Diagnosis of venous extension in renal cell carcinoma. The value of routine inferior venacavography

Surgical Treatment of Renal Cell Carcinoma with Vena Cava Or Cavo-Atrial Involvement. Our Experience

From January 1987 to September 1992, 290 patients were operated for renal cell carcinoma at the Department of Urology of Bergamo General Hospital. Among these, 22 had venous invasion, 13 of them with vena cava or cavo-atrial involvement. The Authors stress several technical details that they judge very helpful in the case of intrahepatic or supradiaphragmatic thrombi. Among them the routine use of transesophageal sonography, which gives precise details on the size, volume, and upper limit of the thrombus especially if floating. 4 patients were operated with the help of cardiopulmonary by-pass, circulatory arrest and profound hypothermia. The Authors stress the major advantages offered by this technique compared to simpler approaches like the control either of the supradiaphragmatic vena cava, or hepatic veins. Cardiopulmonary by-pass and circulatory arrest offers unsurpassed exposure of the IVC interior and allows easy and controlled extraction of the thrombus, previously the most difficult part of the procedure. Having no time limit imposed by liver ischemia (± 20 minutes), it also offers the possibility of resecting segments of caval wall and repairing it with patch grafts. Among 13 patients who underwent radical nephrectomy and intracaval thrombus removal, limited complications and no peri-operative mortalities are reported.

Inferior venacavography in the preoperative assessment of renal adenocarcinoma

Although inferior venacavography has been suggested as a routine test for patients with renal adenocarcinoma we have used urographic criteria of a large and/or medially placed tumor, and/or decreased visualization of the affected kidney to select patients for inferior venacavography. Of 235 patients with renal adenocarcinoma undergoing excretory urograms 64 of 76 (84 per cent) with gross renal vein involvement and 72 of 151 (47 per cent) without renal vein involvement had at least 1 criterion. All 20 patients with inferior vena caval thrombi and excretory urograms had at least 1 criterion. High dose selective renal angiography identified successfully a renal vein thrombus in 11 patients, 4 with inferior vena caval thrombi, while the renal vein was not visualized in 7 with renal vein involvement and 1 with an inferior vena caval thrombus. Inferior venacavography identified correctly an inferior vena caval thrombus in 16 patients. With the correct preoperative identification in 19 of 22 patients with inferior vena caval thrombi our criteria for inferior venacavography are outlined.

Results of inferior vena cava resection for renal cell carcinoma

A total of 24 patients with renal cell carcinoma involving the inferior vena cava underwent thoracoabdominal radical nephrectomy with removal of tumor thrombus by an open or closed technique. The tumor extended in the inferior vena cava to the level of the renal or lower hepatic veins in 18 patients and it reached the level of the diaphragm or right atrium in 6. Of the 24 patients 3 with preoperative findings minimally suggestive of disseminated disease were shown later to have metastases in the questionable areas, 3 with disease at the level of the diaphragm had incomplete resections, 4 had metastases to regional lymph nodes and 1 had questionable preoperative findings and lymph node metastases. Only 13 of the 24 patients (54 per cent) did not have either disseminated or residual tumor postoperatively. The mean survival duration of this subgroup (20 months) was comparable to that of the group as a whole (21 months). However, 4 patients from this subgroup are free of disease, with a mean followup of 30 months. There was 1 postoperative death. Morbidity, including renal failure, intraoperative hypotension and sepsis, was common. The results in this series suggest that the prognosis for patients with renal cell carcinoma and inferior vena cava involvement is guarded.

Renal venography: anatomy, technique, applications, analysis of 132 venograms, and a review of the literature

Selective renal venography is a simple but important diagnostic procedure which has few complications. A thorough knowledge of renal venous anatomy is essential for its proper performance and clinical application. This is particularly true because renal venous variations are frequent and may interfere with the successful appraoch to retroperitoneal surgery. The method is widely accepted for the evaluation of the renal venous bed in patients with suspected renal vein thrombosis or hematuria of unknown etiology. It depicts the extent of renal venous involvement in renal carcinoma and clarifies the diagnosis in some patients with avascular tumors, renal pelvic carcinoma, and retroperitoneal tumors. It may also be useful in defining the morphologic abnormality when the kidney fails to visualize on urography, in delineating the extent and nature of renal parenchymal disease, and in enhancing the precision of renal vein renin collection.

Inferior caval venography in the assessment of renal carcinoma

Inferior caval venography by a non-catheter technique was carried out in 30 cases of renal cell carcinoma. Occlusion of the renal vein was shown in 15 of these and occlusion of the inferior vena cava in a further three. Deformity of the vena cava by adjacent growth was found in nine instances. Renal arteriography was performed in 27 of these patients and the demonstration of the renal vein by this method has been compared with that of caval venography. The incidence of collateral veins on the arteriogram and the finding of impaired renal function as an index of renal vein occlusion has been discussed.