with venous tumor thrombus: 15 year experience and lessons learned

BACKGROUND

The management of patients with renal cell carcinoma (RCC) with venous tumor thrombus (VTT) is challenging. We report our 15 year experience in the management of patients with RCC with VTT utilizing a multidisciplinary team approach, highlighting improved total and specifically Clavien III-V complication rates.

METHODS

We reviewed the records of 146 consecutive patients who underwent radical nephrectomy with venous thrombectomy between 1998 and 2012. Data on patient history, staging, surgical techniques, morbidity, and survival were analyzed. Additionally, complication rates between two surgical eras, 1998-2006 and 2006-2012, were assessed.

RESULTS

The study included 146 patients, 97 males (66 %), and a median age of 61 years (range, 24-83). Overall complications rate was 53 %, high grade complications (Clavien III -V) occurred in 10 % of patients. Most importantly, there was a lower incidence of overall and high grade complications (45 % and 8 %, respectively) in the last 6 years compared to the earlier surgeries included in the study (67 % and 13 % respectively) [p = .008 and .03, respectively). 30 day postoperative mortality was 2.7 %. 5 year overall survival (5Y- OS) and 5 year cancer specific survival (5Y- CSS) were 51 % and 40 %, respectively. Metastasis was the only independent predictor factor for CSS (HR 3.8, CI 1.9-7.6 and p < .001) and OS (HR 2.6, CI 1.5-4.7 and p = .001) in all patients.

CONCLUSIONS

Our data suggest that patients with RCC and VTT can be treated safely utilizing a multidisciplinary team approach leading to a decrease in complication rates.

Effect of utilization of veno-venous bypass vs. cardiopulmonary bypass on complications for high level inferior vena cava tumor thrombectomy and concomitant radical nephrectomy

Purpose:

To determine if patients with renal cell carcinoma (RCC) with levels III and IV tumor thrombi are receive any reduction in complication rate utilizing veno-venous bypass (VVB) over cardiopulmonary bypass (CPB) for high level (III/IV) inferior vena cava (IVC) tumor thrombectomy and concomitant radical nephrectomy.

Materials and Methods:

From May 1990 to August 2011, we reviewed 21 patients that had been treated for RCC with radical nephrectomy and concomitant IVC thrombectomy employing either CPB (n =16) or VVB (n=5). We retrospectively reviewed our study population for complication rates and perioperative characteristics.

Results:

Our results are reported using the validated Dindo-Clavien Classification system comparing the VVB and CPB cohorts. No significant difference was noted in minor complication rate (60.0% versus 68.7%, P=1.0), major complication rate (40.0% versus 31.3%, P=1.0), or overall complication rate (60.0% versus 62.5%, P=1.0) comparing VVB versus CPB. We also demonstrated a trend towards decreased time on bypass (P=0.09) in the VVB cohort.

Conclusion:

The use of VVB over CPB provides no decrease in minor, major, or overall complication rate. The use of VVB however, can be employed on an individualized basis with final decision on vascular bypass selection left to the discretion of the surgeon based on specifics of the individual case.

The safety and validity of surgical resection for hemodialysis-dependent patients with renal cell carcinomas involving the inferior vena cava

Perioperative morbidity and mortality increase during renal cell carcinoma resection with inferior vena cava involvement in hemodialysis-dependent end-stage renal disease patients. We evaluated the safety and validity of surgical management for renal cell carcinoma with inferior vena cava thrombi in such patients undergoing radical nephrectomies and tumor thrombectomies. There were three patients with tumor thrombus level II, and one each with tumor thrombus level III and IV. We evaluated median operative time (337 min), median estimated blood loss (1300 mL), and median postoperative hospitalization (15 days). Postoperative complications included surgical site dehiscence and pulmonary thromboembolism. One patient with preoperatively identified lung metastases developed a pulmonary thromboembolism on day 3 and died on day 15. The other four patients had long postoperative survival (19-104 months). Successful surgical management of renal cell carcinoma involving the inferior vena cava requires preoperative evaluation of the patient's condition to improve survival for hemodialysis-dependent end-stage renal disease patients.

Robot-assisted Laparoscopic Inferior Vena Cava Thrombectomy: Different Sides Require Different Techniques

BACKGROUND

The safety and feasibility of robot-assisted laparoscopic inferior vena cava (IVC) thrombectomy (RAL-IVCTE) have been investigated in limited reports.

OBJECTIVE

To share our initial experience with RAL-IVCTE, as well as describe respectively the detailed techniques for RAL-IVCTE for left or right renal cell carcinoma (RCC).

DESIGN, SETTING, AND PARTICIPANTS

From May 2013 to July 2014, 17 patients with RCC involving IVC tumor thrombus were admitted to our hospital.

SURGICAL PROCEDURE

For right RCC, the caudal IVC, left renal vein, and cephalic IVC were sequentially clamped. The IVC wall was cut, and the thrombus was removed. For left RCC, the left renal vein, which included the thrombus, was ligated with Endo-GIA. The caudal IVC, right renal artery, right renal vein, and cephalic IVC were sequentially clamped.

MEASUREMENTS

The detailed techniques for RAL-IVCTE for different sides were described and the perioperative outcomes recorded.

RESULTS AND LIMITATIONS

The operations were successfully performed without open conversion. Median operation time was 131min (100-150min) and 250min (190-275min) for the right and left RCC, respectively. Median estimated blood loss was 240ml (145-320ml). Median IVC blocking time was 17min (12-25min). For left RCC, median warm ischemia time for the right kidney was 18min (14-22min). A grade IV complication-bleeding from tributaries of the IVC-developed in one case and was successfully resolved with intraoperative endoscopic suture.

CONCLUSIONS

RAL-IVCTE is safe and feasible. For left RCC involving IVC thrombus, right renal warm ischemia time is necessary during the procedure, requiring a more advanced technical skill. The therapeutic effect and overall survival rate require further investigation with a larger sample size and longer follow-up.

PATIENT SUMMARY

Robot-assisted laparoscopic inferior vena cava thrombectomy is technically challenging but safe and feasible. The therapeutic effect needs further investigation.

Renal cell carcinoma with vena caval involvement: a contemporary clinicopathologic analysis of 53 cases

A clinicopathologic analysis of patients with renal cell carcinoma (RCC) and vena caval involvement diagnosed at our institution was performed. Multiple clinicopathologic parameters were examined. Fifty-three cases were identified. Mean patient age was 62 years (range, 40-82 years). The cohort comprised 36 of 53 (68%) men and 17 of 53 (32%) women. Mean primary tumor size was 10.4 cm (range, 3.1-21.0 cm). The breakdown of tumor stage was as follows: 37 of 53 (70%) were pT3b, 14 of 53 (26%) were pT3c, and 2 of 53 (4%) were pT4. Most of the tumors were clear cell RCC (45/53, 84.6%), although other variants were also represented. All cases were Fuhrman nuclear grade 3 (34/53, 64%) or 4 (19/53, 36%). Tumor necrosis was present in 41 of 53 (77%) cases. At the time of the initial tumor resection, 11 of 53 (21%) cases were staged pM1. Of the 42 patients staged as pMX at the time of primary tumor resection, 12 of 42 (29%) later developed metastasis, most commonly to the lungs. Of all 53 cases with these very advanced tumors, only 6 of 53 (11.3%) had positive surgical margins: 4 of 53 (7.5%) had positive vascular resection margins, and 2 of 53 (3.8%) had focally positive perinephric fat margins. The mean 5-year survival in our cohort was 50%. Our findings suggest that a select group of patients with RCC with vena caval involvement may benefit from radical nephrectomy, although some tumors may have positive vascular and/or nonvascular surgical resection margins even in the best surgical hands. Multi-institutional studies are needed to further characterize these advanced tumors from the molecular standpoint.

Role and Operative Technique of Portal Venous Tumor Thrombectomy in Patients with Pancreatic Neuroendocrine Tumors

INTRODUCTION

Venous tumor thrombi have been reported in as many as 33 % of patients with pancreatic neuroendocrine tumors (pNETs). Surgical thrombectomy is often used to manage tumor thrombi that develop in association with cancers of the liver or kidney. We have likewise used thrombectomy to extract portal venous tumor thrombi in selected cases of pNET.

METHODS

We describe all cases of portal venous thrombectomy that were performed at our institution between 2007 and 2014 and illustrate the thrombectomy techniques we used in detail. In addition, we report the results of a PubMed search for English-language articles that were published between 1990 and 2014 and that described surgical therapy for portal venous thrombus developing in association with pNETs.

RESULTS

Among 245 patients with pNET that underwent pancreatectomy at our institution, 26 (11 %) patients required surgical management of tumor involvement of the portal vein or its tributaries concomitant with pancreatectomy, including 9 (3.8 %) patients who underwent portal venous tumor thrombectomy. Eight cases describing surgical management of tumor thrombus including two additional cases of portal venous tumor thrombectomy were identified in the medical literature. Among patients with pNET who underwent thrombectomy at our institution, all nine had non-functioning tumors and eight (89 %) had tumors of the body and/or tail of the pancreas. Six (67 %) were treated with systemic therapy prior to pancreatectomy. Seven (78 %) patients are alive at a median follow-up of 33 months (range 3 to 97).

CONCLUSION

Venous tumor thrombectomy may be used to safely and effectively extract thrombi from the portal venous system in selected patients with advanced pNET concomitant with pancreatectomy.

Clinical and oncological outcomes in Chinese patients with renal cell carcinoma and venous tumor thrombus extension: single-center experience

BACKGROUND

To evaluate the clinical and oncological outcomes and to identify prognostic factors for survival in Chinese patients with renal cell carcinoma (RCC) and venous tumor thrombus (VTT).

METHODS

A total of 86 patients who underwent nephrectomy and tumor thrombectomy for RCC and venous tumor thrombus extension from 2003 to 2013 were included in this retrospective study. The records of these patients were reviewed. Kaplan-Meier analysis was used to determine cancer-specific survival (CSS). Prognostic factors for CSS were identified by univariate and multivariate analyses using the Cox proportional hazards regression mode.

RESULTS

All patients in this cohort received radical nephrectomy and tumor thrombectomy. Median follow-up period was 27.0 months (range 3-111). No patients died intraoperatively, and the complication rate was 36.0%. The 1-, 3-, and 5-year CSS rates for all patients were 93.0%, 70.9%, and 58.1%, respectively, and those for patients without distant metastasis at presentation were 95.3%, 82.6%, and 68.6%, respectively. Multivariate Cox regression analysis showed that lymph node invasion, distant metastasis at presentation, and invasion of the inferior vena cava (IVC) wall were the independent prognostic factors for CSS in all patients. For patients without distant metastasis, tumor grade, lymph node invasion, and perinephric fat invasion were significantly associated with CSS on multivariate analysis.

CONCLUSIONS

Survival rates for patients with RCC and VTT were still poor. Our results indicated that lymph node invasion, distant metastasis at presentation, and invasion of the IVC wall were independent negative prognostic factors.

Outcomes after inferior vena cava thrombectomy and reconstruction for advanced renal cell carcinoma with tumor thrombus

BACKGROUND

This report details the experience of a multidisciplinary surgical team in the management of stage III and stage IV renal cell carcinoma (RCC) with concomitant inferior vena cava (IVC) tumor thrombus.

METHODS

A retrospective inquiry of our vascular database from 2003 to 2012 identified 55 surgical cases of stage III (n = 40) and stage IV (n = 15) RCC presenting with IVC tumor thrombus. Tumor characteristics and IVC tumor thrombus were evaluated by clinical staging and postoperative pathology staging. Patient demographics and surgical reconstruction are detailed. Cancer-specific outcomes consisted of oncologic surveillance with computed tomography or magnetic resonance imaging. A Clavien-Dindo classification of early (<30 days) complications and mortality was recorded, including a review of secondary surgical interventions.

RESULTS

According to the Novick classification of IVC tumor thrombus, there were 10 supradiaphragmatic (level IV), 20 intrahepatic (level III), and 25 infrahepatic (level II or I) tumor thrombi. Vena cava reconstruction was completed in 54 patients (98%), with one patient deemed unresectable. Vena cava control required cardiac bypass (n = 10), venovenous bypass (n = 4), or infrahepatic IVC control (n = 40). Reconstruction of the IVC was completed with two prosthetic interposition grafts for one stage IV thrombus and one stage III thrombus; two patch repairs were done for stage III thrombus, and there were 50 primary IVC repairs. All other IVC reconstructions were patent at a mean follow-up of 23 months. A single asymptomatic patient with primary IVC repair had estimated 30% IVC narrowing but no other measurable stenosis as detected by postoperative imaging. Three patients required reoperation (two for surgical site bleeding, one for small bowel fistula). Early surgical complications included Clavien-Dindo grades I (n = 3), II (n = 6), IIIa (n = 2), IIIb (n = 3), and V (n = 2). Regional retroperitoneal or distant recurrent RCC occurred in 26 patients (48%); a single patient demonstrating recurrent IVC tumor thrombus at 8 months required secondary IVC thrombectomy. All patients with tumor invasion of the IVC wall developed recurrent RCC, and no patient survived beyond 5 years. Early mortality was 3.6% (n = 2), with 27 patients (49%) dying within 24 months, resulting in an overall mortality for the cohort of 80% (n = 44) as established on routine regular postoperative surveillance.

CONCLUSIONS

A multidisciplinary approach for the management of advanced RCC and IVC tumor thrombus helps optimize outcomes. Primary IVC repairs are possible in most patients, and IVC patency is good. Recurrent tumor thrombus rates are low; however, RCC tumor recurrence and mortality are high, especially among patients with advanced cancer with IVC wall invasion.

Renal cell carcinoma accompanied by venous invasion and inferior vena cava thrombus: classification and operative strategies for the vascular surgeon

Venous invasion is a common characteristic of renal cell carcinoma, manifesting as tumor thrombus with possible extension into the renal vein and, in extensive cases, the thrombus can reach from the renal vein to the right atrium. Currently, cytoreductive nephrectomy and tumor thrombectomy are the foundations for improving quality of life and survival in the treatment of renal cell carcinoma, and a role has emerged for a vascular specialist to become an integral part of operative planning and therapy.

Pre-operative risk stratification for cancer-specific survival in patients with renal cell carcinoma with venous involvement who underwent nephrectomy

OBJECTIVE

The aim of this study is to identify the pre-operative prognostic factors and create a risk stratification model for patients with renal cell carcinoma with extension into the renal vein or inferior vena cava.

METHODS

The study cohort included 61 patients with renal cell carcinoma extending into the renal vein or inferior vena cava that underwent operations between 1993 and 2012. Cancer-specific survival rates were estimated, and univariate and multivariate analyses were carried out to determine the prognostic factors. A simple risk stratification model was developed for these patients.

RESULTS

The median follow-up period of the current patient cohort was 33.7 months. Their 1, 3 and 5-year cancer-specific survival were 89, 70 and 65%, respectively. On multivariate analysis, the level of tumor thrombus extension (extension into the supradiaphragm), presence of distant metastasis and elevation of lactate dehydrogenase and C-reactive protein were independent negative prognostic factors for cancer-specific survival. Cancer-specific survival rates were clearly discriminated by the stratification according to the scoring model (P < 0.001). The concordance index of the new model was 0.80.

CONCLUSIONS

We demonstrated a simple risk stratification model with four pre-operative independent prognostic factors for patients with renal cell carcinoma with venous involvement. This may be a useful decision-making model in the management of such patients.

Oncologic outcomes following surgical resection of renal cell carcinoma with inferior vena caval thrombus extending above the hepatic veins: a contemporary multicenter cohort

PURPOSE

Suprahepatic inferior vena caval tumor thrombus in renal cell carcinoma cases has historically portended a poor prognosis. With advances in perioperative treatment of patients with high level thrombus contemporary outcomes are hypothesized to be improved. We evaluated long-term oncologic outcomes of contemporary surgical treatment of patients with renal cell carcinoma in whom level III-IV inferior vena caval thrombus was managed at high volume centers.

MATERIALS AND METHODS

We examined clinical and pathological data on patients with renal cell carcinoma and level III-IV thrombus treated with surgery from January 2000 to June 2013 at 4 tertiary referral centers. Survival outcomes and associated prognostic variables were assessed by Kaplan-Meier and multivariate Cox regression analyses.

RESULTS

We identified 166 patients, including 69 with level III and 97 with level IV thrombus. Median postoperative followup was 27.8 months. Patients with no evidence of nodal or distant metastasis (pN0/X, M0) had 5-year 49.0% cancer specific survival and 42.2% overall survival. There was no difference in survival based on tumor thrombus level or pathological tumor stage. Variables associated with an increased risk of death from kidney cancer on multivariate analysis were regional nodal metastases (HR 3.94, p <0.0001), systemic metastases (HR 2.39, p = 0.01), tumor grade 4 (HR 2.25, p = 0.02), histological tissue necrosis (HR 3.11, p = 0.004) and increased preoperative serum alkaline phosphatase (HR 2.30, p = 0.006).

CONCLUSIONS

Contemporary surgical management achieves almost 50% 5-year survival in patients without metastasis who have renal cell carcinoma thrombus above the hepatic veins. Factors associated with increased mortality included nodal/distant metastases, advanced grade, histological necrosis and increased preoperative serum alkaline phosphatase. These findings support an aggressive surgical approach to the treatment of patients with renal cell carcinoma who have advanced tumor thrombus.

[Surgery of inferior vena cava-associated urological tumor lesions]

BACKGROUND

Tumor lesions of the inferior vena cava are extremely challenging with regard to adequate therapeutic management also in advanced malignant urological tumor lesions which can be caused by malignant adhesion, impression and tumor infiltration from the surrounding tissue. This can be the case with metastases from a seminoma or testicular carcinoma (differential diagnosis: primary vena cava leiomyosarcoma), tumor-associated growth into and within the inferior vena cava originating from renal cell carcinoma or carcinoma of the pararenal gland. The aim of this overview was to summarize current clinical and operative experiences in the treatment of inferior vena cava-associated urological tumor lesions, perioperative management, individual-specific and finding-adapted surgical technique and possible outcome, including prognostic considerations from clinical daily practice and representative data found in the literature.

BASIC STATEMENTS

The primary aim of the surgical approach is to achieve R0 resection with reconstruction of the inferior vena cava lumen providing a reasonable risk-benefit ratio, which comprises i) complete resection and substitution of the inferior vena cava by a prosthesis along the previous extent of tumor growth, ii) partial resection of the vena cava wall with subsequent patch-plasty or tangential resection with primary suture or iii) removal of the vena cava thrombus after cavotomy. Particular attention should be paid to tumor thrombi reaching the right atrium which need to be extracted after sternotomy and atriotomy using an extracorporeal circulation (cardiac surgeon). For surgical planning, subdivision of the inferior vena cava into three segments, infracardiac, infrahepatic and infrarenal third, has been proven and tested.

CONCLUSIONS

The current development status and advances in surgical approaches as well as advances in medical technology allow the successful approach to such advanced stage urological tumor manifestations. A deciding factor is the abdominal and cardiovascular surgical expertise of each surgeon after formation of a team of surgical specialists (including urologists) and only then prognostic advantages can be achieved.