Hand-Assisted Laparoscopic Nephrectomy for Renal Cell Cancer with Renal Vein Tumor Thrombus

Correlation of preoperative imaging characteristics with donor outcomes and operative difficulty in laparoscopic donor nephrectomy

This study aimed to understand the relationship of preoperative measurements and risk factors on operative time and outcomes of laparoscopic donor nephrectomy. Two hundred forty-two kidney donors between 2010 and 2017 were identified. Patients' demographic, anthropomorphic, and operative characteristics were abstracted from the electronic medical record. Glomerular filtration rates (GFR) were documented before surgery, within 24 hours, 6, 12, and 24 months after surgery. Standard radiological measures and kidney volumes, and subcutaneous and perinephric fat thicknesses were assessed by three radiologists. Data were analyzed using standard statistical measures. There was significant correlation between cranio-caudal and latero-lateral diameters (P < .0001) and kidney volume. The left kidney was transplanted in 92.6% of cases and the larger kidney in 69.2%. Kidney choice (smaller vs. larger) had no statistically significant impact on the rate of change of donor kidney function over time adjusting for age, sex and race (P = .61). Perinephric fat thickness (+4.08 minutes) and surgery after 2011 were significantly correlated with operative time (P ≤ .01). In conclusion, cranio-caudal diameters can be used as a surrogate measure for volume in the majority of donors. Size may not be a decisive factor for long-term donor kidney function. Perinephric fat around the donor kidney should be reported to facilitate operative planning.

Treatment of caval vein thrombosis associated with renal tumors

INTRODUCTION

Renal carcinoma represents 3% of all solid tumors and is associated with renal or inferior caval vein (IVC) thrombosis between 2-10% of patients, extending to right atrial in 1% of cases.

METHODS

This is a retrospective study that comprises 5 patients who underwent nephrectomy and thrombectomy by laparotomy because of renal tumor with IVC thrombosis level iii.

RESULTS

Four patients were males and one was female, and the mean age was 57,2 years (range: 32-72). Most important clinical findings were hematuria, weight loss, weakness, anorexia, and pulmonary embolism. Diagnostic confirmation was performed by CT scanner. Metastatic disease was diagnosed before surgery in 3 patients. Suprahepatic caval vein and hepatic hilium (Pringle's maneouver) were clamped in 4 patients, and ligation of infrarrenal caval vein was carry out in one patient. Five patients developed mild complications (Clavien I/II). No patient died and the mean hospital stay was 8,6 days. All patients were treated with chemotherapy, and 3 died because distant metastasis, but 2 are alive, without recurrence, at 5 and 60 months, respectively.

CONCLUSIONS

Nephrectomy and thrombectomy in renal tumors with caval thrombosis can be curative in absence of metastasis or, at less, can increase survival or quality of live. Then these patients must be treated in liver transplant units because major surgical and anesthesiologic expertise. Adjuvant treatment with tyrosin kinase inhibitors must be validate in the future with wider experiences.

Surgical resection of recurrent inferior vena cava tumor following radical nephrectomy for renal cell carcinoma: A case report

Late recurrence is a known characteristic of the biological behavior of renal cell carcinoma (RCC) following radical nephrectomy. However, the development of recurrent inferior vena cava (IVC) tumors following radical nephrectomy for RCC is a rare event, and surgical resection of recurrent IVC tumors is a challenge for urologists. The present study reports the case of a patient with a local recurrent tumor in the IVC following a right radical nephrectomy 4 years previously for RCC. The patient was referred to the Department of Urology, First Affiliated Hospital of Anhui Medical University, due to bilateral lower extremity edema, and magnetic resonance imaging showed an intraluminal tumor thrombus in the IVC. Therefore, a thrombectomy and partial IVC resection with defect reconstruction were performed successfully. The results of follow-up for 72 months showed that there were no signs of recurrence as local or distant metastasis. This case of local recurrence in the IVC highlights that active long-term surveillance for RCC patients of all stages is important for the early diagnosis of tumor recurrence, which improves the potential resectability.

Less invasive treatment option for renal carcinoma with venous tumor thrombus

Aim

To retrospectively analyze patients treated by renal tumor and venous tumor thrombus (VTT) removal and to introduce a less stressful and safer surgical method without thoracotomy in Neves level 3 cases.

Methods

From 2002 to 2011, 33 patients underwent surgery for renal cell cancer combined with tumor thrombus of the inferior vena cava. Preoperative symptoms, tumor-node-metastasis classification of tumors, thrombus extension classified by Neves and Zincke system, types of surgical interventions, complications, postoperative management, and survival results were analyzed.

Results

Ten patients had level 1, 17 had level 2, and 6 had level 3 thrombi according to Neves and Zincke. In 5 patients with level 3 thrombi, the liver was mobilized without thoracotomy and in 1 patient endoluminal occlusion was utilized. There was no intraoperative mortality. The median survival time of 10 patients who died during follow-up period was 36.6 months (range, 1-116 months).

Conclusion

Renal cell cancer complicated with tumor thrombus without metastasis can be curable by performing a complete resection. The thrombus level determines the surgical approach and method. Our results confirm that level 3 caval vein tumor thrombus can be safely surgically treated by laparotomy with liver mobilization. Thoracotomy, use of cardiopulmonary bypass, and hypothermic circulatory arrest can be avoided with adequate liver- and vascular surgery methods.

Laparoscopic management of advanced renal cell carcinoma with renal vein and inferior vena cava thrombus

OBJECTIVE

To report the results and oncological efficacy of laparoscopic radical nephrectomy (LRN) in patients with renal cell carcinoma with renal vein and inferior vena cava thrombus.

METHODS

We performed retrospective record review of 41 patients who underwent LRN along with venous thrombectomy at 2 Canadian centers from 2002 to 2012 by dedicated laparoscopic surgeons.

RESULTS

The mean age and body mass index of the 41 study patients (34 males and 7 female) were 64.4 years and 28.7 kg/m(2), respectively. Median tumor size was 9.3 cm; 39 patients had renal vein thrombus, and 2 had inferior vena cava thrombus. Nine patients (22%) had metastatic disease to begin with and underwent laparoscopic cytoreductive nephrectomy. Median estimated blood loss, operative time, and length of stay were 100 mL (range, 50-400 mL), 134.5 minutes (range, 99-183 minutes), and 4 days (range, 4-6 days), respectively. There were 4 (9.7%) grade 2 complications. There was no intraoperative death. Mean duration of follow-up was 42 months (range, 6-107 months). Of 32 patients with localized disease, 4 (12.5%) died of progressive disease, 3 (9.3%) died of unrelated causes, and 3 patients (9.3%) were lost to follow-up. Twenty-two patients (68.7%) were alive at a mean follow-up of 47 months.

CONCLUSION

LRN and venous thrombectomy for advanced renal tumors with venous thrombus are safe procedures in experienced hands with significant laparoscopic skills. The short-term oncological data are encouraging and advocate the efficacy of this procedure in this subset of patients, although longer follow-up is required in larger number of patients to further define its role.

[Treatment of renal cell carcinoma associated with vena inferior cava tumor thrombus]

AIM

Follow-up and review of patients who underwent surgery for renal cell cancer combined with tumor thrombus of the inferior vena cava at the Department of Urology Semmelweis University, Budapest, Hungary.

MATERIAL AND METHODS

From l998 to 2010 twenty one patients underwent surgery for renal cell cancer combined with tumor thrombus of the inferior caval vein. Preoperative symptoms, TNM classification of the tumors, types of surgical interventions, complications, postoperative management and survival results were involved in the analysis. Mean follow-up period was 39 months, ranging from 3 to 101 months.

RESULTS

In five cases of level 3 thrombi the liver was mobilized without thoracotomy, and endoluminar occlusion was applied in one case. Intraoperative mortality was 9,5%. Survival time of patients with distant metastases was 12.1 months (3-9). Three patients without metastases died in the follow up period, their survival time was 26.7 months ranging from 22 to 31 months. Eight patients (73%) were alive at the time of the last follow-up. The mean survival time was 5.6 years ranging from 39 to 101 months.

CONCLUSION

Our results support that level 3 caval vein tumor thrombus can be removed by less aggressive surgical approach and underline the benefit of the surgical intervention without thoracotomy.

International consultation on urologic diseases and the European Association of Urology international consultation on locally advanced renal cell carcinoma

CONTEXT

Although an ever-increasing number of patients are being incidentally diagnosed with small renal masses, there is still a sizable portion of patients with renal cell carcinoma (RCC) who present with locally advanced or metastatic disease. Those with locally advanced disease present a challenge because they may be difficult to distinguish from those with organ-confined disease at the time of diagnosis. However, this distinction is important because they may require a different management strategy. These advanced RCC patients include those with venous tumour thrombi, extracapsular tumour extension, adjacent organ involvement, as well as nodal disease.

EVIDENCE ACQUISITION

A thorough literature search of the following terms was undertaken: advanced renal cell carcinoma, renal cell carcinoma venous tumour thrombi, renal cell carcinoma extra-capsular extension, renal cell carcinoma nodal metastasis, and locally recurrent renal cell carcinoma. An international expert panel convened by the International Consultation on Urologic Diseases and the European Association of Urology reviewed these articles.

EVIDENCE SYNTHESIS

Review of the available literature allowed for assessment of the level of evidence for the diagnosis, management, and therapy of locally advanced RCC with the ultimate goal of providing a synthesis of this information with a consensus statement from leaders in the field.

CONCLUSIONS

Despite the advances in prognostic markers and targeted molecular therapies for RCC, currently the only curative treatment for locally advanced RCC is aggressive surgical resection.

Laparo-endoscopic single-site (LESS) radical nephrectomy with renal vein thrombectomy: initial report

BACKGROUND

By combining trocar sites and extraction incision, Laparo-endoscopic Single-site Surgery (LESS) may provide less morbidity than traditional laparoscopy. Concerns continue about LESS for locally advanced tumors. We present our experience with LESS-radical nephrectomy with renal vein thrombectomy (LESS-RN-RVT) CASE PRESENTATION: Between 5-6/2009, 2 patients underwent LESS-RN-RVT (1 right-/1 left-side). Standard steps of multi-site laparoscopic radical nephrectomy were performed, including stapled renal vein thrombectomy and intact specimen extraction. Both cases were successfully completed by LESS without complications. Mean tumor size was 7.8 cm, incision size 4.5 cm, operative time 152 min, EBL 100 ml, and hospital stay 2.5 days. Both patients had negative margins, and are alive at time of last follow-up. One did not require postoperative opiates.

CONCLUSIONS

LESS-RN-RVT is safe and feasible in selected patients with renal vein thrombi. Further accumulation of data and comparison to multiport laparoscopic technique are requisite.

Surgery for vena caval tumor extension in renal cancer

PURPOSE OF REVIEW

We review recent efforts designed to improve the preoperative assessment, minimize the surgical morbidity, and develop multimodal treatments for patient with renal cell carcinoma and venous tumor thrombus.

RECENT FINDINGS

The ability of computerized tomography to classify venous thrombus has improved with recent advancements in multidetector/three-dimensional technology. The utility of preoperative imaging to predict vascular wall invasion, which carries adverse prognostic significance, has also been demonstrated. Minimally invasive approaches to low-level thrombus cases have been explored, whereas techniques to minimize the morbidity associated with the use of cardiopulmonary bypass and circulatory arrest in patients with a retrohepatic or supradiaphragmatic thrombus, including antegrade cerebral perfusion, the use of cardiopulmonary bypass with mild hypothermia, and the increased application of veno-venous bypass, have improved perioperative outcomes. Meanwhile, results from several case reports suggest a potential role for neoadjuvant systemic therapy with tyrosine kinase inhibitors prior to resection.

SUMMARY

Improvements in perioperative assessment and surgical technique have decreased the morbidity and improved the outcomes for patients with renal cell carcinoma and venous tumor thrombus. Further investigations of the role for targeted therapies in the management of these complex patients are needed to define the optimal multimodal approach.