En Bloc Mobilization of the Pancreas and Spleen to Facilitate Resection of Large Tumors, Primarily Renal and Adrenal, in the Left Upper Quadrant of the Abdomen: Techniques Derived from Multivisceral Transplantation

Cadaveric analysis of surgical techniques and working space for retroperitoneal tumors as model for improving resection of neuroblastoma

PURPOSE

Neuroblastoma, the most common extracranial solid tumor in children under 5 years, often surrounds visceral arteries. This study aimed to analyze the working space provided by standardized surgical techniques at key arterial landmarks in adult cadavers.

METHODS

We assessed in eight adult cadavers the mobilization of the left colon, spleen and pancreas, right colon, duodenum and mesenteric root, access to the bursa omentalis. The average working space score (AWSS) was evaluated at the left and right renal artery, left and right side of the coeliac trunk, superior mesenteric and common hepatic artery. The score was defined as: (0) vessel not visible, (1) working space at the vessel ≤ 1x diameter of the aorta, (2) < 3x the diameter of the aorta, (3) ≥ 3x diameter of the aorta.

RESULTS

The maximum AWSS of 3 was achieved at key vascular landmarks through specific mobilization techniques.

CONCLUSION

Additional mobilization of spleen, pancreas and mesenteric root and access to the bursa omentalis increase surgical working space at major visceral arteries. The results of our investigation provide surgeons with a useful guide to prepare for abdominal neuroblastoma resection.

Surgical Management of Renal Cell Carcinoma with Inferior Vena Cava Tumor Thrombus

Most kidney cancers are primary renal cell carcinomas (RCC) of clear cell histology. RCC is unique in its ability to invade into contiguous veins - a phenomenon terms venous tumor thrombus. Surgical resection is indicated for most patients with RCC and an inferior vena cava (IVC) thrombus in the absence of metastatic disease. Resection also has an important role in selected patients with metastatic disease. In this review, we discuss the comprehensive management of the patient with RCC with IVC tumor thrombus, emphasizing a multidisciplinary approach to the surgical techniques and perioperative management.

Surgical Management of Upper Urinary Tract Urothelial Cell Carcinoma with Venous Tumor Thrombus: A Liver Transplant-Based Approach

Upper urinary tract urothelial cell carcinoma (UTUC) with venous tumor thrombus (TT) that extends into the renal vein (RV) and inferior vena cava (IVC) is a rare entity and its management is a surgical challenge. We report the largest single experience of surgical management of UTUC and accompanying venous TT with radical nephroureterectomy and tumor thrombectomy (RNATT) using transplant-based (TB) surgical techniques. From September 2003 to June 2021, nine patients with UTUC and venous TT underwent RNATT. Demographics, disease characteristics, surgical details, 30-day postoperative complications, and overall survival (OS) were analyzed. All nine patients had extension of the TT into the RV. Of those, seven had additional extension of the TT into the IVC. Venous TT level was categorized as 0 (n = 2), I (n = 2), II (n = 4), and IIIa (n = 1). Median tumor size was 12 cm (range 3–20 cm). Median estimated blood loss was 300 (range 150–1000) cc. One patient was still alive at last follow-up (4 months), and in total, eight patients have died with a median time-to-death of 12 months (range 10 days–24 months). RNATT using TB maneuvers like liver mobilization and pancreas-spleen en bloc mobilization provide excellent exposure to the retroperitoneal space and enable the safe removal of UTUC with venous TT.

Inferior Vena Cava Reconstruction Using a Ringed Polytetrafluoroethylene Interposition Graft and Inferior Vena Cava Filter Placement Following Resection of Renal Cell Carcinoma With a Tumor Thrombus Directly Infiltrating the Inferior Vena Cava

BackgroundRenal cell carcinoma (RCC) with tumor thrombus (TT) may extend into and, in rare cases, actually invade the inferior vena cava (IVC). Techniques of IVC reconstruction after removal of the RCC, TT, and infiltrated portion of the IVC have not been well documented. Methods A ringed polytetrafluoroethylene (PTFE) interposition graft along with an IVC filter placed within the graft (to prevent the development of pulmonary emboli) was used for patients who underwent surgical resection of RCC with TT extending into and directly invading the wall of the IVC. Demographic information about these patients along with their pathology reports, surgical procedures, and patency of the PTFE graft was obtained and described. Results Four male patients were identified as having RCC and TT with histologic invasion of the IVC requiring IVC dissection and replacement with a PTFE graft (as described above); their TT levels were II, IIIa, IIIc, and IV, respectively. Patient ages were 58, 65, 58, and 51 years and tumor sizes were 7.5, 7.5, 15.0, and 6.5 cm, respectively. These patients were followed for 36, 24, 32, and 48 months, respectively. At last follow-up, each patient had a patent IVC graft, and none of them developed any pulmonary emboli post-operatively. Conclusions Ringed PTFE interposition graft along with an IVC filter deployed inside the graft appears to be a safe vascular conduit for IVC reconstruction after surgical resection of RCC with TT directly invading the IVC.

Nephron-Sparing Surgery for Renal Cell Carcinoma with Tumor Thrombus

OBJECTIVE

The aim of the study was to describe our experience in patients who underwent nephron-sparing surgery (NSS) with tumor thrombectomy.

PATIENTS AND METHODS

Three consecutive patients who underwent NSS and tumor thrombectomy for localized single/multifocal renal cell carcinomas (RCCs) in conjunction with tumor thrombus between 2007 and 2011 were included. Open partial nephrectomy and thrombectomy was performed. Reconstruction included main renal vein, collecting system, and remaining parenchymal closure. One of the cases required additional artery repair and flushing with preservation solution.

RESULTS

Ischemic time was kept for 30-40 min. Mean estimated blood loss was 183.3 cc (range:100-300). One patient required the transfusion of 1 packed red blood cells unit. One of the patients developed a urinary fistula requiring double-J stenting. Hospital staying ranged between 5 and 8 days. None of the patients required renal replacement therapy either postoperatively or in the follow-up. Serum creatinine level at last follow-up (mean 83 months) ranged from 0.8 to 2.8 mg/dL.

CONCLUSION

Our experience supports the feasibility of imperative partial nephrectomy and tumor thrombectomy for cases of RCC with renal vein involvement by tumor thrombus. In experienced hands, this approach may offer the patient a low morbidity postoperative course and long-term freedom from disease while maintaining the renal function, thus avoiding the need of renal replacement therapy.

Renal Cell Carcinoma with or without Tumor Thrombus Invading the Liver, Pancreas and Duodenum

Simple Summary

Renal cell carcinoma rarely invades the surrounding visceral structures. While surgical extirpation has been the mainstay of treatment for the localized disease, the role of surgery in cases of venous involvement, adjacent invasion or distant metastasis remains controversial. Furthermore, the surgical option may represent a challenge. A large series of locally advanced renal cancer with involvement of the liver, pancreas, and/or duodenum, sometimes in conjunction with tumor thrombus extending inside the inferior vena cava is herein reported. Our series establishes the technical feasibility of this complex surgical procedure with acceptable complication rates, no perioperative death, and potential for durable response. With the use of new systemic therapy schedules, these patients will probably have a better opportunity of survival extension.

Abstract

Background: The purpose of this study is to report the outcomes of a series of patients with locally advanced renal cell carcinoma (RCC) who underwent radical nephrectomy, tumor thrombectomy, and visceral resection. Patients and methods: 18 consecutive patients who underwent surgical treatment in the period 2003-2019 were included. Neoplastic extension was found extending into the pancreas, duodenum, and liver in 9(50%), 2(11.1%), and 7(38.8%) patients, respectively. Seven patients (38.8%) presented also inferior vena cava tumor thrombus level I (n = 3), II (n = 2), or III (n = 2). The resection was tailored according to the degree of invasiveness. Demographics, clinical presentation, disease characteristics, surgical details, 30-day postoperative complications, and overall survival (OS) were analyzed. Results: Median age was 56 years (range: 40–76). Median tumor size was 14.5 cm (range, 8.8–22), and 10 cm (range: 4–15) for those cases with pancreatico-duodenal and liver involvement, respectively. Median estimated blood loss (EBL) was 475 mL (range: 100–4000) and resulted higher for those cases requiring thrombectomy (300 mL vs. 750 mL). Nine patients (50%) required transfusions with a median requirement of 4 units (range: 2–8). No perioperative deaths were registered in the first 30 days. Overall complication rate was 44.4%. Major complications were detected in 6/18 patients (33.3%). Overall median follow-up was 24 months (range: 0–108). Five-year OS (actuarial) rate was 89.9% and 75%, for 9/11 patients with pancreatico-duodenal involvement and 6/7 patients with liver invasion, respectively. Conclusion: Our series establishes the technical feasibility of this procedure with acceptable complication rates, no deaths, and potential for durable response.

Adrenal tumors of different types with or without tumor thrombus invading the inferior vena cava: An evaluation of 33 cases

BACKGROUND AND OBJECTIVES

Adrenal tumors with/out tumor thrombus (TT) in the inferior vena cava (IVC) pose a challenge to the surgeon due to the potential of massive hemorrhage and tumor thromboembolism. We report our experience in managing different types of adrenal tumors.

METHODS

From 11/1996-5/2015, 33 patients underwent resection of adrenal tumors with/without TT/IVC in 8 and 25 patients, respectively. Transplant-based (TB) techniques were utilized to resect the tumors. Intra-operative as estimated blood loss (EBL) and cardiopulmonary bypass (CPB) use; post-operative as length of hospital stay (LOS); and actuarial survival outcomes were recorded.

RESULTS

Median EBL was 200 cc (10-8,000), tumor size was 9.0 cm (4-25), and LOS was 7days (5-60). Adrenocortical carcinoma (ACC,11/33) was the commonest type. Three ACC/level IV TT/IVC underwent CPB to extract TT from the right atrium(n = 1), right atrium and right ventricle(n = 1), and right atrium and right pulmonary artery(n = 1), respectively. A complete resection of the adrenal tumors was achieved in all patients, and no deaths were observed in the immediate postoperative period. With a median follow-up of 60 (range: 18-120) months, 4/11 ACC patients have died of their disease. Actuarial survival for ACC patients at 60 months was 57.1 ± 16.4%.

CONCLUSIONS

An aggressive surgical approach is the only hope for curing large adrenal tumors with/without TT/IVC. TB techniques provide excellent exposure to the retroperitoneal space and safe removal of large adrenal masses.

Resection of Large Urological Tumors With or Without Inferior Vena Cava Extension in Jehova's Witnesses

Background: Renal and adrenal tumors with/without tumor thrombus in the inferior vena cava (IVC) pose a challenge to the surgeon due to the potential for massive hemorrhage and tumor thromboemboli. The situation would be more critical for Jehovah's Witness (JW) patients which refuse blood transfusion. A transplant-based (TB) approach to these tumors in JWs would result a safe surgical method, providing limited blood loss and perioperative complications. We report our experience using a TB surgical approach in JW harboring large adrenal/renal tumors with/without tumor thrombus trying to determine its usefulness in this setting.

Patients and Methods: From 2003 to 2011, 7 patients underwent resection of renal/adrenal tumors with/without tumor thrombus in the IVC by means of a TB approach. Thrombus level was renal (n = 2), retrohepatic (n = 1), and suprahepatic (n = 1). The remaining 3 patients did not present thrombus. No pre-operative optimization or cell-saver were used. Estimated blood loss, perioperative complications (Clavien-Dindo and cause), hemoglobin/hematocrit loss, and length of stay were considered main outcomes.

Results: The intervention was successfully completed without transfusion in all cases. Operative time and blood loss were 2.5 h (range: 1.83–5.75) and 150 cc (range: 100–750), respectively. No major post-operative complications were registered. However, minor complications were detected in 57% of the patients included. Median hemoglobin loss was 1.13 mg/dL, which translated a median hematocrit loss of 2.3%. Patients were discharged in a median of 7 days (range 5–20).

Conclusions: A TB-surgical approach provides enhanced retroperitoneal exposure and optimal vascular control, thus limiting operative blood loss or major complication development, thus resulting useful in JWs.

Usage of Modified Makuuchi Incision for Surgical Management of Complex Renal and Adrenal Lesions

BACKGROUND

 Modified Makuuchi (MM) incision is less popular among the urological fraternity as Chevron, subcostal, flank, and midline incisions are commonly used for most of the complex renal and adrenal conditions. We present our experience and report the outcomes of patients operated using this incision.

MATERIALS AND METHODS

 The records of patients who underwent open surgery for upper abdominal urological conditions using MM incision over the last five years in our department were retrospectively reviewed. Patient demographics, laterality of the lesion, size of the lesion, level of inferior vena caval (IVC) thrombus, intraoperative blood loss, local tumor invasion, need for concomitant hepatectomy, need of diaphragmatic resection, use of self-retaining retractors, operative time, hospital stay, wound-related complications, and readmissions were analyzed.

RESULTS

 Some 18 patients underwent open surgery by this incision for various complex renal and adrenal conditions during the study period. Patients included those with large upper pole renal and adrenal masses, renovascular conditions like renal artery aneurysm, renal/adrenal masses with liver and diaphragmatic infiltration requiring hepatectomy, diaphragmatic resections, or IVC thrombectomy. The mean size of renal and adrenal masses was 13.8 (±6.3) cm, mean operative time was 370 (±210.6) minutes, mean blood loss was 1124 (±990.3) mL, and mean hospital stay was 11.65 (±13.2) days. Four patients had surgical site infection (SSI) and one had readmission.

CONCLUSION

 The MM incision can be widely adapted for complex renal and adrenal surgeries and should become a part of the various commonly used incisions by urologists.

Retrospective analysis of relapsed abdominal high-risk neuroblastoma

BACKGROUND/PURPOSE

The impact of abdominal topography and surgical technique on resectability and local relapse pattern of relapsed abdominal high-risk neuroblastoma (R-HR-NB) is not clearly defined.

METHODS

A sample of thirty-nine patients with R-HR-NB enrolled in the German neuroblastoma trials between 2001 and 2010 was analyzed retrospectively using surgical and imaging reports. We evaluated resectability and local relapse pattern within 6 standardized abdominal regions, impact of extent of the first resective surgery on overall survival (OS), and of number of operations and a higher cumulative surgical assessment score (C-SAS) on OS after the first event.

RESULTS

In the left upper abdomen, rates for tumor persistence and relapse were 45.9% and 13.5% and in the left lower abdomen 27.7% and 8.3%, respectively. OS in months did not differ between complete and incomplete first resections (median (interquartile range): 35 (45.6) vs. 40 (65.4), P=.649). Better OS after the first event was associated with repeated as compared to single surgery (47.7 (64.7) vs. 4.3 (12.5), P=.000), and with higher as compared to lower C-SAS (47.7 (64.3) vs. 7.6 (14.7), P=.002).

CONCLUSIONS

OS after relapse/progression was not dependent on the extent of first resection. The number of operations was associated with better outcome after event.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

LEVEL III Retrospective comparative study.

[Postchemotherapy residual tumour resection in complex metastatic sites of advanced testicular germ cell tumours]

INTRODUCTION

Postchemotherapy residual tumour resection (PC-RTR) is an integral part of the multimodal therapy for advanced testicular germ cell tumours. Depending on the extent and localisation of the residual mass, PC-RTR may necessitate a multidisciplinary procedure (which should be planned preoperatively), to resolve even complex situations in an oncologically sound manner, with lower treatment-related morbidity The aim of article is to report on the interdisciplinary management of complex residual masses.

PATIENTS AND METHODS

Of a total of 162 patients who underwent PC-RTR, 24 (17.8 %) patients underwent, in addition to a bilateral postchemotherapy retroperitoneal lymphadenectomy (PC-RPLND), complex adjunctive resections including the abdominal aorta, the inferior vena cava, or the thoracic/lumbar spine, and the neighbouring vessels (n = 15). We performed a retrospective analysis of treatment-associated complications according to the Clavien-Dindo classification and of progression-free, cancer-specific and overall survival.

RESULTS

Median patient age was 24.5 (18-52) years. All patients had an intermediate or poor prognosis according to the International Germ Cell Cancer Collaboration Group (IGCCCG). Median tumour diameter at the time of surgery was 18.6 (9.0-35) cm. In 5 patients 1-2 metastatic lumbar vertebral bodies were completely resected, stabilised and replaced by means of a cage. In 6 patients resection of the abdominal aorta/inferior vena cava with vascular prosthesis replacement was required owing to infiltration. In 2 patients the common iliac artery or vein was resected and replaced. In addition, retrocrural lymph nodes had to be resected in 5 patients and 3 patients required adjunctive nephrectomy. In another 4 patients the Whipple procedure was required owing to infiltration into the pancreas and/or duodenum. The median operating time was 7.8 (6-15) h, the median blood loss was around 1,450 (900-3,400) ml, and 2 Clavien-Dindo grade IVa complications occurred. Pathohistology revealed teratoma/vital cancer in 16/24 patients and scarring/necrosis in 8 patients. After a median follow-up of 2.5 years, 1 patient developed recurrent disease and 1 patient died of the disease.

CONCLUSIONS

Postchemotherapy, a few patients with advanced nonseminomas (NS) need complex residual tumour resection in an interdisciplinary setting, with a good functional and oncological outcome. Even the involvement of vascular vertebral structures does not constitute a contraindication for complete resection.

Liver transplantation for hepatobiliary malignancies: a new era of "Transplant Oncology" has begun

The indications of liver transplantation for hepatobiliary malignancies have been carefully expanded in a stepwise fashion, despite the fundamental limitations in oncological, immunological, and technical aspects. A new era of "Transplant Oncology," the fusion of transplant surgery and surgical oncology, has begun, and we stand at the dawn of a paradigm shift in multidisciplinary cancer treatment. For hepatocellular carcinoma, new strategies have been undertaken to select recipients based on biological and dynamic markers instead of conventional morphological and static parameters, opening the doors for a more deliberate expansion of the Milan criteria and locoregional therapies before liver transplantation. Neoadjuvant chemoradiation therapy followed by liver transplantation for unresectable perihilar cholangiocarcinoma developed by the Mayo Clinic provided excellent outcomes in a US multicenter study; however, the surgical indications are not necessarily universal and await international validation. Similarly, an aggressive multidisciplinary approach has been applied for other tumors, including intrahepatic cholangiocarcinoma, hepatoblastoma, liver metastases from colorectal and neuroendocrine primary and gastrointestinal stromal tumors as well as rare tumors, such as hepatic undifferentiated embryonal sarcoma and infantile choriocarcinoma. In conclusion, liver transplantation is an important option for hepatobiliary malignancies; however, prospective studies are urgently needed to ensure the appropriate patient selection, organ allocation and living donation policies, and administration of antineoplastic immunosuppression.

[Complex residual tumors after chemotherapy of nonseminomatous germ cell tumors. Laparoscopic management - limits and chances]

PURPOSE

Laparoscopic retroperitoneal lymph node dissection (L-RPLND) is often required in patients with metastatic nonseminomatous germ cell tumors (NSGCT) and residual tumors after chemotherapy. Laparoscopy has become established as a safe procedure in the surgical management of these tumors. Due to the rapid development of laparoscopy, complex retroperitoneal and even intrathoracic residuals can also be treated in high volume centers.

PATIENTS AND METHODS

This study included 21 retrospectively identified NSGCT and seminoma patients (mean age 29 years) with metastatic disease and clinical stage (CS) IIA-IIIB. A bilateral L-RPLND was performed in all male patients between 2009 and 2014. In 19 patients an infiltration of the great vessels was detected during surgery and vascular reconstruction was necessary. In 2 patients an intrathoracic residual 5.4 cm and 7 cm in size, respectively, was diagnosed during follow-up. Exclusion criteria for L-RPLND were positive tumor markers after chemotherapy, patients with local recurrence after previous open L-RPLND and patients with excessive vascular involvement.

RESULTS

In this series no conversions to open surgery were necessary. The mean tumor size post-chemotherapy was 3.6 cm (range 1.5-9.7 cm). The mean measured blood loss was 294 ml (range 50-1000 ml). The mean hospitalization time was 6 days (range 3-9 days) and mean follow-up was 16 months (range 1-37 months). No complications higher than grade II (Clavien-Dindo classification) were registered in the immediate postoperative course. During the follow-up period no in-field recurrences were registered.

CONCLUSION

The L-RPLND seems to be a safe alternative surgical procedure for certain complex residuals with vascular involvement after chemotherapy of testicular cancer. Bilateral L-RPLND is technically feasible and reproducible under guaranteed oncological principles. An infiltration of the great vessels and also intrathoracic residuals can be managed in selected patients without compromising the clinical and oncological course.

Current status of the organ replacement approach for malignancies and an overture for organ bioengineering and regenerative medicine

Significant achievements in the organ replacement approach for malignancies over the last 2 decades opened new horizons, and the age of "Transplant Oncology" has dawned. The indications of liver transplantation for malignancies have been carefully expanded by a strict patient selection to assure comparable outcomes with non-malignant diseases. Currently, the Milan criteria, gold standard for hepatocellular carcinoma, are being challenged by high-volume centers worldwide. Neoadjuvant chemoradiation therapy and liver transplantation for unresectable hilar cholangiocarcinoma has been successful in specialized institutions. For other primary and metastatic liver tumors, clinical evidence to establish standardized criteria is lacking. Intestinal and multivisceral transplantation is an option for low-grade neoplasms deemed unresectable by conventional surgery. However, the procedure itself is in the adolescent stage. Solid organ transplantation for malignancies inevitably suffers from "triple distress," i.e., oncological, immunological, and technical. Organ bioengineering and regenerative medicine should serve as the "triple threat" therapy and revolutionize "Transplant Oncology."

Budd-Chiari syndrome in urology: Impact on nephrectomy for advanced renal cell carcinoma

Objectives:

Budd-Chiari syndrome (BCS) is a poorly understood entity in urology. It results from obstruction of the hepatic veins and the subsequent complications. It has been infrequently reported to be secondary to hepatic venous obstruction from invasion by an inferior vena cava (IVC) tumor thrombus in renal cell carcinoma (RCC). We report the largest known series of patients with RCC and BCS.

Patients and Methods:

Ten patients presented to a tertiary hospital with locally advanced RCC with IVC tumor thrombus. All were evaluated and had clinical or radiographic evidence of BCS. All underwent nephrectomy, IVC thrombectomy or ligation, and tumor removal from the hepatic veins. The perioperative and pathological factors were measured. These included estimated blood loss (EBL) and transfusions. Inpatient factors including duration of intubation, length of intensive care unit (ICU) stay, and overall length of stay (LOS) were recorded. The tumor-free status was evaluated.

Results:

The average age was 59 years. No intraoperative deaths occurred. Two intraoperative complications were noted. The mean EBL was 4244 cc; mean surgery length was 8 hours 12 minutes; and the mean ICU stay was nine days. The overall LOS averaged 13.25 days. One patient died postoperatively of sepsis and multisystem organ failure. One patient required reoperation for an abdominal wall hematoma caused by subcutaneous enoxaparin administration. Average follow-up was 28 months. Five patients are alive with no evidence of disease.

Conclusions:

Budd-Chiari syndrome is a rare entity in urology, with a potential for significant morbidity and mortality. Surgical excision of the primary tumor along with thrombectomy results in alleviation of BCS and improvement in the patient.