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.     

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.     

Results of inferior vena caval interruption by greenfield filter, ligation or resection during radical nephrectomy and tumor thrombectomy

PURPOSE: Surgical resection for patients with renal cell carcinoma and venous tumor thrombus may require interruption of the inferior vena cava using a Greenfield filter, ligation or resection. We describe the indications, technique, complications and outcomes of vena caval interruption during nephrectomy with tumor thrombectomy. MATERIALS AND METHODS: We identified 160 patients treated for level II-IV tumor thrombus at our institution between 1970 and 2004. Operative reports were reviewed to establish vena caval interruption. All patients who underwent interruption were assessed for postoperative disability according to the American Venous Forum International Consensus Committee. RESULTS: Vena caval interruption was performed in 40 of 160 cases (25%), including 14 level II, 10 level III and 16 level IV thrombi. A total of 34 patients (85%) were symptomatic at presentation. A Greenfield filter was deployed before cavotomy closure in 4 of 160 patients (2.5%) for bland thrombus of the infrarenal vena cava. Vena caval ligation was used for bland thrombus that completely occluded the infrarenal vena cava in 23 of 160 patients (14.4%), while segmental vena caval resection was performed for tumor thrombus growing into the wall of the vena cava or for tumor thrombus that interfaced with bland thrombus in 13 of 160 (8.1%). Postoperatively no case was class 3 disability, 12 of 40 (30%) were class 2, 12 of 40 (30%) were class 1 and 16 of 40 (40%) showed no disability. CONCLUSIONS: The need to interrupt the inferior vena cava is not infrequent in patients undergoing radical nephrectomy and tumor thrombectomy, and it may be well tolerated postoperatively. Management should be based on the degree of venous occlusion and the presence of bland thrombus.     

Robotic renal surgery for renal cell carcinoma with inferior vena cava thrombus

Surgical management of renal cell carcinoma (RCC) with inferior vena cava (IVC) thrombus is inherently complex, posing challenges for even the most experienced urologists. Until the mid-2000s, nephrectomy with IVC thrombectomy was exclusively performed using variations of the open technique initially described decades earlier, but since then several institutions have reported their robotic experiences. Robotic IVC thrombectomy was initially reported for level I and II thrombi, and more recently in higher-lever III thrombi. In general, the robotic approach is associated with less blood loss and shorter hospital stays compared to the open approach, low rates of open conversion in reported cases, relatively low rates of high-grade complications, and favorable overall survival on short-term follow-up in limited cohorts. Operative times are longer, costs are significantly higher, and left-sided tumors always require intraoperative repositioning and usually require preoperative embolization. To date, criteria for patient selection or open conversion have not been defined, and long-term oncologic outcomes are lacking. While the early published robotic experience demonstrates feasibility and safety in carefully selected patients, longer-term follow-up remains necessary. Patient selection, indications for open conversion, logistics of conversion particularly in emergent settings, necessity and safety of preoperative embolization, the value proposition, and long-term oncologic outcomes must all be clearly defined before this approach is widely adopted.     

Comparison of hand assisted versus standard laparoscopic radical nephrectomy for suspected renal cell carcinoma

PURPOSE: We compared standard and hand assisted laparoscopic radical nephrectomy for suspected renal cell carcinoma. MATERIALS AND METHODS: We retrospectively reviewed 22 hand assisted and 16 standard laparoscopic radical nephrectomies performed for suspected renal cell carcinoma. Operative and recovery data were collected prospectively and from medical records as part of an institutional review board approved protocol. Patients completed pain, activity and the 12-item short form health related quality of life surveys preoperatively and postoperatively. RESULTS: Although patients undergoing hand assisted laparoscopic nephrectomy had larger tumors (mean 6.3 versus 4.1 cm., p = 0.009), tended toward greater corrected mean specimen weight (658 versus 482 gm., p = 0.111) and had greater medical co-morbidity (p = 0.0228), mean operative time for hand assisted laparoscopic procedures was significantly shorter (205 versus 270 minutes, p = 0.0004). With experience mean operative time decreased for standard but not for hand assisted laparoscopy (293 to 232 minutes, p = 0.0445, versus 206 to 204, p = 0.6162). Procedure type, surgeon experience and adrenal sparing were the only significant predictors of operative time. There was no difference in the groups in terms of the complication rate, hospital cost or stay, return to activity or overall pain score, or in the difference in preoperative and postoperative 12-item short form scores. Hand assisted laparoscopic nephrectomy tended to be associated with more abdominal pain early in convalescence and more wound complications but not significantly so. CONCLUSIONS: Hand assisted laparoscopic radical nephrectomy offers recovery, morbidity and cost that are comparable to those of standard laparoscopy. The benefits of the technique include shorter operative times, no need for specimen morcellation and direct manual control of the operative field. It is particularly useful early in surgeon experience, for large specimens or when patient co-morbidities require a rapid procedure.     

Resection of the abdominal inferior vena cava for complicated renal cell carcinoma with tumour thrombus

OBJECTIVE: To describe our experience of excising the inferior vena cava (IVC) without a graft; en bloc resection of a renal cell carcinoma (RCC) with the renal vein and vena cava tumour thrombus and a segment of the entire abdominal IVC is technically feasible, but traditionally, after resection, attempts are made to restore continuity with the use of synthetic or homologous venous grafts. PATIENTS AND METHODS: Between May 1997 and September 2004, 60 patients (mean age 62 years) underwent surgical resection of a renal tumour with a thrombus extending into the IVC. To resect the entire evident tumour, excision of the affected portion of the IVC was required in three patients (5%); the IVC was not reconstructed. RESULTS: The three patients were aged 38, 39 and 74 years; the mean operative duration was 5.88 h, the mean (range) estimated blood loss was 833 (500-1000) mL, the mean number of blood units transfused was 3.3 (0-7) units, and the mean follow-up was 24 months. The course after surgery was uneventful; specifically, none of the patients had a venous thrombosis or a pulmonary embolus. CONCLUSIONS: RCC has a propensity to invade the renal vein and IVC. Occasionally the thrombus invades the wall of the IVC and complete removal requires excision of a circumferential portion of the IVC; this can be done safely without a graft.     

Renal vein or inferior vena caval extension in patients with renal cortical tumors: impact of tumor histology

PURPOSE: We determined the prognostic significance of renal vein or inferior vena caval (IVC) extension in patients with nonmetastatic renal cell carcinoma (RCC) or oncocytoma undergoing surgery. MATERIALS AND METHODS: The charts of patients undergoing radical or partial nephrectomy from 1989 to 2001 for nonmetastatic RCC or oncocytoma were retrospectively reviewed. A total of 1082 patients (1120 renal units) underwent radical (850 renal units) or partial (270 renal units) nephrectomy. RESULTS: Renal vein extension was present in 60 patients (65.9%) and IVC extension was present in 31 (34.1%). The histological type associated with an increased risk of renal vein/IVC extension was conventional (80 of 702 cases, p <0.0001) and histological types with a decreased risk were oncocytoma (0 of 117, p = 0.00052) and papillary histology (0 of 146, p <0.0001). The 5-year actuarial recurrence-free probability was 59%, 65% and 91% in patients with IVC extension, renal vein extension and no renal vein or IVC extension, respectively. Larger tumor size, nodal metastases and conventional histology were associated with an increased risk of recurrence (RR = 3.38, 95% CI 2.53 to 4.51 for a doubling in size, RR = 9.97, 95% CI 5.51 to 18.1 and RR 3.78, 95% CI 2.15 to 6.65) as well as death (RR = 1.44, 95% CI 1.20 to 1.74 for a doubling in size, RR = 5.39, 95% CI 2.86 to 10.2 and RR = 1.56, 95% CI 1.09 to 2.24, respectively). CONCLUSIONS: Conventional RCC is associated with an increased risk, and oncocytoma and papillary histology are associated with a decreased risk of renal vein or IVC extension. Renal vein or IVC extension alone does not impart a worse prognosis independent of tumor size, nodal status and histology.     

Squamous cell carcinoma of the renal pelvis with inferior vena caval extension

BACKGROUND: We report here on a third case of squamous cell carcinoma (SCC) of the renal pelvis extending to the inferior vena cava. METHODS/RESULTS: A 48-year-old man was diagnosed with an advanced left renal pelvic tumor on computed tomography. He had undergone extracorporeal shock wave lithotripsy for left staghorn calculi 10 years ago. An inferior vena cavagram showed tumor thrombus extending to the inferior vena cava. Percutaneous left renal biopsy revealed SCC. The patient received three courses of combination chemotherapy with cisplatin, bleomycin and etoposide. However, 1 month after the last course of chemotherapy, he died of cancer progress. CONCLUSION: This is the third case of SCC of the renal pelvis extending to the inferior vena cava in the world.     

Endoluminal occlusion of the inferior vena cava in renal cell carcinoma with retro- or suprahepatic caval thrombus

OBJECTIVE: To evaluate endoluminal occlusion of the inferior vena cava (IVC) during surgical treatment of renal cell carcinoma (RCC) with either retrohepatic (level II) or suprahepatic (level III) caval tumour thrombus. PATIENTS AND METHODS: From January 2000 to February 2005, 31 patients with renal vein/IVC involvement (T3b/c) of 278 who had a radical nephrectomy, were selected for review. Of these 31, 13 consecutive patients with RCC presenting a thrombus level II or III were prospectively treated with endoluminal occlusion of the free IVC cranial to the thrombus, to avoid dissection of the suprahepatic IVC or the subdiaphragmatic IVC. The occlusion balloon was positioned using transoesophageal echocardiography (TEE) control through a cavotomy at the ostium of the renal vein. Thrombectomy and radical nephrectomy were then performed. The operative duration, peri-operative bleeding, and complications during and after surgery were assessed. Overall patient survival time, disease-free survival and development of metastasis were calculated. RESULTS: Caval thrombectomy was successful in all patients. The IVC needed to be replaced with an expanded polytetrafluoroethylene graft in three patients and a patch closure after lateral cavectomy was used in four. There was no case of air embolism. One case of asymptomatic tumour migration was detected during the procedure by TEE. The mean (sd) and median (range) operative duration was 170 (29) and 170 (120-210) min, and the mean number of units of packed red cells transfused during hospitalization was 5 (5) and 3 (0-16). There was no peri-operative mortality. The complications were one splenectomy and one early thrombosis of the IVC. The mean (range) follow-up was 22.1 (2-50) months. Distant metastases occurred in seven patients; there was no local or IVC tumour recurrence. Four patients died from metastatic progression and six are alive with no progression. CONCLUSION: Endoluminal occlusion of the IVC with TEE monitoring for level II and III thrombus avoided a suprahepatic or subdiaphragmatic approach to the IVC. This technique caused no major complications and was very reliable, due to TEE monitoring. Segmental resection and reconstruction of the IVC could also be used for adherent thrombi.     

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。     

Clinical outcome of surgical management for patients with renal cell carcinoma involving the inferior vena cava

BACKGROUND: The objective of this study was to evaluate the clinical outcome after surgical management of renal cell carcinoma (RCC) extending to the inferior vena cava (IVC). METHODS: This study included a total of 55 patients (41 men and 14 women; mean age, 59.3 years) with RCC (39 right- and 16 left-sided tumors) involving the IVC, who underwent radical nephrectomy and tumor thrombectomy between 1983 and 2005 at a single institution in Japan. The level of thrombus was classified as follows: level I, infrahepatic; level II, intrahepatic; level III, suprahepatic; and level IV, extending to the atrium. Clinicopathological data from these patients were retrospectively reviewed to identify factors associated with survival. RESULTS: There were 11 and 18 patients who were diagnosed as having lymph node and distant metastases, respectively. Twenty-two patients had tumor thrombus in level I, 20 in level II, 10 in level III, and 3 in level IV. Pathological examinations demonstrated that 34 and 21 patients had clear cell carcinoma and non-clear cell carcinoma, respectively, 42, 9 and 4 were pT3b, pT3c and pT4, respectively, and 6, 35 and 14 were Grades 1, 2 and 3, respectively. Cancer-specific 1-, 3- and 5-year survival rates of these 55 patients were 74.5%, 51.4% and 30.3%, respectively. Among several factors examined, clinical stage (P = 0.047), lymph node metastasis (P = 0.016), histological subtype (P = 0.034) and tumor grade (P < 0.001) were significantly associated with cancer-specific survival by univariate analysis. Furthermore, multivariate analysis demonstrated clinical stage (P = 0.037) and tumor grade (P < 0.001) as independent predictors of cancer-specific survival irrespective of other significant factors identified by univariate analysis. CONCLUSIONS: In patients with RCC involving the IVC, biological aggressiveness characterized by tumor grade rather than tumor extension would have more potential prognostic importance; therefore, more intensive multimodal therapy should be considered in patients with high grade RCC with tumor thrombus extending into the IVC.     

Renal cell carcinoma with inferior vena caval extention: impact of tumour extent on surgical outcome

OBJECTIVE

To evaluate our experience with surgical resection of renal cell carcinoma (RCC) with inferior vena cava (IVC) involvement and examine the relationship between prognosis and tumour extent.

PATIENTS AND METHODS

A retrospective review of nephrectomy performed between 1985 and 2005 identified 50 patients presenting with tumour thrombus extension into the IVC. Clinical characteristics and outcome were evaluated.

RESULTS

Of the 50 patients evaluated, 7, 26, 10 and 7 presented with level I, II, III and IV thrombus, respectively. Major postoperative complications occurred in 16% of patients. Local or distant failure occurred in 25 (64%) patients. The mean time to recurrence was 10 months. Only supra‐diaphragmatic extension of the tumour thrombus was predictive of disease recurrence.

CONCLUSION

Locally advanced RCC with IVC thrombus remains associated with significant local and distant failure rate. The level of thrombus extension is significantly associated with disease recurrence. Effective adjuvant therapy is needed to improve outcome in this patient population.     

Hand assisted laparoscopic partial nephrectomy for peripheral and central lesions: a review of 30 consecutive cases

PURPOSE: We reviewed our first 30 hand assisted laparoscopic partial nephrectomies and compared the results of 8 centrally located vs 22 peripherally located tumors. MATERIALS AND METHODS: Tumors were classified by computerized tomography as central (less than 5 mm from the pelvicaliceal system or hilar vessels) or peripheral. The hand assisted technique consisted of mobilization and manual parenchymal compression without vascular occlusion or ureteral stent placement. Argon beam coagulation and a fibrin glue bandage were used for hemostasis. RESULTS: Mean tumor size was 2.6 cm (range 1.0 to 4.7). Mean operative time was 199 and 271 minutes, and estimated blood loss was 240 and 894 ml for peripheral and central lesions, respectively. No case required open conversion. The final diagnoses were renal cell carcinoma in 21 patients, angiomyolipoma in 4, benign or hemorrhagic cyst in 3 and oncocytoma in 2. Initial positive margins were found in 5 of 30 specimens (16.7%) (1 central and 4 peripheral) and all final resection margins were negative. Four central (50%) and 2 peripheral (9.1%) tumor cases required transfusion. Drain creatinine was elevated in 6 patients (20%) postoperatively, of whom 3 had a central and 3 had a peripheral lesion. All responded to conservative management except 1 patient (3.3%) who required stent placement. Postoperative bleeding in a central tumor case required transfusion of 4 units. There were no short-term local recurrences and 1 patient had an asynchronous tumor. CONCLUSIONS: Hand assisted laparoscopic partial nephrectomy is safe with excellent immediate cancer control. Careful dissection and frozen section analysis are mandatory to ensure a negative tumor margin. Blood loss and transfusion rates were higher in patients with centrally located tumors and renal hilar vascular control should be considered for central lesions.     

Renal cell carcinoma with tumor thrombus extension: biology,role of nephrectomy and response to immunotherapy

PURPOSE: We outline the biology, prognosis and role of immunotherapy for renal cell carcinoma with gross venous tumor thrombus. MATERIALS AND METHODS: A total of 207 patients with unilateral renal cell carcinoma and tumor thrombus into the renal vein (107) and inferior vena cava (100) who underwent nephrectomy and thrombectomy were compared with 607 without tumor thrombus. RESULTS: At diagnosis 77 patients (37%) had N0M0 disease and 130 (63%) had lymph node (N+) or distant (M1) metastases. Compared with nontumor thrombus cases tumor thrombus was associated with more advanced stage, N+ (26% versus 12%), M1 (54% versus 31%) disease, higher grade and Eastern Cooperative Oncology Group performance status. In N0M0 cases with inferior vena caval tumor thrombus capsular penetration, collecting system invasion and extension into the hepatic vein were more important prognostic variables then the level of inferior vena caval thrombus. In patients with confined N0M0 tumors mean 2 and 5-year survival +/- SD was 83% +/- 8.8% and 72% +/- 10.7% in those with inferior vena caval tumor thrombus, and 90% +/- 9.4% and 68% +/- 16.1% in those with renal vein tumor thrombus, similar to the 93.4% +/- 1.7% and 81 +/- 3.1% rates, respectively, in those without thrombus who had no recurrence within 6 months after nephrectomy. Of patients with M1 disease in whom cytoreductive surgery was done those with and without thrombus showed a similar response to immunotherapy. When there was inferior vena caval and renal vein thrombus, mean 2-year survival was higher after nephrectomy and immunotherapy than after nephrectomy alone (41% +/- 9% and 52% +/- 7% versus 32% +/- 13% and 45% +/- 7%), immunotherapy alone (0% and 13% +/- 12%, respectively) and no treatment (0%). CONCLUSIONS: Renal cell carcinoma with tumor thrombus is associated with worse characteristics. Local tumor extension has greater prognostic importance than the level of inferior vena caval tumor thrombus. Survival is fair in patients with truly confined N0M0 disease and thrombus. The combination of surgery and immunotherapy has a role in thrombus cases. Our data provide the rationale for a prospective study of adjuvant immunotherapy after surgery in N0M0 cases with extensive tumor thrombus.     

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.