Elsevier

Urology

Volume 74, Issue 4, October 2009, Pages 846-850
Urology

Oncology
Vascular Stapling of the Inferior Vena Cava: Further Refinement of Techniques for the Excision of Extensive Renal Cell Carcinoma With Unresectable Vena-caval Involvement

https://doi.org/10.1016/j.urology.2009.04.075Get rights and content

Objectives

To present our experience with a novel technique of tumor removal: en bloc resection of the tumor, thrombus, and inferior vena cava (IVC) via vascular staple ligation and excision, and to excise all tumor, which may include a portion of the IVC when invasion is present. Management of renal cell carcinoma (RCC) with IVC thrombus presents a challenge. Options for tumor excision include thrombectomy with or without cardiopulmonary bypass, replacement of the cava with synthetic or venous graft, or caval excision without replacement.

Methods

Six patients with extensive RCC with IVC thrombus were evaluated. All patients underwent preoperative imaging that depicted completely obstructing IVC thrombus of varying cranial extension with apparent invasion of the caval wall. None had lower extremity edema. Patients underwent IVC staple ligation and en bloc resection of tumor and thrombus. Pre-, intra-, and postoperative as well as pathological factors were measured. These included estimated blood loss, transfusions, and procedure length. Inpatient factors including duration of intubation, length of intensive care unit stay, and overall length of stay were recorded. Tumor-free status was evaluated.

Results

All patients had Fuhrman Grade 4 RCC. No perioperative deaths occurred. Mean estimated blood loss was 6350 mL (range 900-25 000). Length of intubation averaged 1.5 days. Mean intensive care unit stay was 4.3 days. Overall length of stay averaged 9.3 days.

Conclusions

Complete excision of a portion of the IVC, using a vascular stapler in conjunction with radical nephrectomy is a satisfactory method to remove RCC with IVC invasion. Sufficient collateral circulation exists for venous return from the lower extremities.

Section snippets

Patients and Methods

From July 2005 to August 2008, a total of 6 patients underwent a right radical nephrectomy with vascular stapling and en bloc removal of the IVC, which contained a thrombus. The study protocol was approved by the Institutional Review Board and written informed consent was obtained from all patients. None of the patients had lower extremity edema preoperatively. None of them had undergone preoperative angioembolization of tumor. Radiographic imaging was consistent with a completely obstructing

Surgical Technique

The surgical approach was similar for each patient. All had an extended subcostal or “Chevron” incision. The initial step was to mobilize the liver sufficiently to place the Rochard retractor. This included division of the triangular and falciform ligaments and medial mobilization of the right lobe of the liver. Subsequently, the right colon was mobilized off Gerota fascia, which allowed mobilization of the right kidney and ligation of the renal artery from the posterior approach. The

Results

Of the 6 patients, 1 was female. The mean age was 60 years (range, 53-70). All tumors were right sided. Average length of surgery was 7 hours. No patients needed cardiopulmonary bypass or deep hypothermic circulatory arrest. Average blood loss was 6350 mL. Excluding patient 1, whose blood loss was 25 000 mL, the average estimated blood loss was 2620 mL. Including patient 1, the average number of units of red blood cells transfused was 13. Excluding this patient the mean was 7.4 U. Average

Comment

Although there has been a well-documented shift toward earlier detection of RCC with resultant downstaging,11 extensive RCC with IVC tumor thrombus is not rare.12 Accurate staging of these lesions is vitally important in planning treatment strategy. The most widely used system for reporting the level of IVC thrombus has been reported.9

The management paradigm of RCC with tumor thrombus in the IVC has undergone major shifts. Initially, such lesions were felt to be incurable and often palliative

Conclusions

Six patients have undergone vascular stapling and resection of the IVC for RCC with an adherent, completely obstructing, tumor thrombus. Since significant collateralization has occurred in these patients, the IVC may be removed without sequelae. This technique is somewhat simpler to perform than suture ligation, requires less operative time, and is consistently reproducible. It is safe, with no patients demonstrating postoperative hemorrhage or renal failure. No complications were noted in this

References (24)

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