Right renal mass with vena caval thrombus

This case illustrates the difficulties that sometimes occur in the evaluation of patients with a nonfunctioning kidney. Because of the clinical presentation, suggestive of renal cell carcinoma, no urinary cytology study was obtained from the affected kidney. This study certainly would have led to the correct diagnosis. Despite this fact, the operative management would not have changed except for complete removal of the ureter. In our case we elected to follow the distal ureter by ureteral washings and ureteroscopy during follow-up cystoscopy studies to preclude a further operation. Although no data are available on the role of adjuvant therapy in these patients, because of the poor prognosis associated with such extensive disease we gave our patient 2 courses of M-VAC in an attempt to prevent progression of the disease.     

Successful resection of a retroperitoneal malignant fibrous histiocytoma with caval tumor thrombus

We report herein the case of a 56-year-old man who presented with a huge, fast-growing abdominal tumor. Renal angiograms revealed a hypervascular tumor stain from the renal capsular arteries, and magnetic resonance imaging revealed a caval tumor thrombus. The tumor was resected en bloc with the tumor thrombus, the right kidney, and part of the liver. The histological diagnosis confirmed malignant fibrous histiocytoma (MFH) both in the tumor and the caval tumor thrombus. This is the first report of the successful resection of a MFH originating in the renal capsular tissue and extending into the inferior vena cava.     

Extracorporeal circulation for renal cell carcinoma with supradiaphragmatic caval thrombus

Removal of the tumor thrombus extended into the intrapericardial vena cava, was accomplished under direct vision with minimal blood loss in a patient with renal cell carcinoma. The liver was mobilized to expose the retrohepatic vena cava by incision of the falciform, triangular and coronary ligaments, and cardiopulmonary bypass was used to create a bloodless field avoiding the migration of tumor thrombus and uncontrollable hemorrhage. Tumor thrombus was delivered intact with a 20 Fr. Foley catheter. Vena cava surgery was done for the tumor invasion, and an artificial vascular graft was then sutured to replace the caval wall. We believe that this technique can be effectively used in selected patients with extensive intracaval involvement of renal cancer.     

Renal cell carcinoma with an infrarenal vena caval tumor thrombus

Extension of renal cell carcinoma (RCC) along venous drainage pathways is a well-recognized entity. All previously reported cases of inferior vena cava (IVC) involvement by RCC have been with tumor thrombus in the suprarenal IVC. We report a 45-year-old man who had RCC arising from the lower pole of the right kidney with a tumor thrombus totally occluding the infrarenal IVC. The patient underwent radical nephrectomy with successful ligation and resection of the infrarenal IVC.     

Primary renal carcinoid tumour with inferior vena caval tumour thrombus

Carcinoid tumours, most frequently reported in the gastrointestinal and respiratory tracts, are exceedingly rare primary renal cancers. Few cases have been published to date. To our knowledge, we report the first case of a primary carcinoid tumour of the kidneys involving the inferior vena cava. We treated a 58-year-old woman with an open radical nephrectomy and cavotomy with thrombectomy. We describe the presentation, investigations and pathology results. We discuss the current experience with carcinoid tumours as a literature review relating to the diagnosis of the disease and the prognosis of patients with this neoplasm. Localized carcinoid tumours of the kidneys, including those involving the vena cava, can be successfully treated with surgical excision.     

Management of primary nonrenal parenchymal malignancies with vena caval thrombus

We report our experience with the management of 7 primary nonrenal parenchymal malignancies with vena caval tumor thrombus. Included are 3 cases of adrenal cortical carcinoma and 1 each of transitional cell carcinoma, embryonal cell testicular carcinoma, pheochromocytoma and primary small cell carcinoma of the lung with metastases to the kidney. Surgical treatment and followup are presented, as well as a review of the literature. An aggressive surgical approach is warranted because prolonged survivals free of disease are possible.     

Strategy for management of retroperitoneal tumors with caval tumor thrombus

The surgical management of retroperitoneal tumors extending into the inferior vena cava (IVC) can be challenging. Although Wilms' tumor is the most common retroperitoneal tumor extending into the IVC, one must approach these tumors systematically as other diagnoses are possible. We present 4 consecutive cases of retroperitoneal tumors with IVC extension as a basis for a management strategy in approaching these patients. Despite similar presentations, these cases illustrate the nuances in surgical management and need for multidisciplinary care with the pediatric oncologists, pediatric surgeons, and pediatric cardiac surgeons.     

Venacavoscopy during nephrectomy for renal cell carcinoma with inferior vena caval thrombus

PURPOSE: Renal cell carcinoma with inferior vena caval thrombus remains a complex challenge for the urologist. Aggressive surgery to remove all tumor can result in long-term survival. Liver transplant techniques, assistance from cardiac surgeons and bypass techniques can yield optimal vascular control but there is still a blind element inside the inferior vena cava when the thrombus is evacuated. We present data on a technique using a flexible cystoscope to evaluate the lumen of the intrahepatic and suprahepatic inferior vena cava after nephrectomy and tumor thrombectomy. MATERIALS AND METHODS: Seven patients underwent radical nephrectomy and tumor thrombectomy for renal cell carcinoma with inferior vena caval thrombus. During surgery and after removal of the tumor thrombus a flexible cystoscope was inserted into the venacavotomy for direct inspection of the inferior vena caval lumen. Any residual tumor was manipulated out of the lumen and removed. Patient records were reviewed for data on the time of this procedure, estimated blood loss, residual tumor, postoperative complications and survival. RESULTS: Venacavoscopy required an average additional 5.6 minutes and residual tumor was found in 3 of 7 patients. Average estimated blood loss was 1,170 cc and it was not affected by venacavoscopy. One patient experienced acalculous cholecystitis, possibly as a result of this procedure. Mean followup was 17.6 months with 5 of 7 patients alive. CONCLUSIONS: Venacavoscopy is a safe, reliable method of intraoperative inspection of the inferior vena cava that uses equipment and techniques familiar to every urologist. This can help prevent incomplete thrombectomy and disastrous pulmonary embolus.     

Use of veno-venous bypass for resection of malignant pheochromocytoma with vena caval thrombus

Surgical management of malignant pheochromocytoma with tumor-induced venous obstruction involving the entrance to the right atrium is challenging. The risk of marked hypotension and hemodynamic instability following clamping of the vena cava is increased as a consequence of the sudden decrease in circulating catecholamines. The use of cardiac bypass, however is burdened with additional operating time and coagulopathy. The present report illustrates that veno-venous bypass is a valuable tool during resection of phenochromocytoma with a large vena caval tumor thrombus.     

Solitary floating vena caval thrombus as a late recurrence of renal cell carcinoma

We report an unusual case of solitary thrombus floating in the inferior vena cava (IVC) in a patient who underwent radical nephrectomy for a renal cell carcinoma (RCC) of the right kidney extended into the renal vein with no capsular and perinephric tissue invasion (pT3b). Twenty months after surgery, a routine computed tomography scan identified an intraluminal mass floating in the IVC. Cavotomy and thrombectomy with no caval resection were successfully performed. A review of the literature showed only three previous published cases of RCC recurring in the IVC only, with no local recurrence or distant metastases. We outline the possible etiology of these unusual and solitary recurrences in the IVC and we emphasize the need for a strict surveillance for all patients with RCC and especially for those with pT1b, pT2 and pT3 disease. An early diagnosis of this rare recurrence can permit an easy removal of the thrombus with no caval resection and graft replacement, making this disease potentially curable by surgery.     

Technique for removal of renal cell carcinoma with suprahepatic vena caval tumor thrombus

Hemorrhage and poor visualization of the interior of the vena cava frequently occur with the removal of a renal cell carcinoma with a suprahepatic vena caval tumor thrombus. The use of cardiopulmonary bypass, hypothermia, and temporary cardiac arrest facilitates surgical removal of a suprahepatic vena caval tumor thrombus. This technique provides total control of the circulation of the body and creates a disciplined, well-visualized operative field.     

Retroperitoneal laparoscopic radical nephrectomy for renal cell carcinoma with infrahepatic vena caval thrombus

PURPOSE: The retroperitoneal laparoscopic approach is utilized to treat a right renal tumor with vena caval thrombus reaching infrahepatic veins. MATERIALS AND METHODS: The patient is an 87-year-old woman with a tumor measuring 8 x 9 cm and a vena caval thrombus (7 cm), stretching as far as the subhepatic vein. The retroperitoneal laparoscopic approach is used with the patient in the lateral position and the usual 4 laparoscopy trocars. A wide incision is made through Gerota's fascia, the renal artery clipped and severed, and the vena cava is dissected to the level of the infrahepatic veins; a vessel loop is encircled twice upstream of the thrombus. Vessel loop is similarly tied below the thrombus. An 8 cm abdominal wall incision is made joining two trocars on the medial and anterior axillary side. After retrieving the vessel loops and closing the vena cava by pulling gently on the loops, thrombus is extracted through a cavotomy under direct vision, with removal of the surgical specimen, positioning of the Satinsky haemostatic forceps, and closure of the vena cava using uninterrupted Prolene 2/0 sutures. RESULTS: Blood loss was 300 cc. The patient was discharged on day 6, and a CT-scan 4 months later disclosed no signs of recurrence. CONCLUSIONS: This is an original solution that opens the way to further indications for using retroperitoneal laparoscopy to treat tumors extending into the inferior vena cava.     

Long-term survival of untreated bilateral renal cell carcinoma with supradiaphragmatic vena caval thrombus

We report a case of bilateral, synchronous and biopsy proved renal cell carcinoma with a vena caval thrombus and supradiaphragmatic extension. Although the patient was not treated she is asymptomatic 5 1/2 years after the diagnosis was established.     

Renal cell carcinoma with inferior vena cava tumor thrombus and metastatic caval wall invasion

We present a case of renal cell carcinoma with inferior vena caval tumor thrombus and metastatic involvement of the distal inferior vena cava.     

Hand assisted laparoscopic radical nephrectomy for renal cell carcinoma with inferior vena caval thrombus

PURPOSE: To our knowledge we present the initial clinical report of hand assisted laparoscopic radical nephrectomy for renal cell carcinoma with tumor thrombus extending into the inferior vena cava. MATERIALS AND METHODS: A 76-year-old man was referred to our medical center with a 12.5 x 10 cm. stage T3b right renal tumor extending into the inferior vena cava. The caval thrombus was limited and completely below the level of the hepatic veins. After preoperative renal embolization via the hand assisted transperitoneal approach the right kidney was completely dissected with the renal hilum. Proximal and distal control of the inferior vena cava was obtained with vessel loops and a single lumbar vein was divided between clips. An endoscopic Satinsky vascular clamp was placed on the inferior vena cava just beyond its juncture with the right renal vein, thereby, encompassing the caval thrombus. The inferior vena cava was opened above the Satinsky clamp and a cuff of the inferior vena cava was removed contiguous with the renal vein. The inferior vena cava was repaired with continuous 4-zero vascular polypropylene suture and the Satinsky clamp was then removed. A literature search failed to reveal any similar reports of laparoscopic radical nephrectomy for stage T3b renal cell cancer. RESULTS: Surgery was completed without complication with an estimated 500 cc blood loss. Pathological testing confirmed stage T3b grade 3 renal adenocarcinoma with negative inferior vena caval and soft tissue margins. CONCLUSIONS: The introduction of vascular laparoscopic instrumentation and the hand assisted approach enabled us to extend the indications for laparoscopic radical nephrectomy to patients with minimal inferior venal caval involvement.