1
|
Shu F, Hao Y, Yan Y, Lu M, Ma L, Deng S, Ge L, Zhang S. Renal Angiomyolipoma with Tumor Thrombus in the Inferior Vena Cava and Right Atrium Accompanied by Renal Cell Carcinoma: A Case Report. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1293. [PMID: 39202574 PMCID: PMC11356200 DOI: 10.3390/medicina60081293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2024] [Revised: 07/27/2024] [Accepted: 08/05/2024] [Indexed: 09/03/2024]
Abstract
Background: Renal angiomyolipoma (AML) without local invasion is generally considered benign. However, it may extend to the renal sinus, even the renal vein, or the inferior vena cava (IVC). In patients with non-tuberous sclerosis complex, coexistence of renal cell carcinoma (RCC) and renal AML is uncommon. Case presentation: A 72-year-old woman was incidentally found to have a solitary right renal mass with an IVC thrombus extending into the right atrium during a routine health checkup. Robot-assisted laparoscopic radical nephrectomy and thrombectomy were successfully performed through adequate preoperative examination and preparation. Two tumor lesions were found and pathologically confirmed as renal AML and RCC, and the tumor thrombus was derived from the renal AML. During the one-year follow-up period, no signs of recurrence or metastatic disease were observed. Conclusions: Renal AML with a tumor thrombus in the IVC and right atrium accompanied by RCC may occur, although rarely. In clinical practice, if preoperative manifestations differ from those of common diseases, rare diseases must be considered to avoid missed diagnoses. In addition, adequate examination and multidisciplinary discussions before making a diagnosis are necessary. For a level 4 tumor thrombus with no infringement of the venous wall, adoption of robot-assisted minimally invasive surgery, without extracorporeal circulation technology, is feasible.
Collapse
Affiliation(s)
- Fan Shu
- Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - Yichang Hao
- Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - Ye Yan
- Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - Min Lu
- Department of Pathology, Peking University Third Hospital, Beijing 100191, China
- Department of Pathology, School of Basic Medical Sciences, Peking University Health Science Center, Beijing 100083, China
| | - Lulin Ma
- Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - Shaohui Deng
- Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - Liyuan Ge
- Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - Shudong Zhang
- Department of Urology, Peking University Third Hospital, Beijing 100191, China
| |
Collapse
|
2
|
Perdue J, Wells A, Patel K, Du Plessis W, Varre J, Salibi P. Multidisciplinary approach to the management of renal angiomyolipoma with inferior vena cava thrombus and pulmonary embolism: a case report. J Surg Case Rep 2024; 2024:rjae174. [PMID: 38524682 PMCID: PMC10960940 DOI: 10.1093/jscr/rjae174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 02/28/2024] [Indexed: 03/26/2024] Open
Abstract
Renal angiomyolipoma (AML) is a benign tumor with rare venous extension. We present a case of a patient with renal AML with inferior vena cava (IVC) tumor thrombus and acute pulmonary embolism (PE). A 34-year-old female presented with chest pain. Imaging revealed a 5 cm right renal AML, with tumor thrombus into the renal vein and IVC, and acute left lower lobe PE. Right radical nephrectomy and caval thrombectomy were performed using intraoperative ultrasound. Rarely, these benign tumors generate thrombus with caval extension. The location of IVC thrombus guides surgical planning, which may involve suprahepatic IVC control or cardiopulmonary bypass. Early involvement of a multidisciplinary team with extensive preoperative planning can help achieve successful outcomes.
Collapse
Affiliation(s)
- Jordyn Perdue
- Department of General Surgery, OhioHealth Riverside Methodist Hospital, Columbus, OH 43214, United States
| | - Alexandra Wells
- Department of Hepato-Pancreato-Biliary (HPB) Surgery, Atrium Health, Charlotte, NC 28203, United States
| | - Krishna Patel
- Department of General Surgery, OhioHealth Riverside Methodist Hospital, Columbus, OH 43214, United States
| | - Wihan Du Plessis
- Department of General Surgery, OhioHealth Riverside Methodist Hospital, Columbus, OH 43214, United States
| | - Jaya Varre
- Department of General Surgery, OhioHealth Riverside Methodist Hospital, Columbus, OH 43214, United States
| | - Patrick Salibi
- Department of General Surgery, OhioHealth Riverside Methodist Hospital, Columbus, OH 43214, United States
| |
Collapse
|
3
|
Faegh A, Moeinafshar A, Rezaei N. Nephrectomy and IVC thrombectomy in renal cancer: a narrative review. Clin Transl Oncol 2024; 26:574-583. [PMID: 37568007 DOI: 10.1007/s12094-023-03302-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 07/29/2023] [Indexed: 08/13/2023]
Abstract
Renal cell carcinoma accounts for two to three percent of adult malignancies and can lead to inferior vena cava (IVC) thrombosis. This condition can decrease the rate of 5-year survival for patients to 60%. The treatment of choice in such cases is radical nephrectomy and inferior vena cava thrombectomy. This surgery is one of the most challenging due to many perioperative complications. There are many controversial methods reported in the literature. Achieving the free of tumor IVC wall and the possibility of thrombectomy in cases of level III and level IV IVC thrombosis are two essential matters previously advocated open approaches. Nevertheless, open approaches are being replaced by minimally invasive techniques despite the difficulty of the surgical management of IVC thrombectomy. This paper aims to review recent evidence about new surgical methods and a comparison of open, laparoscopic, and robotic approaches. In this review, we present the latest surgical strategies for IVC thrombectomy and compare open and minimally invasive approaches to achieve the optimal surgical technique. Due to the different anatomy of the left and right kidneys and variable extension of venous thrombosis, we investigate surgical methods for left and right kidney cancer and each level of IVC venous thrombosis separately.
Collapse
Affiliation(s)
- Ali Faegh
- School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Aysan Moeinafshar
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Nima Rezaei
- Network of Immunity in Infection, Malignancy, and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran.
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
- Children's Medical Center Hospital, Dr. Qarib St, Keshavarz Blvd, Tehran, 14194, Iran.
| |
Collapse
|
4
|
Surcel C, Dotzauer R, Mirvald C, Popa C, Olariu C, Baston C, Harza M, Gangu C, Tsaur I, Sinescu I. Current role of intraoperative cell salvage techniques in the management of renal tumors with level III and IV inferior vena cava thrombus extension. Ther Adv Urol 2024; 16:17562872241229248. [PMID: 38333071 PMCID: PMC10851714 DOI: 10.1177/17562872241229248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 01/08/2024] [Indexed: 02/10/2024] Open
Abstract
Background En bloc removal of the kidney with tumor thrombus excision in a multidisciplinary team remains the standard treatment for renal cell carcinoma (RCC) with tumor thrombus extension. In order to minimize the hemodynamic impact of the surgical blood loss, intraoperative cell salvage (IOCS) techniques can decrease the need for allogeneic blood and prevent blood transfusion related complications. Objective In this article, we evaluated the safety of IOCS during radical nephrectomy with inferior vena cava thrombectomy under cardiopulmonary bypass with or without deep hypothermic circulatory arrest. Design and method In this retrospective comparative multicenter analysis, clinical characteristics of 27 consecutive patients who underwent surgery with or without IOCS between 2012 and 2022 in three referral care units were collected into a database. The need for an allogenic blood transfusion (ABT) was also recorded, defined as any transfusion that occurred either intraoperatively or during the hospital stay. Results The need for ABT in the cell saver arm was significantly smaller due to the reinfusion of rescued blood (p < 0.015). In multivariate analysis, no cell saver usage was an independent predictor for complications ⩾3 Clavien 3a [odds ratio (OR) 18.71, 95% CI 1.056-331.703, p = 0.046]. No usage of IOCS was an independent predictor for a lower risk of death (OR 0.277, 95% CI 0.062-0.825, p = 0.024). During follow-up, patients who received salvaged blood did not experience an increased risk for developing local recurrence or distant metastases. Conclusion Transfusion of autologous blood is safe and can be using during nephrectomy and thrombectomy for advanced RCC.
Collapse
Affiliation(s)
- Cristian Surcel
- Department of Urology, Fundeni Clinical Institute, Bucharest, Romania
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Robert Dotzauer
- Department of Urology, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - Cristian Mirvald
- Department of Urology, Fundeni Clinical Institute, “Carol Davila” University of Medicine and Pharmacy, 258 Fundeni Street, 2nd District, Bucharest, Romania
| | - Calin Popa
- Cardiac Center, Monza Hospital, Bucharest, Romania
| | | | - Catalin Baston
- Department of Urology, Fundeni Clinical Institute, Bucharest, Romania
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Mihai Harza
- Department of Urology, Fundeni Clinical Institute, Bucharest, Romania
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Constantin Gangu
- Department of Urology, Fundeni Clinical Institute, Bucharest, Romania
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Igor Tsaur
- Department of Urology, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - Ioanel Sinescu
- Department of Urology, Fundeni Clinical Institute, Bucharest, Romania
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| |
Collapse
|
5
|
Möbius A, Grieshaber P, Turra J, Riesterer D, Zaradzki M, Soso P, Hatiboglu G, Hohenfellner M, Warnecke G, Tochtermann U. Cavoatrial hypernephroma resection on cardiopulmonary bypass: Mild/normo-versus moderate hypothermia. Perfusion 2023; 38:1644-1651. [PMID: 36125270 PMCID: PMC10612369 DOI: 10.1177/02676591221128143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCION Renal cell carcinoma (RCC) is one of the most prevalent malignant tumors. It extends up into the systemic veins and right atrium. Surgical extraction of such extensions is usually carried out using cardiopulmonary bypass (CPB) with moderate hypothermic (MH) being frequently applied in order to obtain a clear surgical field. However, due to obvious disadvantages of hypothermia, approaches with mild/normothermia (NT) during CPB have also been established. The current study aims to compare the outcomes of patients undergoing RCC tumor and extensions resection using MH versus NT. MATERIAL AND METHODS This is a retrospective, non-randomized study. All patients who underwent RCC tumor and extensions resection for stage III or IV (Staehler) RCC in a single center between 2006 and 2020 were included. During surgery, MH or NT were applied. CPB was realized using aortic and bicaval cannulation. We compared the procedural times, transfusion requirements and postoperative outcomes, respectively between the MH and NT groups. RESULTS A total of 24 consecutive patients (n(NT) = 12, n(MH) = 12) were included in the study (median age NT 68.5 and MH 66.5). The study only showed a significant difference in heart-lung machine times (median CPB time NT 45.5 min and MH 110.0 min, p = 0.004). All other results, loss of drainage, administration of blood products, as well as the postoperative course and mortality were comparable in both groups. CONCLUSION The results showed a high perioperative and long-term mortality. The perioperative course was similar after surgery with NT or MH. Therefore, NT which minimizes potential complications of MH should be preferred.
Collapse
Affiliation(s)
- Andreas Möbius
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Philippe Grieshaber
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Jan Turra
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - David Riesterer
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Marcin Zaradzki
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Petar Soso
- Department of Cardiothoracic Surgery, Hospital Passau, Passau, Germany
| | - Gencay Hatiboglu
- Department of Urology, SLK Hospital Group Heilbronn, Heilbronn, Germany
| | | | - Gregor Warnecke
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Ursula Tochtermann
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| |
Collapse
|
6
|
He W, Cong Z, Liu Y, Yao Z, Cheng F, Zhang Y, Niu Z. A novel technique for avoidance of sternotomy, diaphragmic incision and cardiopulmonary bypass during cavoatrial tumor thrombectomy for renal cell carcinoma with intraatrial tumor thrombus: a case series at a single center. BMC Surg 2023; 23:252. [PMID: 37620830 PMCID: PMC10463378 DOI: 10.1186/s12893-023-02156-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/16/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Radical nephrectomy with thrombectomy in patients with renal cell carcinoma (RCC) and level IV thrombus extending to the right atrium (RA) offers improved survival. However, this procedure is associated with significant perioperative morbidity and mortality. In this report, we describe a novel milking technique for patients with RA tumor thrombus using abdominal access, which does not require diaphragmic incision, sternotomy, right atriotomy, or cardiopulmonary bypass (CPB). METHODS Between January 2019 and January 2022, four patients underwent resection of renal cell carcinoma extending into RA by a milking technique developed to avoid diaphragmic incision, sternotomy, or CPB. Patient characteristics, perioperative data, pathological features, and survival were evaluated. RESULTS Complete resection was successful through pure transabdominal access without diaphragmic incision, sternotomy, or CPB in all patients. CONCLUSION We conclude that radical nephrectomy and thrombectomy in optimized cases with renal cell carcinoma extending into RA can be safely and effectively performed without diaphragmic incision, sternotomy, or CPB, avoiding serious perioperative complications while providing acceptable oncological outcomes.
Collapse
Affiliation(s)
- Wei He
- Department of Urology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324, Jingwu Road, Huaiying District, Jinan, 250021, Shandong, China
| | - Zixiang Cong
- Department of Urology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong province, China
| | - Yaqing Liu
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Zhongshun Yao
- Department of Urology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324, Jingwu Road, Huaiying District, Jinan, 250021, Shandong, China
| | - Fajuan Cheng
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Yiming Zhang
- Department of Urology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324, Jingwu Road, Huaiying District, Jinan, 250021, Shandong, China
| | - Zhihong Niu
- Department of Urology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324, Jingwu Road, Huaiying District, Jinan, 250021, Shandong, China.
- Department of Urology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong province, China.
| |
Collapse
|
7
|
Sidiropoulos T, Parasyris S, Ntella V, Margaris I, Christodoulou S, Theodoraki K, Vassiliu P, Smyrniotis V, Arkadopoulos N. En-Bloc Resection of Renal Cell Carcinoma With Tumor Thrombus Propagating Into the Intrapericardial Inferior Vena Cava: Efficacy and Safety of Transabdominal Approach. Cureus 2023; 15:e42394. [PMID: 37621783 PMCID: PMC10446507 DOI: 10.7759/cureus.42394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Renal cell carcinoma (RCC) is the most common primary kidney cancer. In up to 4-10% of patients, the tumor is complicated with a malignant thrombus extending to the inferior vena cava (IVC). Complete surgical excision of the RCC and the neoplastic thrombus can be curative. We aim to present a safe and feasible alternative transabdominal operative technique with the omission of thoracotomy, as applied in six patients diagnosed with RCC and IVC thrombus extending over the diaphragm. METHODS This case series study was conducted in a tertiary university hospital in Athens, Greece. All six patients, who were operated on for RCC and a malignant thrombus exceeding in the intrapericardial IVC in our department from January 2009 until March 2020, were screened. Intraoperatively, the infrarenal and intrapericardial IVC were clamped simultaneously with the renal and liver blood inflow. Access to the intrapericardial IVC was obtained via the central tendon of the diaphragm. Intrathoracic extension of the tumor was confirmed by transesophageal or intraoperative ultrasonography. The intrathoracic IVC was exposed to direct vision and two finger palpation was applied to secure the clamping of the IVC above the tip of the thrombus. The tumor was resected through a longitudinal venotomy and the operation was completed on a standard radical nephrectomy. RESULTS During the study period six patients presented with RCC and intrapericardial IVC thrombus. All patients, five female and one male, underwent radical nephrectomy combined with IVC thrombectomy, without the need for a thoracotomy. The mean age was 66 years old and the mean operative time was 122.5 minutes. Mean blood loss was 338 ml and only four of the patients were transfused with two units of RBC. Operative and hospital mortality was 0%. The hospital stay was seven (six to nine) days. Only one patient required readmission and reoperation 30 days later, due to intrapericardial herniation. CONCLUSIONS The proposed surgical technique may be curative in patients with advanced intracaval thrombus and helps reduce the associated morbidity, mortality, and the overall cost of more extended operations.
Collapse
Affiliation(s)
- Theodoros Sidiropoulos
- 4th Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Stavros Parasyris
- 4th Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Vassiliki Ntella
- 4th Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Ioannis Margaris
- 4th Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Spyridon Christodoulou
- 4th Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Kassiani Theodoraki
- 1st Department of Anesthesiology, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Panteleimon Vassiliu
- 4th Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Vassilios Smyrniotis
- 4th Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Nikolaos Arkadopoulos
- 4th Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| |
Collapse
|
8
|
Alam AS, Yashi K, Elkhawaga M. Management of Renal Cell Carcinoma With Intra-atrial Tumour Thrombus: A Case Report. Cureus 2023; 15:e35380. [PMID: 36987480 PMCID: PMC10039968 DOI: 10.7759/cureus.35380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2023] [Indexed: 02/25/2023] Open
Abstract
Renal cell cancer (RCC) is at times associated with intravascular tumour thrombus (TT), which in rare cases can extend to the right atrium. The management of RCC with intravascular tumour thrombus is complex and requires a multidisciplinary approach involving urologists, vascular surgeons, and cardiologists. The pre-operative workup is extensive and includes imaging studies to determine the extent of the tumour thrombus and assess the patient's overall health status. Here, we present a case report detailing the operative and perioperative management of a patient presenting with renal cell cancer and intravascular TT.
Collapse
|
9
|
Kacani A, Goga M, Kuci S, Aliu A, Ibrahimi A, Gjergo P, Janko A, Dogjani A. Invading of Renal Cell Carcinoma in Inferior Vena Cava and Right Atrium with a Huge Metastatic Thrombus. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.8552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Renal cell carcinoma (RCC) with cavoatrial involvement represents a major surgical challenge. Several surgical techniques for the treatment of these tumors have been proposed, but due to a small number of patients and limited follow-up, substantial controversy about the best operative management still exists.
CASE REPORT: A 54-year-old woman, with no previous comorbidities, comes to the emergency room with low back pain, weight loss, and edema of the lower legs that computed tomography revealed a massive infiltrative expansive formation in the abdomen that affected practically the entire right kidney, measuring 8.2 cm × 7.6 cm that invaded the collecting system and was in close contact with the right hepatic lobe and the head of the pancreas. During the intervention, infiltration of the renal vein on this side is found, and the inferior vena cava (IVC) that extends in its intrahepatic part, up to the junction of the suprahepatic veins, with almost complete closure of the lumen accompanied by the presence of retroperitoneal lymph nodes, with size up to 10 mm.
CONCLUSION: Advanced extension of RCC can occur with no apparent symptoms and be detected incidentally. In rare circumstances, atypical presentation of RCC should be considered in a patient presenting with the right atrial mass detected by echocardiography. RCC with IVC and right atrium extension is a complex surgical challenge, but excellent results can be obtained with proper patient selection, meticulous surgical techniques, and close perioperative patient care.
Collapse
|
10
|
Liu Z, Li Y, Zhang Y, Zhao X, Ge L, Tang S, Hong P, Zhang S, Tian X, Wang S, Liu C, Zhang H, Ma L. PUTH Grading System for Urinary Tumor With Supradiaphragmatic Tumor Thrombus: Different Surgical Techniques for Different Tumor Characteristics. Front Oncol 2022; 11:735145. [PMID: 35070959 PMCID: PMC8770268 DOI: 10.3389/fonc.2021.735145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 12/09/2021] [Indexed: 01/11/2023] Open
Abstract
Purpose To explore the different treatment strategies for urinary tumors with Mayo IV thrombus. Materials and Methods We retrospectively analyzed the patients with Mayo IV thrombus in Peking University Third Hospital from January 2014 to April 2021. We used the Peking University Third Hospital (PUTH) grading system to classify urinary tumors with supradiaphragmatic thrombus. PUTH-A referred to the filled thrombus whose tip just reached above the diaphragm, or the thrombus entering the right atrium (< 2cm). PUTH-B referred to the filled thrombus entering the right atrium (> 2cm), or the thrombus invading the wall of the inferior pericardial vena cava. Detailed techniques were described for various scenarios. Clinicopathological data and perioperative outcomes were reported. Group difference statistical analysis was performed. Results A total of 26 cases of urinary tumors with supradiaphragmatic IVC thrombus (Mayo grade IV) underwent treatment were enrolled in this study. 19 patients in the PUTH-A group received the open approach without sternotomy and cardiopulmonary bypass. Seven patients in the PUTH-B group received open thoracotomy assisted by cardiopulmonary bypass. No intraoperative death occurred. After 56 months of follow-up, 46.2% (12 of 26) patients died of all causes. Estimated 1-year, 2-year, and 3-year overall survival were 72.0% (95% CI, 54.4%-89.6%), 58.2% (95% CI, 38.0%-78.4%), and 52.4% (95% CI, 31.2%-73.6%), respectively. Conclusions We introduced the PUTH grading system for the characteristics of urinary tumors with supradiaphragmatic tumor thrombus, and selected different surgical techniques according to different classifications. This grading system was relatively feasible and effective.
Collapse
Affiliation(s)
- Zhuo Liu
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Yuxuan Li
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Yu Zhang
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Xun Zhao
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Liyuan Ge
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Shiying Tang
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Peng Hong
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Shudong Zhang
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Xiaojun Tian
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Shumin Wang
- Department of Ultrasound, Peking University Third Hospital, Beijing, China
| | - Cheng Liu
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Hongxian Zhang
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Lulin Ma
- Department of Urology, Peking University Third Hospital, Beijing, China
| |
Collapse
|
11
|
Prevalence and risk factors of myocardial and acute kidney injury following radical nephrectomy with vena cava thrombectomy: a retrospective cohort study. BMC Anesthesiol 2021; 21:243. [PMID: 34641781 PMCID: PMC8513361 DOI: 10.1186/s12871-021-01462-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 09/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Radical nephrectomy with thrombectomy is the mainstay treatment for patients with renal cell carcinoma with vena cava thrombus. But the procedure is full of challenge, with high incidence of major complications and mortality. Herein, we investigated the incidence and predictors of myocardial injury and acute kidney injury (AKI) in patients following radical nephrectomy with inferior vena cava thrombectomy. METHODS Patients who underwent nephrectomy with thrombectomy between January 2012 and June 2020 were retrospectively reviewed. Myocardial injury was diagnosed when peak cardiac troponin I was higher than 0.03 ng/ml. AKI was diagnosed according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Multivariable logistic regression models were used to identify predictors of myocardial injury or AKI after surgery. RESULTS A total of 143 patients were included in the final analysis. Myocardial injury and AKI occurred in 37.8 and 42.7% of patients after this surgery, respectively. Male sex (odds ratio [OR] 0.27, 95% confidence interval [CI] 0.10-0.71; P = 0.008) was associated with a lower risk, whereas high level Mayo classification (compared with Mayo level I + II, Mayo level III + IV: OR 4.21, 95% CI 1.42-12.4; P = 0.009), acute normovolemic hemodilution before surgery (OR 2.66, 95% CI 1.10-6.41; P = 0.029), long duration of intraoperative tachycardia (per 20 min: OR 1.49, 95% CI 1.10-2.16; P = 0.036), and long duration of surgery (per 1 h, OR 1.48, 95% CI 1.03-2.16, P = 0.009) were associated with a higher risk of myocardial injury. High body mass index (OR 1.18, 95% CI 1.06-1.33; P = 0.004) and long duration of intraoperative hypotension (per 20 min: OR 1.30, 95% CI 1.04-1.64; P = 0.024) were associated with a higher risk, whereas selective renal artery embolism before surgery (OR 0.20, 95% CI 0.07-0.59, P = 0.004) was associated with a lower risk of AKI. CONCLUSION Myocardial injury and AKI were common in patients recovering from radical nephrectomy with inferior vena cava thrombectomy. Whether interventions targeting the above modifiable factors can improve outcomes require further studies.
Collapse
|
12
|
Tian X, Hong P, Tang S, Liu Z, Yang F, Zhang S, Wang G, He H, Ma L. Urothelial carcinoma of the renal pelvis with renal vein and inferior vena cava tumor thrombus: case series and literature review. Transl Androl Urol 2021; 10:2879-2888. [PMID: 34430390 PMCID: PMC8350241 DOI: 10.21037/tau-21-253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/24/2021] [Indexed: 11/06/2022] Open
Abstract
Background Urothelial carcinoma (UC) of the renal pelvis with renal vein and inferior vena cava (IVC) tumor thrombus (TT) was extremely rare. We aimed to explore the clinical and pathological characteristics, diagnosis and treatment of renal pelvis UC with renal vein and IVC TT. Methods From March 2016 to January 2019, eight patients of renal pelvis UC with renal vein and IVC TT were diagnosed and underwent operation in our hospital. Clinical features, operative details, pathological outcomes, and prognosis data were reviewed and collected. Results There were five males and three females (52-84 years old). Their main symptoms were flank pain and hematuria. According to the Mayo classification, the TT was 4 level-0 (1 left and 3 right), 2 level-I (right), and 2 level-II (right). Half the patients underwent retroperitoneal laparoscopic radical nephroureterectomy with thrombectomy, and the other underwent open procedures. The mean operative time was 298.9 minutes. Pathological outcomes revealed high-grade UC, with positive lymph nodes in 6 cases. Four patients received adjuvant chemotherapy, one target therapy and one adjuvant chemotherapy combined with immunotherapy after surgery. The mean follow-up time was 11.1 months. Three patients are alive, and two of them developed recurrence and lung metastasis. Conclusions Preoperative differentiation between renal pelvis UC and renal cell carcinoma with venous TT was very important for the management. Radical nephroureterectomy with thrombectomy might be a reasonable method for renal pelvis UC with venous TT. The prognosis of such cases was poor even if adjuvant therapy was scheduled.
Collapse
Affiliation(s)
- Xiaojun Tian
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Peng Hong
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Shiying Tang
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Zhuo Liu
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Feilong Yang
- Department of Urology, Peking University Third Hospital, Beijing, China.,Department of Urology, General Hospital of Ningxia Medical University, Ningxia, China
| | - Shudong Zhang
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Guoliang Wang
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Huiying He
- Department of Pathology, Peking University Third Hospital, Beijing, China
| | - Lulin Ma
- Department of Urology, Peking University Third Hospital, Beijing, China
| |
Collapse
|
13
|
Fontana F, Deho F, Piacentino F, Curti M, Capogrosso P, Coppola A, Cocozza E, Tozzi M, Venturini M. Management of Renal Cell Carcinoma With Extensive Caval Thrombosis Utilizing a Temporary Atrial Caval Filter Through a Combined Endovascular and Open Surgical Technique. Vasc Endovascular Surg 2021; 55:505-509. [PMID: 33535913 DOI: 10.1177/1538574421989862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The most common cause of neoplastic thrombotic infiltration of the inferior vena cava is renal cell carcinoma (RCC). In the present report we described a case of a patient with massive RCC and extensive neoplastic thrombosis reaching the retrohepatic tract of the inferior vena cava. After a discussion in a multidisciplinary team meeting we decided to perform a radical nephrectomy with vena cava thrombectomy along with the support of a novel removable vena cava filter in order to avoid thromboembolism during the surgical procedure. Furthermore, a preoperative renal artery embolization with a non-adhesive liquid embolic agent was performed ahead of the surgical procedure in order to reduce the risk of intraoperative bleeding. The surgical procedure performed the day after was based on a hybrid endovascular-surgical approach consisting in nephrectomy, liver derotation, cavotomy with the additional use of a novel temporary caval filter, thus reducing the risk of intraoperative thromboembolic dissemination.
Collapse
Affiliation(s)
- Federico Fontana
- Department of Diagnostic and Interventional Radiology, University of Insubria, Circolo Hospital, Varese, Italy
| | - Federico Deho
- Department of Urology, University of Insubria, Circolo Hospital, Varese, Italy
| | - Filippo Piacentino
- Department of Diagnostic and Interventional Radiology, Circolo Hospital, Varese, Italy
| | - Marco Curti
- Department of Diagnostic and Interventional Radiology, University of Insubria, Circolo Hospital, Varese, Italy
| | | | - Andrea Coppola
- Department of Diagnostic and Interventional Radiology, Circolo Hospital, Varese, Italy
| | - Eugenio Cocozza
- Department of General Surgery, Circolo Hospital, Varese, Italy
| | - Matteo Tozzi
- Department of Vascular Surgery, University of Insubria, Circolo Hospital Varese, Italy
| | - Massimo Venturini
- Department of Diagnostic and Interventional Radiology, University of Insubria, Circolo Hospital, Varese, Italy
| |
Collapse
|
14
|
Kalapara AA, Frydenberg M. The role of open radical nephrectomy in contemporary management of renal cell carcinoma. Transl Androl Urol 2020; 9:3123-3139. [PMID: 33457285 PMCID: PMC7807349 DOI: 10.21037/tau-19-327] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Radical nephrectomy (RN) remains a cornerstone of the management of localised renal cell carcinoma (RCC). RN involves the en bloc removal of the kidney along with perinephric fat enclosed within Gerota's fascia. Key principles of open RN include appropriate incision for adequate exposure, dissection and visualisation of the renal hilum, and early ligation of the renal artery and subsequently renal vein. Regional lymph node dissection (LND) facilitates local staging but its therapeutic role remains controversial. LND is recommended in patients with high risk clinically localised disease, but its benefit in low risk node-negative and clinically node-positive patients is unclear. Concomitant adrenalectomy should be reserved for patients with large tumours with radiographic evidence of adrenal involvement. Despite a recent downtrend in utilisation of open RN due to nephron-sparing and minimally invasive alternatives, there remains a vital role for open RN in the management of RCC in three domains. Firstly, open RN is important to the management of large, complex tumours which would be at high risk of complications if treated with partial nephrectomy (PN). Secondly, open RN plays a crucial role in cytoreductive nephrectomy (CN) for metastatic RCC, in which the laparoscopic approach achieves similar results but is associated with a high reoperation rate. Finally, open RN is the current standard of care in the management of inferior vena caval (IVC) tumour thrombus. Management of tumour thrombus requires a multidisciplinary approach and varies with cranial extent of thrombus. Higher level thrombus may require hepatic mobilisation and circulatory support, whilst the presence of bland thrombus may warrant post-operative filter insertion or ligation of the IVC.
Collapse
Affiliation(s)
| | - Mark Frydenberg
- Department of Surgery, Monash University, Melbourne, Australia.,Cabrini Institute, Cabrini Health, Melbourne, Australia
| |
Collapse
|
15
|
Surgical Outcome of Renal Cell Carcinoma with Tumor Thrombus Extension into Inferior Vena Cava and Right Atrium (Beating Heart Removal of Level 4 Thrombus): A Challenging Scenario. J Kidney Cancer VHL 2020; 7:11-17. [PMID: 32953422 PMCID: PMC7479807 DOI: 10.15586/jkcvhl.2020.149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 07/06/2020] [Indexed: 11/18/2022] Open
Abstract
Aim “To evaluate oncological and surgical outcomes of different levels of tumor thrombus and tumor characteristics secondary to renal cell carcinoma (RCC)”. Materials and Methods Retrospective review from 2013 to 2020 of 34 patients who underwent radical nephrectomy with thrombectomy for RCC with tumor thrombus extending into the inferior vena cava (IVC) and right atrium (RA) at our center. Level I and most level II tumors were removed using straight forward occluding maneuvers with control of the contralateral renal vein. None of the patients had level III tumor extensions in our study group. For level IV thrombus, a beating heart surgery using a simplified cardiopulmonary bypass (CPB) technique was used for retrieval of thrombus from the right atrium. Results “ Of the 34 patients with thrombus”, 19 patients had level I, 12 patients had level II, none had level III, and three patients had level IV thrombus. Two patients required simplified CPB. Another patient with level IV thrombus CPB, was not attempted in view of refractory hypotension intraoperatively. Pathological evaluation showed clear-cell carcinoma in 67.64%, papillary carcinoma in 17.64%, chromophobe in 5.8%, and squamous cell carcinoma in 8.8% of cases. Left side thrombectomy was difficult surgically, whereas right side thrombectomy did not have any survival advantage. Mean blood loss during the procedure was 325 mL, ranging from 200 to 1000 mL, and mean operative time was 185 min, ranging from 215 to 345 min. The immediate postoperative mortality was 2.9%. Level I thrombus had better survival compared to level II thrombus. Conclusion Radical nephrectomy with tumor thrombectomy remains the mainstay of treatment in RCC with inferior venacaval extension. The surgical approach and outcome depends on primary tumor size, location, level of thrombus, local invasion of IVC, any hepato-renal dysfunction or any associated comorbidities. The higher the level of thrombus, the greater is the need for prior optimization and the adoption of a multidisciplinary approach for a successful surgical outcome.
Collapse
|
16
|
Removal of the Tumor Thrombus from the Right Atrium without Extracorporeal Circulation: Emphasis on the Displacement of the Tumor Apex. Adv Urol 2020; 2020:6063018. [PMID: 32612649 PMCID: PMC7320280 DOI: 10.1155/2020/6063018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 02/21/2020] [Accepted: 02/27/2020] [Indexed: 12/02/2022] Open
Abstract
Objectives To assess the outcomes of cavoatrial tumor thrombus removal using the liver transplantation technique for thrombectomy, a retrospective study was conducted. Materials and Methods Five patients with atrial tumor thrombi who underwent piggy-back mobilization of the liver, surgical access to the right atrium from the abdominal cavity, and external manual repositioning of the thrombus apex below the diaphragm (milking maneuver) were included into the study. Extracorporeal circulation was used in none of the cases. The average length of the atrial component of the tumor was 20.0 ± 11.7 mm (10 to 35 mm), and the width was 14.8 ± 8.5 mm (10 to 30 mm). In this work, the features of patients and surgical interventions as well as perioperative complications and mortality were analyzed. Results External manual repositioning of the tumor thrombus apex below the diaphragm was successfully performed in all patients. Tumor thrombi with the length of the atrial part up to 1.5 cm were removed through the extrapericardial approach. For evacuation of the thrombi with the large atrial part (3.0 cm or more), a transpericardial surgical approach was required. Specific complications associated with the access to the right atrium from the abdominal cavity (paresis of the right phrenic nerve, pneumothorax, and mediastinitis) were not detected in any case. The average clamping time of the supradiaphragmatic inferior vena cava (IVC) was 6.3 ± 4.6 min. The volume of intraoperative blood loss varied from 2500 to 5600 ml (an average of 3675 ± 1398.5 ml). Conclusion Our work represents the initial experience in the liver transplantation technique for thrombectomy in distinct and well-selected patients with atrial tumor thrombi. The effectiveness of this approach needs further study. The video presentation of our research took place in March 2019 at the 34th Annual EAU Congress in Barcelona.
Collapse
|
17
|
Erector spinae plane and intra thecal opioid (ESPITO) analgesia in radical nephrectomy utilising a rooftop incision: novel alternative to thoracic epidural analgesia and systemic morphine: a case series. Scand J Pain 2020; 20:847-851. [DOI: 10.1515/sjpain-2020-0034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/05/2020] [Indexed: 11/15/2022]
Abstract
Abstract
Background
Open radical nephrectomy and inferior vena cava exploration through a roof top incision involves significant peri-operative morbidity including severe postoperative pain. Although thoracic epidural analgesia provides excellent pain relief, recent trends suggest search for effective alternatives. Systemic morphine is often used as an alternative analgesic technique. However, it does not provide dynamic analgesia and can often impede recovery in patients undergoing major surgery on the abdomen. The authors present the first report of a novel analgesic regimen in this cohort with good outcomes.
Methods
Five patients undergoing open radical nephrectomy and inferior vena cava exploration received erector spinae plane infusion and intra thecal opioid analgesia at a tertiary care university teaching hospital. Outcomes included dynamic analgesia, length of hospital stay and complications
Results
Five adult patients undergoing major upper abdominal surgery, who refused thoracic epidural analgesia, received erector spinae plane infusion and intrathecal opioid analgesia. Patients reported effective dynamic analgesia, minimal use of rescue analgesia, early ambulation and enhanced recovery.
Conclusion
The novel regimen that avoids both epidural analgesia and systemic morphine can be an option in enabling enhanced recovery in this cohort.
Collapse
|
18
|
Shen D, Du S, Huang Q, Gao Y, Fan Y, Gu L, Liu K, Peng C, Xuan Y, Li P, Li H, Ma X, Zhang X, Wang B. A modified sequential vascular control strategy in robot-assisted level III-IV inferior vena cava thrombectomy: initial series mimicking the open 'milking' technique principle. BJU Int 2020; 126:447-456. [PMID: 32330369 DOI: 10.1111/bju.15094] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To introduce a modified sequential vascular control strategy, mimicking the open 'milking' technique principle, for the early release of the first porta hepatis (FPH) and to stop cardiopulmonary bypass (CPB) in level III-IV robot-assisted inferior vena cava (IVC) thrombectomy (RA-IVCTE). PATIENTS AND METHODS From November 2014 to June 2019, 27 patients with a level III-IV IVC tumour thrombus (IVCTT) underwent RA-IVCTE in our department. The modified sequential control strategy was used in 12 cases. Previously, we released the FPH after the thrombus was resected and the IVC was closed completely, and CPB was stopped at the end of surgery (15 patients). Presently, using our modified strategy, we place another tourniquet inferior to the second porta hepatis (SPH) once the proximal thrombus is removed from the IVC below the SPH. Then, we suture the right atrium and perform early release of the FPH, and stop CPB. Finally, tumour thrombectomy, vascular reconstruction, and radical nephrectomy are performed. RESULTS Compared with the previous strategy, the modified steps resulted in a shorter median FPH clamping (19 vs 47 min, P < 0.001) and CPB times (60 vs 87 min, P < 0.05); a lower rate of Grade II-IV perioperative complications (25% vs 60%, P < 0.05); and better postoperative hepatorenal and coagulation function, including better median serum alanine aminotransferase (172.7 vs 465.4 U/L, P < 0.001), aspartate aminotransferase (282.4 vs 759.8 U/L, P < 0.001), creatinine (113.4 vs 295 μmol/L, P < 0.01), blood urea nitrogen (7.3 vs 16.7 mmol/L, P < 0.01), and D-dimer (5.9 vs 20 mg/L, P < 0.001) levels. CONCLUSION With the early release of the FPH and stopping CPB, the modified sequential vascular control strategy in level III-IV RA-IVCTE reduced the perioperative risk for selected patients and improved the feasibility and safety of the surgery. We would recommend this approach to other centres that plan to develop robotic surgery for renal cell carcinoma with level III-IV IVCTT in the future.
Collapse
Affiliation(s)
- Donglai Shen
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - Songliang Du
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China.,School of Medicine, Nankai University, Tianjin, China
| | - Qingbo Huang
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - Yu Gao
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - Yang Fan
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - Liangyou Gu
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - Kan Liu
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - Cheng Peng
- Department of Urology, The Seventh Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yundong Xuan
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - Pin Li
- Department of Pediatric Urology, Bayi Children's Hospital Affiliated to The Seventh Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Hongzhao Li
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - Xin Ma
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - Xu Zhang
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - Baojun Wang
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| |
Collapse
|
19
|
Kishore TA, Pathrose G, Raveendran V, Ganpule A, Gautam G, Laddha A, Pooleri GK, Desai M. Robot-assisted laparoscopic radical nephrectomy and inferior vena cava thrombectomy: A multicentre Indian experience. Arab J Urol 2020; 18:124-128. [PMID: 33029418 PMCID: PMC7473165 DOI: 10.1080/2090598x.2020.1738104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective To assess feasibility of robot-assisted laparoscopic radical nephrectomy (RALRN) and inferior vena cava thrombectomy (IVCT) in treating renal tumours with level I–III IVC thrombi and to assess their outcomes. Patients and methods We conducted a retrospective analysis of RALRN-IVCTs, involving four centres across India, from September 2015 to June 2019. We analysed patients who underwent RALRN-IVCT for level I–III thrombi according to the Mayo classification. The total operative duration with console time, length of hospital stay, preoperative and postoperative creatinine, IVC clamp time and intraoperative blood loss were recorded. Results Of the 13 patients that underwent RALRN-IVCT, five had a level I thrombus, seven had level II, and one had a level III thrombus. In all, 11 of the patients had right-sided tumours and the remaining two had left-sided tumours. The mean (SD) age of the patients was 56.5 (12.3) years, the mean (SD) operative time was 329.5 (97.22) min, the mean (SD) console time was 222.5 (70) min, the mean (SD) blood loss was 395 (170) mL, and the mean (SD) IVC clamp time was 19.14 (9.5) min. The mean (SD) length of hospital stay was 7.8 (3.27) days. Of the 13 patients, 12 had clear cell renal cell carcinoma (RCC) and one had papillary RCC. The mean (range) follow-up was 19 (4–50) months. One patient had upfront metastasis and two patients developed metastasis, while 10 patients remained disease-free during the follow-up. Conclusion With appropriate patient selection, surgical planning and robotic experience, completely intracorporeal robotic level I–III IVCT is feasible and can be performed efficiently. Larger experiences, with longer follow-ups and comparisons with open surgery are needed to confirm these initial outcomes. Abbreviations ECOG: Eastern Cooperative Oncology Group; IVC: inferior vena cava; IVCT: inferior vena cava thrombectomy; (RAL)RN: (robot-assisted laparoscopic) radical nephrectomy
Collapse
Affiliation(s)
| | | | | | - Arvind Ganpule
- Department of Urology, Muljibhai Patel Urology Hospital, Nadiad, India
| | - Gagan Gautam
- Department of Urology, Max Hospital Saket, New Delhi, India
| | - Abhishek Laddha
- Department of Urology, Amrita Institute of Medical Sciences, Kochi, India
| | | | - Mahesh Desai
- Department of Urology, Muljibhai Patel Urology Hospital, Nadiad, India
| |
Collapse
|
20
|
Ralla B, Adams L, Maxeiner A, Mang J, Krimphove M, Dushe S, Makowski M, Miller K, Fuller F, Busch J. Perioperative and oncologic outcome in patients treated for renal cell carcinoma with an extended inferior vena cava tumour thrombus level II-IV. Aktuelle Urol 2019; 53:431-438. [PMID: 31163462 DOI: 10.1055/a-0919-4043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE Surgical treatment of patients with renal cell carcinoma (RCC) and an extended tumour thrombus (TT) in the inferior vena cava (IVC) is challenging and often requires a multidisciplinary approach. The aim of this study was to analyse results in the real-world management of RCC patients with an extended IVC TT (level II-IV according to the Mayo classification of macroscopic venous invasion in RCC) in terms of pre-, peri- and postoperative outcome, complications and oncologic outcome. METHODS We investigated 61 patients with evidence of RCC and an extended TT in the IVC undergoing radical nephrectomy and tumour thrombectomy at our tertiary referral centre. Patients and operative characteristics were recorded and complications were analysed using the Clavien-Dindo classification. Follow-up data were retrieved by contacting the treating outpatient urologists, general practitioners and patients. RESULTS The TT level was II in 36, III in 8 and IV in 17 patients. Complications grade IIIb and higher according to the Clavien-Dindo classification occurred in n = 3 (8.4 %), n = 2 (25.0 %) and n = 5 (29.5 %) patients with level II, III and IV TT, respectively. The overall survival of patients with TT level II, III and IV at 24 months (60 months) was 66.9 % (41.6 %), 83.3 % (83.3 %) and 64.1 % (51.3 %). Presence of primary metastatic disease was the only significant independent predictor for OS. CONCLUSIONS: Radical nephrectomy with tumour thrombectomy appears to be a feasible and effective treatment option in the management of patients with RCC and an extended IVC TT.
Collapse
Affiliation(s)
| | - Lisa Adams
- Charité – Universitätsmedizin Berlin, Radiologie, Berlin
| | | | - Josef Mang
- Charité – Universitätsmedizin Berlin, Urologie, Berlin
| | | | - Simon Dushe
- Charité – Universitätsmedizin Berlin, Herzchirurgie, Berlin
| | | | - Kurt Miller
- Charité – Universitätsmedizin Berlin, Urologie, Berlin
| | | | - Jonas Busch
- Charité – Universitätsmedizin Berlin, Urologie, Berlin
| |
Collapse
|
21
|
Ho D, Samarakoon L, Kai TY, Kum S, Lim D. Novel Use of Capturex Device and Reliant Balloon for Inferior Vena Cava Tumor Thrombectomy: A Case Report and Review of Literature. Vasc Endovascular Surg 2019; 53:351-354. [DOI: 10.1177/1538574419831834] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: Most common tumor extending into the inferior vena cava (IVC) are renal carcinomas, such extension have been noted in nearly one-fifth of tumors. Tumor thrombectomy improves the prognosis of patients including those with extension of tumor as far as supra hepatic vena cava. In contrast, if radical nephrectomy is performed as the sole procedure, the prognosis is reduced drastically. Case Presentation: We present a case of a 42-year-old male who presented to us with renal cell carcinoma with tumor thrombus extending to IVC. We performed a hybrid endovascular and open procedure using novel surgical techniques to obtain proximal vena caval control and to remove the tumor thrombus—Capturex filter which was placed endovascularly 1 cm above the thrombus via the right internal jugular vein and reliant balloon was placed above the capturex below the hepatic veins. At this position, when the reliant balloon was inflated, it acted as a retro hepatic IVC control. Following vascular control, we proceeded to tumor thrombectomy and radical nephrectomy using transperitoneal approach. Patient made an uneventful recovery and was subsequently referred for medical oncology service for consideration of targeted therapy. Detailed description of the procedure is followed by the discussion of the literature.
Collapse
Affiliation(s)
- Derek Ho
- Division of vascular surgery, Changi General Hospital, Singapore
| | | | - Tan Yih Kai
- Division of vascular surgery, Changi General Hospital, Singapore
| | - Steven Kum
- Division of vascular surgery, Changi General Hospital, Singapore
| | - Darryl Lim
- Division of vascular surgery, Changi General Hospital, Singapore
| |
Collapse
|
22
|
Radical nephrectomy and intracaval thrombectomy for advanced renal cancer with extensive inferior vena cava involvement utilising cardiopulmonary bypass and hypothermic circulatory arrest: Is it worthwhile? Arab J Urol 2018; 16:378-385. [PMID: 30534435 PMCID: PMC6277273 DOI: 10.1016/j.aju.2018.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 05/14/2018] [Accepted: 06/23/2018] [Indexed: 11/21/2022] Open
Abstract
Objective To report our long-term outcomes of surgical treatment of renal tumours with inferior vena cava (IVC) tumour thrombus above the hepatic veins, utilising cardiopulmonary bypass (CBP) and hypothermic circulatory arrest (HCA), as surgical resection remains the only effective treatment for renal cancers with extensive IVC tumour thrombus. Patients and methods We retrospectively reviewed 48 consecutive patients (median age 58 years) who underwent surgical treatment for non-metastatic renal cancer with IVC tumour thrombus extending above the hepatic veins. Perioperative, histological, disease-free (DFS) and overall survival (OS) data were recorded. Results Tumour thrombus was level III in 23 patients and level IV in 25 patients. The median (range) CBP and HCA times were 162 (120-300) min and 35 (9-64) min, respectively. Three patients underwent synchronous cardiac surgical procedures. There were three (6.3%) perioperative deaths. American Society of Anesthesiologists grade and perioperative blood transfusion requirement were significant factors associated with perioperative death (P < 0.05). Despite extensive preoperative screening for metastases the median (range) DFS was only 10.2 (1.2-224.4) months. The median (range) OS was 23 (0-224.4) months. Cox regression analysis revealed that perinephric fat invasion conferred a significantly poorer DFS (P = 0.005). Conclusions Radical surgery for patients with extensive IVC tumour thrombus has acceptable operative morbidity and mortality. It provides symptom palliation and the possibility of long-term survival. Improvements in preoperative detection of occult metastasis may improve case selection and newer adjuvant therapies may improve survival in this high-risk group.
Collapse
|
23
|
Domínguez-Massa C, Serrano-Martínez F, Blanco-Herrera ÓR, Berbel-Bonillo A, Hornero-Sos F, Montero-Argudo JA. Treatment of Hepatic Embryonal Undifferentiated Sarcoma With Cardiothoracic Involvement. World J Pediatr Congenit Heart Surg 2018; 11:NP199-NP202. [PMID: 30319025 DOI: 10.1177/2150135118775411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Thorough study is required to decide the appropriate management of hepatic tumors in children. We present a case report of a hepatic embryonal undifferentiated sarcoma with unfavorable prognosis in a nine-year-old girl. After undergoing a detailed cancer characteristics and extension study, a two-stage surgery approach was decided. The hepatic tumor resection was the first procedure to be performed. One week later, under cardiopulmonary bypass, deep hypothermia, and circulatory arrest, thrombectomy of the inferior vena cava and right atrium was accomplished, plus thromboendarterectomy of the right pulmonary artery. During a four-year follow-up, the patient continues to be disease-free.
Collapse
Affiliation(s)
- Carlos Domínguez-Massa
- Department of Cardiovascular Surgery, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Félix Serrano-Martínez
- Department of Cardiovascular Surgery, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Óscar R Blanco-Herrera
- Department of Cardiovascular Surgery, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Alberto Berbel-Bonillo
- Department of Cardiovascular Surgery, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Fernando Hornero-Sos
- Department of Cardiovascular Surgery, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - José A Montero-Argudo
- Department of Cardiovascular Surgery, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| |
Collapse
|
24
|
Zhu P, Du S, Chen S, Zheng S, Hu Y, Liu L, Zheng S. The role of deep hypothermic circulatory arrest in surgery for renal or adrenal tumor with vena cava thrombus: a single-institution experience. J Cardiothorac Surg 2018; 13:85. [PMID: 29976214 PMCID: PMC6034231 DOI: 10.1186/s13019-018-0772-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 06/22/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The aim of this study was to review our experience in managing renal or adrenal tumors with level III or IV inferior vena cava thrombus by using deep hypothermic circulatory arrest (DHCA), and to evaluate survival outcomes. METHODS Between September 2004 and March 2016, we treated 33 patients with renal or adrenal malignancy tumor and thrombus extending into the inferior vena cava. Patients were identified according to radiographic records and operative findings. Clinicopathological and operative characteristics were recorded, and comparisons of clinical and operative characteristics through DHCA were performed. A Cox regression model was used to determine predictors of perioperative mortality. RESULTS Twenty-one out of 33 patients with level III (n = 15), level IV (n = 5), or level II (n = 1) renal or adrenal tumors were treated surgically through cardiopulmonary bypass (CPB) with DHCA, and 12 patients with level II or III tumors were treated surgically through normothermic CPB. Three complications were observed, and one death occurred perioperatively, owing to multiple organ failure. The overall perioperative mortality was 4.7%. There were significant differences in the clinicopathological characteristics, operative duration, estimated blood loss, transfusions and hospital stay depending on use of DHCA. Multivariate analysis indicated that the operative duration (OR, 3.78; P < 0.001), estimated blood loss (OR, 1.08; P = 0.02), and transfusion (OR, 2.13; P = 0.038) during/after surgery were positively associated with higher mortality and morbidity. DHCA failed to reach statistical significance (P = 0.378). CONCLUSIONS Use of CPB and DHCA to treat renal or adrenal tumors allows for complete tumor resection, especially at the T4 stage. Although it can cause physical damage, this technique does not increase operative risk and is a relatively safe approach.
Collapse
Affiliation(s)
- Peng Zhu
- Department of Cardiovascular Surgery, NanFang hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, People's Republic of China
| | - Songlin Du
- Department of Cardiovascular Surgery, NanFang hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, People's Republic of China
| | - Shijun Chen
- Department of Urinary Surgery, NanFang hospital, Southern Medical University, GuangZhou, People's Republic of China
| | - Shaobin Zheng
- Department of Urinary Surgery, NanFang hospital, Southern Medical University, GuangZhou, People's Republic of China
| | - Yu Hu
- Department of Cardiovascular Surgery, NanFang hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, People's Republic of China
| | - Li Liu
- Department of Cardiovascular Surgery, NanFang hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, People's Republic of China
| | - Shaoyi Zheng
- Department of Cardiovascular Surgery, NanFang hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, People's Republic of China.
| |
Collapse
|
25
|
Dellaportas D, Arkadopoulos N, Tzanoglou I, Bairamidis E, Gemenetzis G, Xanthakos P, Nastos C, Kostopanagiotou G, Vassiliou I, Smyrniotis V. Technical Intraoperative Maneuvers for the Management of Inferior Vena Cava Thrombus in Renal Cell Carcinoma. Front Surg 2017; 4:48. [PMID: 28932737 PMCID: PMC5592235 DOI: 10.3389/fsurg.2017.00048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 08/23/2017] [Indexed: 12/05/2022] Open
Abstract
Introduction Renal vein or inferior vena cava (IVC) invasion by neoplastic thrombus in patients with renal cell carcinoma (RCC) is not an obstacle for radical oncological treatment. The aim of this study is to present our technical maneuvers for complete removal of the intracaval thrombus without compromising hemodymanic stability of the patient. Materials and methods Between 2000 and 2014, 15 RCC patients with IVC involvement of levels I–III were treated with curative intent and were prospectively studied. The operative technique varied according to thrombus extent. For type I, extraction of the thrombus is facilitated by a 2–3 cm longitudinal incision on the IVC that begins at the level of the renal vein and extends cranially, encompassing a vessel wall rim of the orifice of the resected renal vein. For type II cases, the IVC is clamped above the neoplastic thrombus, and for type III, the IVC clamping is combined with hepatic blood flow control with “Pringle maneuver.” For type IV, the IVC is clamped above the diaphragm, or if the thrombus extends into the right atrium cardiothoracic input is appropriate. Results The main operative steps include preparation and control of the renal vessels and the IVC. Occasionally, for type III tumor thrombi, the patient becomes hemodynamically unstable when IVC is clamped suprahepatically. In such a case, a novel operative maneuver of milking the thrombus below the orifice of the hepatic veins, and subsequently the IVC clamp also beneath the hepatic veins, allowing release of the “Pringle maneuver” is performed. This operative step restores hepatic blood flow and hemodynamic stability and is based on the floating nature of the thrombus into the IVC. Mean operative time was 120 min (range from 90 to 180 min), and average liver and renal warm ischemia time was 20 min (range from 15 to 35 min). Postoperative overall hospital stay ranged from 7 to 13 days. Conclusion The technical solutions employed in the current study allow successful removal of neoplastic thrombi from the IVC in most cases, associated with minimal perioperative complication rate even for patients who due to multiple comorbidities would be considered otherwise inoperable.
Collapse
Affiliation(s)
- Dionysios Dellaportas
- 2nd Department of Surgery, Aretaieion University Hospital, University of Athens School of Medicine, Athens, Greece
| | - Nikolaos Arkadopoulos
- 4th Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
| | - Ioannis Tzanoglou
- 4th Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
| | - Evgenios Bairamidis
- 4th Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
| | - George Gemenetzis
- 4th Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
| | - Pantelis Xanthakos
- 4th Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
| | - Constantinos Nastos
- 2nd Department of Surgery, Aretaieion University Hospital, University of Athens School of Medicine, Athens, Greece
| | - Georgia Kostopanagiotou
- 2nd Department of Anesthesiology, Attikon Hospital, University of Athens School of Medicine, Athens, Greece
| | - Ioannis Vassiliou
- 2nd Department of Surgery, Aretaieion University Hospital, University of Athens School of Medicine, Athens, Greece
| | - Vassilios Smyrniotis
- 4th Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
| |
Collapse
|
26
|
Abstract
Background Renal cell carcinoma accounts for approximately 3% of adult malignancies and over 90% of primary renal tumors. Recurrence rates for patients with locally advanced renal cell carcinoma (LARCC) remain high. Methods The authors review literature regarding prognostic factors, potential biomarkers, surgical strategies, and adjuvant therapy trials for patients with LARCC. Results Molecular tumor markers may improve existing staging systems for predicting prognosis. Surgery is the best initial treatment for most patients with clinically localized renal tumors, although complete surgical resection can be challenging for patients with large tumors, bulky regional lymph node involvement, or inferior vena cava tumor thrombus. Significant recurrence rates for patients with LARCC undergoing nephrectomy indicate the presence of undetected micrometastases at the time of surgery. Adjuvant radiation, chemotherapy, and immunotherapy have been ineffective. Other trials of adjuvant therapy are ongoing. Conclusions Aggressive surgical resection alone for LARCC is not sufficient to prevent disease recurrence in a significant number of patients. Adjuvant therapies are needed to improve cancer-specific survival.
Collapse
Affiliation(s)
- Alejandro Rodriguez
- Genitourinary Oncology Program, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | | |
Collapse
|
27
|
Hofer L, Gasch C, Hatiboglu G, Motsch J, Grüllich C, Duensing S, Hohenfellner M. [Level IV inferior vena cava tumor thrombus : A rare diagnosis in patients with renal cell carcinoma]. Urologe A 2017; 56:868-875. [PMID: 28349189 DOI: 10.1007/s00120-017-0369-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Renal cell carcinoma in combination with a supradiaphragmatic tumor thrombus is a rare tumor entity. Radical surgery including nephrectomy and thrombectomy is still considered standard treatment. The extent of the tumor thrombus should be preoperatively evaluated by MRI and TEE. An interdisciplinary team is important for surgery planning and realization. Despite the known risks of an operation, a longer overall survival is achieved.
Collapse
Affiliation(s)
- L Hofer
- Urologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland.
| | - C Gasch
- Urologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - G Hatiboglu
- Urologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - J Motsch
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C Grüllich
- Klinik für Medizinische Onkologie, Nationales Zentrum für Tumorerkrankungen, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - S Duensing
- Urologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - M Hohenfellner
- Urologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| |
Collapse
|
28
|
Spelde A, Steinberg T, Patel PA, Garcia H, Kukafka JD, MacKay E, Gutsche JT, Frogel J, Fabbro M, Raiten JM, Augoustides JGT. Successful Team-Based Management of Renal Cell Carcinoma With Caval Extension of Tumor Thrombus Above the Diaphragm. J Cardiothorac Vasc Anesth 2017; 31:1883-1893. [PMID: 28502456 DOI: 10.1053/j.jvca.2017.02.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Indexed: 12/24/2022]
Affiliation(s)
- Audrey Spelde
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Toby Steinberg
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Prakash A Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Harry Garcia
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jeremy D Kukafka
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Emily MacKay
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jacob T Gutsche
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jonathan Frogel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michael Fabbro
- Cardiothoracic Anesthesiology, Department of Anesthesiology, Perioperative Medicine and Pain Management, Miller School of Medicine, University of Miami, Miami, FL
| | - Jessie M Raiten
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G T Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| |
Collapse
|
29
|
Management of IVC Thrombus-Surgical Strategies and Outcomes. Indian J Surg Oncol 2017; 8:156-159. [PMID: 28546711 DOI: 10.1007/s13193-016-0583-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 08/15/2016] [Indexed: 10/20/2022] Open
Abstract
Renal cell carcinoma is the most lethal among all urological cancers. The lethality increases with advancing stages of the disease. Renal tumors show a peculiar propensity to invade the venous system. Such invasion not only worsens the disease prognosis but also increases the surgical morbidity making treatment of such tumors challenging. Several small volume series have been published regarding management and outcomes of renal tumors with inferior vena cava (IVC) thrombus which show encouraging results when addressed properly. In this article, we review the outcomes and also describe the step-by-step approach to management of these tumors.
Collapse
|
30
|
Gerstein NS, Zhang R, Davis MS, Ram H. Lessons Still Being Learned: Acute Pulmonary Tumor Embolus During Renal Cell Carcinoma Resection. ACTA ACUST UNITED AC 2017; 7:172-176. [PMID: 27552241 DOI: 10.1213/xaa.0000000000000378] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Renal cell carcinoma (RCC) is the most common primary renal neoplasm and is associated with the intraluminal growth into the venous system with possible extension into the inferior vena cava or even right heart. Intraoperative pulmonary embolism is a complication of resection of RCC, which may be mitigated by the use of the cardiopulmonary bypass with or without deep hypothermic circulatory arrest. We present a case of unexpected pulmonary embolism diagnosed during RCC surgery. The case highlights the central importance of intraoperative transesophageal echocardiography use and the need for proper preoperative planning for the use of cardiopulmonary bypass.
Collapse
Affiliation(s)
- Neal S Gerstein
- From the *Department of Anesthesiology and Critical Care Medicine, University of New Mexico, Albuquerque, New Mexico; and †Division of Urology, Department of Surgery, University of New Mexico, Albuquerque, New Mexico
| | | | | | | |
Collapse
|
31
|
Li M, Shi A, Kong W, Zhang J, Chen Y, Huang J, Huang Y. Transitional cell carcinoma with extension of the renal vein and IVC tumor thrombus: report of three cases and literature review. World J Surg Oncol 2016; 14:309. [PMID: 28031042 PMCID: PMC5192594 DOI: 10.1186/s12957-016-1041-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 11/07/2016] [Indexed: 11/18/2022] Open
Abstract
Background Transitional cell carcinoma (TCC) originating from the renal pelvis with a venous tumor thrombus is a rare entity. However, clinicians should be aware of it because of its high malignancy and poor prognosis. Case presentation Here, we report three cases of pathologically confirmed TCC originating from the renal pelvis with extension into the renal vein or inferior vena cava (IVC). Of these patients, two are males and one is female (58~73 years old). Their main symptom is flank pain; besides, gross hematuria and weight loss is observed in one of the patients. Computed tomography (CT) scan of the first patient revealed multiple space-occupying lesions in the left renal pelvis and left medium and lower ureter with a tumor thrombus in the left renal vein. CT scan of the second patient revealed a right renal mass and extension into the IVC. Abdominal magnetic resonance imaging (MRI) of the third patient showed a soft tissue mass in the region of the left renal sinus, and the signal of the soft tissue was observed in the left renal vein. The preoperative diagnoses of the first and third patient were TCC, while the second patient was renal cell carcinoma (RCC). Two patients with the preoperative diagnosis of TCC underwent laparoscopic radical nephroureterectomy with thrombectomy, and the other patient underwent radical nephrectomy with thrombectomy. The surgeries were successful. Although two of our patients underwent chemotherapy and radiotherapy, they died 2 and 19 months after the surgery, respectively. The other patient refused any adjuvant therapy and died 3 months after the operation. Conclusions Compared to the extension of RCC to the renal vein or IVC, extension of TCC to the renal vein or IVC is rare. TCC with a venous tumor thrombus is often misdiagnosed as RCC. However, a correct preoperative or intraoperative diagnosis is of great importance to decide surgical strategy. Laparoscopic radical nephroureterectomy with thrombectomy may be a safe and feasible operative method in treatment of TCC with a renal vein thrombus. The prognosis of such cases is poor even if chemotherapy and radiotherapy are scheduled.
Collapse
Affiliation(s)
- Mingyang Li
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 1630 Dongfang Road, Shanghai, 200127, China
| | - An Shi
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 1630 Dongfang Road, Shanghai, 200127, China
| | - Wen Kong
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 1630 Dongfang Road, Shanghai, 200127, China
| | - Jin Zhang
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 1630 Dongfang Road, Shanghai, 200127, China
| | - Yonghui Chen
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 1630 Dongfang Road, Shanghai, 200127, China
| | - Jiwei Huang
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 1630 Dongfang Road, Shanghai, 200127, China.
| | - Yiran Huang
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 1630 Dongfang Road, Shanghai, 200127, China.
| |
Collapse
|
32
|
Morita Y, Ayabe K, Nurok M, Young J. Perioperative anesthetic management for renal cell carcinoma with vena caval thrombus extending into the right atrium: case series. J Clin Anesth 2016; 36:39-46. [PMID: 28183571 DOI: 10.1016/j.jclinane.2016.09.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 09/08/2016] [Accepted: 09/28/2016] [Indexed: 11/16/2022]
Abstract
Renal cell carcinoma has a tendency for vascular invasion and may extend into the inferior vena cava and even into the right-sided cardiac chambers. It has been reported that nephrectomy with thrombectomy can provide immediate palliation of symptoms with 5-year survival rates of up to 72% in the absence of nodal or distant metastasis. The location of the tumor dictates the anesthetic and surgical approach, as extension into the heart often necessitates cardiac surgical involvement. Renal cell carcinoma with vena cava tumor thrombus extending into the right cardiac chamber usually requires cardiopulmonary bypass and occasionally deep hypothermic circulatory arrest for surgical resection, and anesthetic approach should be tailored to each individual case. Thorough preoperative evaluation and the commitment of a multidisciplinary surgery team are indispensable.
Collapse
Affiliation(s)
- Yoshihisa Morita
- Department of Anesthesia, Indiana University School of Medicine, Fesler Hall Room 204, 1130 West Michigan St, Indianapolis, IN, 46202-5115.
| | - Kengo Ayabe
- Cardiac Surgery Intensive Care Unit, Department of Cardiothoracic Surgery, Cedars-Sinai Medical Center Heart Institute, 127 San Vicente Blvd Suite 3100, Los Angeles, CA, 90048
| | - Michael Nurok
- Cardiac Surgery Intensive Care Unit, Department of Cardiothoracic Surgery, Cedars-Sinai Medical Center Heart Institute, 127 San Vicente Blvd Suite 3100, Los Angeles, CA, 90048
| | - Jerry Young
- Department of Anesthesia, Indiana University School of Medicine, Fesler Hall Room 204, 1130 West Michigan St, Indianapolis, IN, 46202-5115
| |
Collapse
|
33
|
Simon RM, Kim T, Espiritu P, Kurian T, Sexton WJ, Pow-Sang JM, Sverrisson E, Spiess PE. Effect of utilization of veno-venous bypass vs. cardiopulmonary bypass on complications for high level inferior vena cava tumor thrombectomy and concomitant radical nephrectomy. Int Braz J Urol 2016; 41:911-9. [PMID: 26689516 PMCID: PMC4756967 DOI: 10.1590/s1677-5538.ibju.2014.0371] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 12/18/2014] [Indexed: 11/21/2022] Open
Abstract
Purpose: To determine if patients with renal cell carcinoma (RCC) with levels III and IV tumor thrombi are receive any reduction in complication rate utilizing veno-venous bypass (VVB) over cardiopulmonary bypass (CPB) for high level (III/IV) inferior vena cava (IVC) tumor thrombectomy and concomitant radical nephrectomy. Materials and Methods: From May 1990 to August 2011, we reviewed 21 patients that had been treated for RCC with radical nephrectomy and concomitant IVC thrombectomy employing either CPB (n =16) or VVB (n=5). We retrospectively reviewed our study population for complication rates and perioperative characteristics. Results: Our results are reported using the validated Dindo-Clavien Classification system comparing the VVB and CPB cohorts. No significant difference was noted in minor complication rate (60.0% versus 68.7%, P=1.0), major complication rate (40.0% versus 31.3%, P=1.0), or overall complication rate (60.0% versus 62.5%, P=1.0) comparing VVB versus CPB. We also demonstrated a trend towards decreased time on bypass (P=0.09) in the VVB cohort. Conclusion: The use of VVB over CPB provides no decrease in minor, major, or overall complication rate. The use of VVB however, can be employed on an individualized basis with final decision on vascular bypass selection left to the discretion of the surgeon based on specifics of the individual case.
Collapse
Affiliation(s)
- Ross M Simon
- University of South Florida, Department of Urology, Tampa, FL, USA
| | - Timothy Kim
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Patrick Espiritu
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Tony Kurian
- University of South Florida, Department of Urology, Tampa, FL, USA
| | - Wade J Sexton
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Julio M Pow-Sang
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Einar Sverrisson
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Philippe E Spiess
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA
| |
Collapse
|
34
|
Mastoraki A, Mastoraki S, Tsikala-Vafea M, Papanikolaou IS, Lazaris A, Smyrniotis V, Arkadopoulos N. Prognostic Benefit of Surgical Management of Renal Cell Carcinoma Invading the Inferior Vena Cava. Indian J Surg Oncol 2016; 8:14-18. [PMID: 28127177 DOI: 10.1007/s13193-016-0528-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 04/29/2016] [Indexed: 01/01/2023] Open
Abstract
Renal cell carcinoma (RCC) accounts for approximately 3 % of adult malignancies and 90-95 % of neoplasms arising from the kidney. One of the unique features of RCC is the tumor thrombus formation that migrates into the venous system including renal vein (RV) and inferior vena cava (IVC). Only 10 % of patients with RCC present with the classic triad of flank pain, hematuria and defined mass, while 25-30 % of affected patients are asymptomatic. Signs of para-neoplastic syndrome such as hypercalcemia, hypertension, anemia, cachexia and increased erythrocyte sedimentation rate (ESR) are often apparent. Extension of tumor thrombus into the venous system is depicted by radiological examinations, such as contrast enhanced Computed Tomography (CT), Magnetic Resonance Imaging (MRI) and vena cavography. The level of the thrombus is mostly determined according to the Mayo classification. Despite recent research on the therapeutic strategies against advanced RCC, surgical resection appears the only potentially curative approach. Aggressive surgical management including nephrectomy with thrombectomy is currently the standard therapeutic approach for RCC patients with tumor thrombus extending to the RV or the IVC. Pre-surgical down-staging with the use of molecular targeted therapy has also been proposed. Alternative therapies, such as radio- and chemotherapy proved insufficient. The aim of this review is to evaluate the results of surgical treatment for RCC invading IVC with special reference to the extent of its histological spread. Review of recent world literature was accomplished to provide an update on the current concepts of surgical management of the disease.
Collapse
Affiliation(s)
- Aikaterini Mastoraki
- Athens University Medical School, Attikon University Hospital, Chaidari, Athens Greece
| | - Sotiria Mastoraki
- Athens University Medical School, Attikon University Hospital, Chaidari, Athens Greece
| | - Maria Tsikala-Vafea
- Athens University Medical School, Attikon University Hospital, Chaidari, Athens Greece
| | | | - Andreas Lazaris
- Athens University Medical School, Attikon University Hospital, Chaidari, Athens Greece
| | - Vassilios Smyrniotis
- Athens University Medical School, Attikon University Hospital, Chaidari, Athens Greece
| | - Nikolaos Arkadopoulos
- Athens University Medical School, Attikon University Hospital, Chaidari, Athens Greece
| |
Collapse
|
35
|
Gagné-Loranger M, Lacombe L, Pouliot F, Fradet V, Dagenais F. Renal cell carcinoma with thrombus extending to the hepatic veins or right atrium: operative strategies based on 41 consecutive patients. Eur J Cardiothorac Surg 2016; 50:317-21. [PMID: 27016196 DOI: 10.1093/ejcts/ezw023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 01/12/2016] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The natural history of renal cell carcinoma (RCC) with tumour thrombus extending at or above the hepatic veins is dismal. Different surgical approaches have been described including cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest. We here report our experience in terms of surgical techniques and outcomes on 41 consecutive patients presenting an RCC extending to the hepatic veins or the right atrium. A surgical decision-making algorithm is discussed. METHODS Retrospective review of 41 patients operated for RCC extending in the retrohepatic vena cava (extent level III-IV) between 2000 and 2015. Patients were operated by a dedicated urology/cardiac surgery team. RESULTS The mean age was 62.6 ± 10.4 years; 39% were female. Surgery was emergent in 7.3% of patients, 2.4% of patients had preoperative dialysis, 4.9% required a redo sternotomy and 19.5% had coronary artery disease. Tumour thrombus extended above the diaphragm in 23 patients (level IV) and to the level of hepatic veins (level III) in 18 patients. CPB was used in 38 patients. Arterial cannulation was in the aorta or femoral artery in 14 patients during the initial experience. In the current era, the axillary artery and the innominate artery were used in 12 patients each. Mean CPB, cross-clamp and circulatory arrest times were, respectively, 96.5 ± 42.9, 21.1 ± 16.4 and 10.2 ± 8.2 min (mean temperature of 25.7 ± 4.9°C). Hepatic exclusion without the use of CPB was performed to excise the thrombus in 3 patients. A right nephrectomy was performed in 25 patients, a left in 15 patients and a bilateral nephrectomy in 1 patient. Five patients had a partial inferior vena cava (IVC) resection, with 4 patients requiring a patch reconstruction of the IVC. Three patients had an infrarenal IVC ligation. One patient suffered a cerebrovascular accident in the postoperative period. One in-hospital death occurred (in-hospital mortality 2.4%). The mean follow-up was 1.9 ± 2.0 years. Twenty-three patients died during follow-up; 21 were disease-related. Three-year survival rate was 37.1%. CONCLUSION High-level RCC tumour thrombus is a rare clinical entity, the treatment of which is complex and requires dedicated operative teams. The operative technique should be tailored according to the level of extension and the extent of vena cava obstruction/occlusion of the tumour thrombus. Contemporary operative techniques may be conducted with excellent results. Mid-term survival is limited, supporting the necessity to pursue research efforts towards establishing effective adjunct therapies.
Collapse
Affiliation(s)
- Maude Gagné-Loranger
- Department of Cardiovascular Surgery, Quebec Heart and Lung Institute, Laval University, Sainte-Foy, Canada
| | - Louis Lacombe
- Department of Urology, Hôtel-Dieu de Québec, Centre Hospitalier Universitaire de Québec, Laval University, Québec, Canada
| | - Frédéric Pouliot
- Department of Urology, Hôtel-Dieu de Québec, Centre Hospitalier Universitaire de Québec, Laval University, Québec, Canada
| | - Vincent Fradet
- Department of Urology, Hôtel-Dieu de Québec, Centre Hospitalier Universitaire de Québec, Laval University, Québec, Canada
| | - François Dagenais
- Department of Cardiovascular Surgery, Quebec Heart and Lung Institute, Laval University, Sainte-Foy, Canada
| |
Collapse
|
36
|
|
37
|
Gaudino M, Lau C, Cammertoni F, Vargiu V, Gambardella I, Massetti M, Girardi LN. Surgical Treatment of Renal Cell Carcinoma With Cavoatrial Involvement: A Systematic Review of the Literature. Ann Thorac Surg 2016; 101:1213-21. [DOI: 10.1016/j.athoracsur.2015.10.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 09/08/2015] [Accepted: 10/01/2015] [Indexed: 01/17/2023]
|
38
|
Hevia V, Ciancio G, Gómez V, Álvarez S, Díez-Nicolás V, Burgos FJ. Surgical technique for the treatment of renal cell carcinoma with inferior vena cava tumor thrombus: tips, tricks and oncological results. SPRINGERPLUS 2016; 5:132. [PMID: 26933631 PMCID: PMC4761352 DOI: 10.1186/s40064-016-1825-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 02/15/2016] [Indexed: 11/15/2022]
Abstract
Renal cell carcinoma represents 3 % of all cancers. Around 4–10 % of cases present with inferior vena cava involvement, generally with tumor thrombus. Clinical and preoperative stage will be classified depending of the thrombus extension. A high quality preoperative workup is essential to properly plan surgical approach. Complete surgical resection of the tumor is potentially the only curative treatment, although it supposes a real challenge due to operative difficulty, potential for massive bleeding or tumor pulmonary thromboembolism. Surgery includes techniques derived from transplantation surgery and, in some cases, cardiovascular intervention with cardiopulmonary bypass. Long-term oncological outcomes after complete removal of the entire tumor burden are acceptable. In this report we describe step-by-step surgical maneuvers depending on the thrombus lever, and focusing in complete abdominal approach for the complete excision of the tumor. Moreover, a recent literature review about oncological results is reported.
Collapse
Affiliation(s)
- Vital Hevia
- Urology Department, Renal Surgery and Kidney Transplant Section, Hospital Universitario Ramón y Cajal, Ctra Colmenar km 9,100, 28034 Madrid, Spain
| | - Gaetano Ciancio
- Department of Surgery, Division of Transplantation, University of Miami Miller School of Medicine, Miami, FL USA
| | - Victoria Gómez
- Urology Department, Renal Surgery and Kidney Transplant Section, Hospital Universitario Ramón y Cajal, Ctra Colmenar km 9,100, 28034 Madrid, Spain
| | - Sara Álvarez
- Urology Department, Renal Surgery and Kidney Transplant Section, Hospital Universitario Ramón y Cajal, Ctra Colmenar km 9,100, 28034 Madrid, Spain
| | - Víctor Díez-Nicolás
- Urology Department, Renal Surgery and Kidney Transplant Section, Hospital Universitario Ramón y Cajal, Ctra Colmenar km 9,100, 28034 Madrid, Spain
| | - Francisco Javier Burgos
- Urology Department, Renal Surgery and Kidney Transplant Section, Hospital Universitario Ramón y Cajal, Ctra Colmenar km 9,100, 28034 Madrid, Spain
| |
Collapse
|
39
|
Glebova NO, Hicks CW, Piazza KM, Lum YW, Abularrage CJ, Black JH. Outcomes of Bypass Support Use during Inferior Vena Cava Resection and Reconstruction. Ann Vasc Surg 2016; 30:12-21. [DOI: 10.1016/j.avsg.2015.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 05/04/2015] [Accepted: 05/05/2015] [Indexed: 11/29/2022]
|
40
|
Etkin Y, Foley PJ, Wang GJ, Guzzo TJ, Roses RE, Fraker DL, Drebin JA, Jackson BM. Successful venous repair and reconstruction for oncologic resections. J Vasc Surg Venous Lymphat Disord 2016; 4:57-63. [DOI: 10.1016/j.jvsv.2015.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 05/12/2015] [Indexed: 12/22/2022]
|
41
|
Lardas M, Stewart F, Scrimgeour D, Hofmann F, Marconi L, Dabestani S, Bex A, Volpe A, Canfield SE, Staehler M, Hora M, Powles T, Merseburger AS, Kuczyk MA, Bensalah K, Mulders PFA, Ljungberg B, Lam TBL. Systematic Review of Surgical Management of Nonmetastatic Renal Cell Carcinoma with Vena Caval Thrombus. Eur Urol 2015; 70:265-80. [PMID: 26707869 DOI: 10.1016/j.eururo.2015.11.034] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 11/30/2015] [Indexed: 11/29/2022]
Abstract
CONTEXT Overall, 4-10% of patients with renal cell carcinoma (RCC) present with venous tumour thrombus. It is uncertain which surgical technique is best for these patients. Appraisal of outcomes with differing techniques would guide practice. OBJECTIVE To systematically review relevant literature comparing the outcomes of different surgical therapies and approaches in treating vena caval thrombus (VCT) from nonmetastatic RCC. EVIDENCE ACQUISITION Relevant databases (Medline, Embase, and the Cochrane Library) were searched to identify relevant comparative studies. Risk of bias and confounding assessments were performed. A narrative synthesis of the evidence was presented. EVIDENCE SYNTHESIS The literature search identified 824 articles. Fourteen studies reporting on 2262 patients were included. No distinct surgical method was superior for the excision of VCT, although the method appeared to be dependent on tumour thrombus level. Minimal access techniques appeared to have better perioperative and recovery outcomes than traditional median sternotomy, but the impact on oncologic outcomes is unknown. Preoperative renal artery embolisation did not offer any oncologic benefits and instead resulted in significantly worse perioperative and recovery outcomes, including possibly higher perioperative mortality. The comparison of cardiopulmonary bypass versus no cardiopulmonary bypass showed no differences in oncologic outcomes. Overall, there were high risks of bias and confounding. CONCLUSIONS The evidence base, although derived from retrospective case series and complemented by expert opinion, suggests that patients with nonmetastatic RCC and VCT and acceptable performance status should be considered for surgical intervention. Despite a robust review, the findings were associated with uncertainty due to the poor quality of primary studies available. The most efficacious surgical technique remains unclear. PATIENT SUMMARY We examined the literature on the benefits of surgery to remove kidney cancers that have spread to neighbouring veins. The results suggest such surgery, although challenging and associated with high risk of complications, appears to be feasible and effective and should be contemplated for suitable patients if possible; however, many uncertainties remain due to the poor quality of the data.
Collapse
Affiliation(s)
- Michael Lardas
- Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Fiona Stewart
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | | | - Fabian Hofmann
- Department of Urology, Sunderby Hospital, Sunderby, Sweden
| | - Lorenzo Marconi
- Department of Urology, Coimbra University Hospital, Coimbra, Portugal
| | - Saeed Dabestani
- Department of Urology, Skåne University Hospital, Malmö, Sweden
| | - Axel Bex
- Department of Urology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Alessandro Volpe
- Division of Urology, Maggiore della Carita' Hospital, University of Eastern Piedmont, Novara, Italy
| | - Steven E Canfield
- Division of Urology, University of Texas Medical School at Houston, Houston, TX, USA
| | - Michael Staehler
- Department of Urology, Ludwig-Maximilians University, Munich, Germany
| | - Milan Hora
- Department of Urology, Faculty Hospital and Faculty of Medicine in Pilsen, Charles University in Prague, Prague, Czech Republic
| | - Thomas Powles
- The Royal Free NHS Trust and Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Axel S Merseburger
- Department of Urology, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Markus A Kuczyk
- Department of Urology and Urologic Oncology, Hannover Medical School, Hannover, Germany
| | - Karim Bensalah
- Department of Urology, University of Rennes, Rennes, France
| | - Peter F A Mulders
- Department of Urology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Börje Ljungberg
- Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå University, Umeå, Sweden
| | - Thomas B L Lam
- Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK; Academic Urology Unit, University of Aberdeen, Aberdeen, UK.
| |
Collapse
|
42
|
Mandhani A, Patidar N, Aga P, Pande S, Tewari P. A new classification of inferior vena cava thrombus in renal cell carcinoma could define the need for cardiopulmonary or venovenous bypass. Indian J Urol 2015; 31:327-32. [PMID: 26604444 PMCID: PMC4626917 DOI: 10.4103/0970-1591.166459] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Although the level of inferior vena cava (IVC) thrombus governs the type of surgical approach, there is no consistency in reporting the levels of IVC thrombus in the literature. This prospective study illustrates a simple three-level classification based on the need for clamping hepatoduodenal ligament and venovenous or cardiopulmonary bypass. MATERIALS AND METHODS Between January 2010 and June 2014, 30 patients of renal mass with renal vein and/or IVC thrombus were treated after classifying the IVC thrombus into three levels on the basis of need for clamping the hepatoduodenal ligament. After excluding renal vein thrombi, level I was described as thrombus located caudal to the hepatic vein. Level II included all retrohepatic, suprahepatic infradiaphragmatic or supradiaphragmatic thrombi reaching till the right atrium. Atrial thrombi were categorized as level III. Level I and II thrombi were managed without venovenous or cardiopulmonary bypass. Level III thrombus required cardiopulmonary bypass. RESULTS Of 26 patients with thrombus, 13 had level I thrombus. Of eight cases with level II thrombus, three were retrohepatic, three were suprahepatic infradiaphragmatic and two were supradiaphragmatic. All were removed successfully. Of five patients with level III thrombus, three were operated with cardiopulmonary bypass while the remaining two patients were too sick to be taken up for surgery. The median hepatoduodenal ligament clamp time was 10 min. One patient with level II thrombus had transient liver enzyme elevation. CONCLUSION Renal vein thrombus should not be categorized as level I thrombus. Level II thrombus, irrespective of its relation to the diaphragm, could be managed without venovenous or cardiopulmonary bypass.
Collapse
Affiliation(s)
- Anil Mandhani
- Department of Urology and Renal Transplantation, King George Medical University, Lucknow, India
| | - Nitesh Patidar
- Department of Urology and Renal Transplantation, King George Medical University, Lucknow, India
| | - Pallavi Aga
- Department of Radio Diagnosis, King George Medical University, Lucknow, India
| | - Shantanu Pande
- Department of Cardiothoracic and Vascular Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Prabhat Tewari
- Department of Anesthesia, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| |
Collapse
|
43
|
Abstract
OBJECTIVE In most cases of inferior vena cava (IVC) surgery, IVC clamping is required owing to several factors, including renal cell carcinoma with IVC thrombus extension and IVC leiomyosarcoma. Various clinical results were compared following IVC clamping by classifying clamping levels into juxtarenal, infrahepatic, and suprahepatic. In particular, the risk factors of postoperative thrombosis after IVC clamping were assessed comparatively. METHODS Eighty-four patients who underwent IVC clamping owing to IVC pathology between 2002 and 2012 were retrospectively reviewed with regard to RBC transfusion, operation time, clamping time, liver and kidney functions, duration of hypotension, blood pressure (BP) drops, pulmonary thromboembolism (PTE), venous thrombosis, ICU stay duration, hospital stay duration, 30-day morbidity, and 30-day mortality. In addition, various clinical results were compared when postoperative thrombosis occurred after IVC clamping. RESULTS Values for operation time, clamping time, units of RBC transfused, duration of hypotension, severity of BP drops, use of cardiopulmonary bypass (CPB), aspartate aminotransferase, the use of inotropes, IVC patency, ICU stay, and hospital stay duration were significantly higher in the suprahepatic clamping group than in the other clamping groups. In addition, CPB use and IVC clamping level were significant risk factors for postoperative thrombosis after IVC clamping. CONCLUSIONS Although IVC clamping is a prerequisite for IVC surgery, operative durations, units of RBC transfused, and length of hospital stays increase with higher clamping levels. In addition, CPB use and IVC clamping level are significant risk factors for postoperative thrombosis. In IVC surgery with higher clamping levels, prompt hemodynamic support and proper anticoagulation therapy are important.
Collapse
|
44
|
Ebbing J, Wiebach T, Kempkensteffen C, Miller K, Bachmann A, Günzel K, Rieken M, Friedersdorff F, Baumunk D, Weikert S. Evaluation of perioperative complications in open and laparoscopic surgery for renal cell cancer with tumor thrombus involvement using the Clavien–Dindo classification. Eur J Surg Oncol 2015; 41:941-52. [DOI: 10.1016/j.ejso.2015.02.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 02/17/2015] [Accepted: 02/28/2015] [Indexed: 10/23/2022] Open
|
45
|
El-Habti H, Ghonim S, Andi A, Dubrey S. Metastatic renal carcinoma: a question of management. Br J Hosp Med (Lond) 2015; 76:246-7. [PMID: 25853358 DOI: 10.12968/hmed.2015.76.4.246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Hejrae El-Habti
- Core Trainee in Medicine in the Department of Medicine, Hillingdon Hospital, Uxbridge, Middlesex UB8 3NN
| | | | | | | |
Collapse
|
46
|
González J, Ciancio G. Caval Thrombus in Conjunction with Renal Tumors: Indication for Surgery and Technical Details. Curr Urol Rep 2014; 15:451. [DOI: 10.1007/s11934-014-0451-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
47
|
Lok HT, Chan ES, Hou SS, Yip SK, Ng CF. Surgical management of renal cell carcinoma with inferior vena cava thrombus. SURGICAL PRACTICE 2014. [DOI: 10.1111/1744-1633.12040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Hon-Ting Lok
- Department of Surgery; The Chinese University of Hong Kong; Hong Kong
| | - Eddie S.Y. Chan
- Department of Surgery; The Chinese University of Hong Kong; Hong Kong
| | - Simon S.M. Hou
- Department of Surgery; The Chinese University of Hong Kong; Hong Kong
| | - Sidney K.H. Yip
- Department of Surgery; The Chinese University of Hong Kong; Hong Kong
| | - Chi-Fai Ng
- Department of Surgery; The Chinese University of Hong Kong; Hong Kong
| |
Collapse
|
48
|
Agochukwu N, Shuch B. Clinical management of renal cell carcinoma with venous tumor thrombus. World J Urol 2014; 32:581-9. [PMID: 24752606 DOI: 10.1007/s00345-014-1276-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Accepted: 03/06/2014] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES Venous invasion is common in advanced renal cell carcinoma (RCC) due to the unique biology of this cancer. The presence of a tumor thrombus often makes clinical management challenging. In this review, we detail specific preoperative, perioperative, and surgical strategies involving the care of the complex kidney cancer patient with venous tumor involvement. METHODS We performed a comprehensive review of selected peer-reviewed publications regarding RCC tumor thrombus biology, medical and surgical management techniques, and immediate and long-term outcomes. RESULTS The perioperative management may require special imaging techniques, preoperative testing, very recent imaging, and consultation with other surgical services. There are various approaches to these patients as the clinical presentation, stage of disease, primary tumor size, level of thrombus, degree of venous occlusion, presence of bland thrombus, and primary tumor laterality influence management. Select patients with metastatic disease can do well with cytoreductive nephrectomy and thrombectomy. Those with localized disease have a high risk of recurrence; however, some patients can exhibit durable survival with surgery alone. The evolving surgical and medical treatments are discussed. CONCLUSIONS Even when these surgeries are performed in high volume centers, significant perioperative complications are common and greater complications are seen with higher thrombus extent. If surgery is attempted, it is important for urologic oncologists to follow strict attention to specific surgical principles. These general principles include complete vascular control, avoidance of thrombus embolization, close hemodynamic monitoring, and institutional resources for caval resection/replacement and venous bypass if necessary.
Collapse
Affiliation(s)
- Nnenaya Agochukwu
- Department of Urology, Yale School of Medicine, 310 Cedar Street 238A, New Haven, CT, 06510, USA
| | | |
Collapse
|
49
|
Raman A, Jawale A, Grant A. Radical nephrectomy and vena caval thrombectomy with the use of cardiopulmonary bypass. ANZ J Surg 2014; 84:560-3. [DOI: 10.1111/ans.12559] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Avi Raman
- Urology; Royal Newcastle Centre; Newcastle New South Wales Australia
| | - Atul Jawale
- Surgery; John Hunter Hospital; Newcastle New South Wales Australia
| | - Alexander Grant
- Urology; Royal Newcastle Centre; Newcastle New South Wales Australia
| |
Collapse
|
50
|
Lessons learned from the International Renal Cell Carcinoma-Venous Thrombus Consortium (IRCC-VTC). Curr Urol Rep 2014; 15:404. [DOI: 10.1007/s11934-014-0404-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|