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.     

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.     

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.     

Transitional cell carcinoma of the renal pelvis forming tumor thrombus in the vena cava

A 47-year-old man presented with a left renal incidentaloma without hematuria. The tumor was complicated by inferior vena cava (IVC) thrombus extending from Th11 to L4. A temporary IVC filter was introduced prior to surgery. A midline incision was used to perform a left radical nephrectomy and en bloc lymphadenectomy with excision of the inferior vena cava from above the level of the left renal vein to 2.5 cm above the confluence of the common iliac veins. The pathological diagnosis was invasive transitional cell carcinoma. The tumor thrombus consisted of transitional cell carcinoma that histologically invaded the walls of the IVC. He died of cancer 17 months after the operation for the liver metastases. This is the 18th case report of such a presentation in the literature.     

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.     

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.     

En bloc mobilization of the inferior vena cava and large hypervascular right renal tumors with or without inferior vena cava thrombus: Posterior ligation of the renal artery

We describe our approach of posterior ligation of the renal artery during resection of large hypervascular right renal tumors. This technique uses en bloc mobilization of the inferior vena cava and renal tumor to ligate the renal artery at its origin from the aorta. In our experience, the use of this posterior approach for renal artery ligation is safe and effective, even with large renal tumors with multiple collaterals and/or lymph nodes making the identification of the renal artery difficult.     

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.     

Prognostic factors of renal cell carcinoma with extension into inferior vena cava

Objective:   To evaluate the prognosis of our series of patients with renal cell carcinoma (RCC) and tumor thrombus involving inferior vena cava (IVC) treated with nephrectomy and thrombectomy.
Methods:   In 46 patients with unilateral RCC extending into IVC who underwent nephrectomy and thrombectomy (T3b in 38 patients, T3c in 6, T4 in 2, N+ in 15, M1 in 21), overall and cancer-specific survival rates were estimated, and the univariable and multivariable analysis were carried out to determine the prognostic factors among age, gender, performance status, fever, inflammatory laboratory parameters, nodal and distant metastasis, tumor thrombus level, pathological parameters and postoperative interferon-α administration.
Results:   The median age was 66.5 (range 35–79) years. The median follow-up was 18.0 (mean 36.7 ± 38.7) months. The overall and cancer-specific 5-year survival rates were 32.9% and 40.0%, respectively. The univariate analysis revealed that fever (hazard ratio: HR 4.03), C-reactive protein (HR 4.89), grade of tumor cell (HR 3.83), and lymph node metastasis (HR 5.99) were independent prognostic factors of cause-specific survival in all patients. The multivariate analysis demonstrated that lymph node metastasis (HR 4.13) was the only independent prognostic factor of cause-specific survival. The extension level or postoperative interferon-α administration did not influence the prognosis of patients with tumor thrombus involving IVC.
Conclusions:   Aggressive surgery should be considered first in RCC patients with any levels of tumor thrombus. However, patients with both IVC involvement and nodal metastasis showed significantly poor prognosis, and development of novel intensive multidisciplinary therapies will be needed.     

Factors associated with surgery in patients with renal cell carcinoma and venous tumor thrombus

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? This is the first published report which is an in‐depth analysis of factors associated with surgery versus non‐operative management in patients with renal cell carcinoma and venous tumour thrombus.

OBJECTIVE

? Venous tumour thrombus is common in patients with renal cell carcinoma (RCC). Although surgical morbidity has decreased with time, nephrectomy with caval thrombectomy remains a high‐risk procedure and may not be performed in all patients with this condition. Little is known about the factors influencing the decision to pursue surgery versus conservative management in patients with RCC and venous tumour thrombus.

MATERIALS AND METHODS

? The Surveillance, Epidemiology, and End Results database was used to identify study patients with RCC and venous tumour thrombus. ? Multiple clinical, pathological and sociodemographic variables were assessed. ? Univariable and multivariable logistic regression analysis was performed to identify factors associated with surgery.

RESULTS

? We identified 24 396 patients with RCC, of which 2265 (9.3%) had venous tumour thrombus. ? Distant metastases (odds ratio [OR] 0.1, 95% CI 0.0–0.1), clinical stage T3c (OR 0.3, 95% CI 0.2–0.6), lymph node involvement (OR 0.4, 95% CI 0.2–0.6), being single (OR 0.4, 95% CI 0.3–0.7), and the age categories 61–70 years (OR 0.4, 95% CI 0.2–0.8, P= 0.01), 71–80 years (OR 0.2, 95% CI 0.1–0.3, P < 0.001), and ≥80 years (OR 0.1, 95% CI 0.0–0.1, P < 0.001) were significantly associated with non‐surgical management.

CONCLUSIONS

? In this population‐based study, over 80% of patients with RCC and venous tumour thrombus underwent surgical management. ? Although age and TNM stage were strongly associated with the decision to undergo surgery, marital status was also associated with treatment choice. ? It is unclear whether marital status affects oncological outcomes or complication rates so the reasons behind this association deserve further investigation.     

Successful management of inferior vena cava thrombus complicating advanced germ cell testicular tumor with temporary inferior vena cava filter

We report a case of right testicular tumor with inferior vena cava (IVC) thrombus. Due to the risk of pulmonary embolization, a temporary IVC filter had been inserted during chemotherapy. There were no complications with the temporary IVC filter during the implantation period. The patient was safely treated with systemic chemotherapy using a temporary IVC filter followed by retroperitoneal lymph node and vena cava dissection.     

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.     

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。