Aortic and inferior vena cava resection for renal cell carcinoma invading an aberrant renal vein

Renal cell carcinoma which invades the renal veins is a frequent complicating factor in radical nephrectomy. In a 53-year-old patient with a left renal cell carcinoma, tumor thrombus was present in an aberrant, retroaortic left renal vein, and "en bloc" resection of the overlying aneurysmal aorta with a cuff of inferior vena cava was required. The aorta was reconstructed with a dacron bifurcation graft to the iliac arteries, and the vena cava closed primarily. The patient made an uneventful postoperative recovery. The requirement for extensive aortic and vena cava resection need not compromise attempts to cure locally advanced renal cell carcinoma.     

肾癌并静脉癌栓的影像学诊断与手术方法选择

目的：探讨肾癌并静脉癌栓的影像学诊断与治疗及方法的选择。方法：回顾性分析我科收治的肾癌伴静脉癌栓患者21例的临床资料。结果：MRI精确地诊断出癌栓的范围；20例肾癌根治性切除加癌栓取出术的患者取得了满意的效果。结论：MRI可替代创伤性大、不良反应多的下腔静脉造影，用于确诊肾癌并静脉癌栓；应依据癌栓的类型选择手术方法。     

肾细胞癌伴发肾和腔静脉癌栓的诊治进展及相关的临床体会

肾细胞癌（RCC）是泌尿男生殖系统最常见的恶性肿瘤之一,其发病率居第2位。肾癌的生物学行为较为特殊,对化疗、放疗均不敏感,其转移途径中以血液循环最为常见。容易侵及肾静脉和下腔静脉形成瘤栓（亦称癌栓）是RCC的另一生物学特点,其伴发静脉癌栓的发病率国内外报道在4．O％～22．2％之间。RCC一旦伴发静脉癌栓,其临床分期属Ⅲ期b。随着MRI、CTA、彩超等技术的临床广泛应用,手术治疗癌栓的成功率得到大幅度提高。作者结合文献报道和临床诊治体会,对RCC诊断、治疗进行了总结,并对伴发静脉癌栓新的分类方法进行了探讨。     

Recidive of renal cell carcinoma tumor thrombus in inferior vena cava via lumbar vein

Renal cell carcinoma (RCC) develops tumor thrombus in the renal vein and inferior vena cava (IVC) in 10% of cases. Surgical treatment is radical nephrectomy and thrombectomy of the IVC. Local recidive can develop in the lumbar fossa, lymph nodes, and the IVC. We report a 58-year-old patient admitted to the Clinic for Urology at the Military Medical Academy, Belgrade, Serbia, in February 2009 with RCC of the left kidney and tumor thrombus in the IVC. After ultrasonography exam and multislice computed tomography scan, we performed radical nephrectomy and thrombectomy of the IVC (level II). Four months after the operation, ultrasound exam and cavography showed intracaval and paracaval recidive tumor masses in the renal part of the IVC. On operation we removed intraluminal IVC thrombus, which arises from the lumbar vein on the IVC posterior wall, with paracaval thrombus in the lumbar vein. We conclude that RCC tumor thrombus can spread from the kidney to the IVC through the lumbar vein.     

Early experience of laparoscopic radical nephrectomy for T3b renal cell carcinoma

We report our experience with laparoscopic radical nephrectomy for a 79-year-old man who had renal cell carcinoma (RCC) with a renal vein thrombus. For the transaction of the renal vein with the thrombus, we used an endoscopic gastrointestinal anastomosis stapler. The operating time was 4 h and blood loss was 400 mL. The patient could walk and drink on the first postoperative day. He recovered normal activity 30 days postoperatively. There were no intraoperative and postoperative complications. The present report demonstrates the feasibility of laparoscopic radical nephrectomy in patients with T3b RCC who suffer from tumor thrombus in the renal vein.     

Hand-assisted laparoscopic radical nephrectomy using intraoperative ultrasonography for left renal cell carcinoma involving a level I renal vein tumor thrombus

This report concerns two male patients, 65 (case 1) and 72 (case 2) years old, with a left renal tumor involving a level I renal vein tumor thrombus, who underwent hand-assisted laparoscopic radical nephrectomy using intraoperative ultrasonography. With the patient in the flank position, a midline supraumbilical hand port and two other ports were placed. Intraoperative ultrasonography identified the extent of the tumor thrombus. After hilar control, complete resection with intact removal was performed. Surgery lasted 305 min for case 1 and 237 min for case 2, with respective estimated blood loss of 410 mL and 572 mL. No postoperative complications occurred. Pathological examination showed a clear cell carcinoma with a level I tumor thrombus and negative surgical margins. Because the ultrasound probe can be easily inserted and the specimen can be extracted safely and intact, hand-assisted laparoscopic radical nephrectomy is practicable and effective for left renal cell carcinoma involving a level I renal vein tumor thrombus.     

肾癌伴下腔静脉癌栓4例的手术治疗

目的：提高肾癌（RCC）伴下腔静脉（IVC）癌栓的手术治疗效果。方法：对4例RCC伴IVC癌栓患者在施行肾癌根治性切除、淋巴结清除的同时分别选择行IVC切开、IVC壁切除和IVC节段切除取癌栓术。结果：手术均获成功，无大出血、肺梗塞，术后血尿素氮、肌酐均无明显异常。随访13-34月患者均健在。结论：对本病应采取积极的手术治疗。三种手术方案的选择应取决于癌栓的长度、水平、分型等。     

Ureteral tumor thrombus from renal cell carcinoma extending into bladder

Tumor thrombus from renal cell carcinoma (RCC) usually occurs within the renal vein. We present the first report of a tumor thrombus from RCC extending from the kidney down the ureter and into the lumen of the bladder. This case both: (1) provides evidence for growth of RCC along the urinary tract, and (2) poses a staging dilemma.     

Supradiaphragmatic renal cell carcinoma tumor thrombus: indications for vena caval reconstruction with pericardium

Supradiaphragmatic extension of tumor thrombus from a renal cell carcinoma presents a major surgical challenge. The use of cardiopulmonary bypass, hypothermia and cardiac arrest with temporary exsanguination has allowed for successful surgical excision of these tumors. A renal cell carcinoma on the right side with a supradiaphragmatic tumor thrombus still may only partially occlude the vena cava. The collateral venous circulation of the left renal vein may be developed poorly and a pericardial patch can allow successful reconstruction of the inferior vena cava. If the tumor arises on the left side continued venous drainage of the right kidney is mandatory to prevent venous infarction of the right kidney. The entire vena cava also might be reconstructed theoretically with pericardium.     

Frequency of the retroaortic left renal vein in adults (author's transl)]

In 231 adults the frequency and the pattern of the retroaortic left renal vein were studied. We observed a retroaortic left renal vein in 9.09% ("renal collar" in 5.62%, single retroaortic left renal vein in 3.46%. According to our results and to the findings in the literature a retroaortic left renal vein can be expected in 13.67% ("renal collar" in 9.53%, single retroaortic left renal vein in 4.13%).     

A case of recurrent intracaval renal cell carcinoma effectively treated with sunitinib

A 67-year-old man received left radical nephrectomy for left renal cell carcinoma (RCC) (clear cell carcinoma, G2, pT3bN0M0). After 9 months, he presented with an acute onset of left extremity edema. A computed tomographic (CT) scan and magnetic resonance imaging reveal recurrent renal cell carcinoma in the inferior vena cava (IVC) and the left renal fossa, thrombus in the left external vein and acute pulmonary embolism. We performed treatment with sunitinib for 5 months after anticoagulant therapy for 3 weeks. A new CT scan showed disappearance of RCC in the IVC and reduction in the size of RCC in the renal fossa. Only 11 cases are reported as recurrent RCC in the IVC. We report the first case of recurrent intracaval RCC in which sunitinib treatment was effective.     

Laparoscopic radical nephrectomy incorporating intraoperative ultrasonography for renal cell carcinoma with renal vein tumor thrombus

The purpose of this study was to describe the technique of laparoscopic right radical nephrectomy incorporating intraoperative, real-time ultrasonography in the management of renal cell carcinoma with level 1 renal vein tumor thrombus. With the patient in a modified flank position, a transperitoneal four-port approach was used to laparoscopically resect an 8.5-cm right renal mass with tumor thrombus extending to, but not into, the inferior vena cava. Early arterial control with gentle traction on the right renal vein provided a short proximal renal venous segment devoid of tumor on laparoscopic inspection. Intraoperative laparoscopic ultrasonography allowed confident identification of the proximal extent of the tumor thrombus. After hilar control, complete resection and intact removal of the renal specimen was performed using standard non-hand-assisted laparoscopic techniques. The actual surgical time was 180 minutes. Surgical resection was successfully performed laparoscopically. No postoperative complications or hospital readmission occurred. Pathologic examination confirmed T3b renal cell carcinoma with negative surgical margins. Laparoscopic right radical nephrectomy incorporating intraoperative, real-time ultrasonography is feasible in the management of renal cell carcinoma with a large-sized level 1 renal vein thrombus. Additional studies are necessary to evaluate its role in urologic oncologic surgery.     

Surgical strategy for treating renal cell carcinoma with thrombus extending into the inferior vena cava

OBJECTIVE: A surgical strategy for treating malignant renal tumors with thrombus extending into the inferior vena cava (IVC) was assessed. METHODS: We retrospectively reviewed the records for all patients with renal cell carcinoma (RCC; n=30) or Wilms tumor (n=1) with tumor thrombus extending into the IVC who underwent surgical intervention at our institution between January 1980 and December 2001. Tumors were classified preoperatively according to the cephalad extension of thrombus, and intraoperative procedures were selected on the basis of degree of extension. Patients with RCC underwent radical nephrectomy and removal of thrombus with (n=11) or without (n=19) IVC resection. Partial normothermic cardiopulmonary bypass without cardiac arrest was used in 4 patients. The Pringle maneuver was performed in 8 patients. Infrarenal abdominal aortic cross-clamping was used in 8 patients to maintain systemic blood pressure. IVC cross-clamping and the Pringle maneuver were performed in 5 patients with suprahepatic thrombus extension. Temporary placement of a filter in the IVC or plication of the IVC above the hepatic vein was performed before hepatic mobilization, to decrease the risk for pulmonary embolism. RESULTS: One patient died intraoperatively of pulmonary embolism. Postoperative complications occurred in 11 patients; all resolved with conservative therapy. The postoperative duration of survival in patients with RCC was 37 +/- 44 months (range, 4-180 months); the 5-year survival rate was 42%. CONCLUSION: Aortic cross-clamping during IVC occlusion prevented hypotension and maintained hemodynamic stability that has required bypass in other series. This surgical treatment with the less extensive approach could result in long-term survival of patients with RCC in whom tumor thrombus extends into the IVC. We recommend that radical nephrectomy and tumor thrombectomy, with or without caval resection, be performed in these patients, with less invasive additional maneuvers.     

Renal cell carcinoma in a horseshoe kidney presenting as an acute,left sided varicocele

We present a rare case of renal cell carcinoma (RCC) in a horseshoe kidney presenting as an acute left sided varicocele. A left sided varicocele is a well-described presentation of RCC, usually caused by tumour thrombus extending along the renal vein with resultant testicular vein occlusion. However, in our case a tumour in the lower pole of a horseshoe kidney caused an acute varicocele by direct involvement and occlusion of the testicular vein.     

腹腔镜下微创手术治疗肾癌合并高位肝后下腔静脉癌栓

目的探讨腹腔镜下微创手术治疗肾癌合并高位肝后下腔静脉癌栓的临床经验和文献分析。 方法女性患者,61岁,临床诊断：右肾癌合并高位肝后下腔静脉癌栓。术前全面评估手术风险,组织多学科会诊为患者制定详尽的围手术期治疗与护理方案,拟行腹腔镜下右侧肾癌根治性切除+高位肝后下腔静脉癌栓取出+腹膜后淋巴结清扫术。术后医护密切配合严密观察患者病情变化,进行围手术期观察处理与护理。 结果手术顺利完成,手术时间390 min,无中转开放手术。术中完全游离右侧和左侧肾静脉、肝后下腔静脉直达第二肝门水平远端,近右肾静脉处下腔静脉内侧壁剪开静脉壁,癌栓下部小灶性侵犯静脉壁,切除部分腔静脉壁完整取出癌栓,恢复左侧肾静脉、腔静脉血流回流无障碍。术后病理提示符合透明细胞癌,癌组织侵犯肾窦脂肪,腹膜后淋巴结（-）。术后随访6个月未见肿瘤复发。 结论腹腔镜下微创手术治疗肾癌合并高位肝后下腔静脉癌栓安全可行,多学科协助模式为疑难复杂病例提供了一种新的选择,值得临床进一步推广。     

Tumor thrombosis of the left renal vein and inferior vena cava secondary to renal cell carcinoma. Findings with ultrasonography, Echo-Doppler, and computerized tomography

Renal cell carcinoma represents a 2.5-3% of all neoplastic processes, usually seen un patients older than 50 years. 60-75% are resectable at diagnosis, representing local or metastatic advanced disease the rest of them. This tumor tends to spread intravascularly, leading to tumoral thrombosis within the inferior caval vein (ICV) and renal vein 4-10% and 21-35% of cases, respectively. As the only effective treatment is surgical resection, preoperative determining of the thrombus extension is crucial. Thus, an accurate radiological study including ultrasound, doppler sonography, computed tomography and/or Magnetic Resonance, is key for these patients. We present a 49 year-old patient with renal cell carcinoma and associated tumoral thrombosis in inferior caval vein and left renal vein; we provide the most significant figures, explaining its most characteristic radiological findings.     

Investigation of 14 renal cell carcinoma cases with tumor thrombus in the inferior vena cava

Renal cell carcinoma tends to progress into the renal vein and inferior vena cava. We investigated 14 cases of renal cell carcinoma with tumor thrombus in the inferior vena cava. Surgery was performed in nine cases and mean survival was 53 months. Two cases are alive 8 years after the operation without recurrence or metastasis. The mean survival of 5 cases without operation was 7 months. Surgical management should be considered as a benefit for RCC patients with tumor thrombus in the inferior vena cava.     

Recurrence of renal cell carcinoma with extensive vena caval thrombus three years after radical nephrectomy

A 70-year-old man, who had undergone a radical nephrectomy for localized renal cell carcinoma (RCC) three years ago, was recently evaluated for shortness of breath. During his work-up, a transesophageal echocardiogram and magnetic resonance imaging indicated an extensive vena caval thrombus originating from the renal vein stump. Successful vena caval thrombectomy with cardiopulmonary bypass confirmed that the thrombus was comprised of RCC. This is a rare type of RCC recurrence with an unusual timing (3 years after a nephrectomy), alerting the importance of strict follow-up on all patients even after complete surgical excision of all suspected tumors.     

肾癌伴静脉癌栓外科治疗的疗效观察

目的探讨外科治疗肾癌伴静脉癌栓患者的预后。方法自1994年8月至2004年7月共33例患者行肾癌根治术及静脉癌栓取出术,其中男性26例、女性7例,中位年龄60岁(20~82岁)。肾静脉癌栓15例,下腔静脉癌栓Ⅰ级(肝下水平)9例、Ⅱ级(肝后水平)5例、Ⅲ级(肝上水平)1例、Ⅳ级(右心房水平)3例。采用Kaplan-Meier方法进行生存分析。结果29例患者得到随访,14例死亡,平均生存(16·4±2·9)个月(1~42个月),15例存活,平均随访(17·3±4·6)个月(3~67个月)。1例患者术后第2天死亡,3例失访。5年生存率为16%。肾静脉癌栓患者平均生存(49·9±9·8)个月,明显高于Ⅰ级下腔静脉癌栓患者的(16·7±1·9)个月(P<0·05)。结论肾癌根治性切除加癌栓取出术是治疗肾癌伴静脉癌栓的有效方法,肾静脉癌栓患者的预后好于腔静脉癌栓患者。