Haemodynamic assessment following inferior vena cava resection without replacement

A cut above? Inferior vena cava resection without reconstruction: a dual-centre experience

Objectives:

To evaluate outcomes in our patients undergoing inferior vena cava (IVC) resection without reconstruction, as part of an adrenal/renal cell cancer (RCC) operation.

Methods:

British Association of Urological Surgeons (BAUS) Data and Audit System records were obtained for two operating surgeons, each at geographically separate urological cancer centres. Retrospectively reviewed case notes of patients who had undergone IVC resection without reconstruction as part of an adrenal/RCC operation, assessing operative parameters, length of stay, complications and follow-up status.

Results:

A total of Twenty-eight patients (20 right-sided tumours, 8 left sided) underwent IVC resection without reconstruction in May 2013–February 2017. No perioperative or early deaths occurred. Fourteen patients (50%) had complications: sepsis; pneumonia; congestive cardiac failure; acute kidney injury; symptomatic peripheral deep venous thrombosis; splenectomy; and significant chyle leak. At a median follow-up of 21 months (range 1–55 months) six patients (21.4%) have died and two patients (7.1%) progressed to metastatic disease, giving a 71.4% progression-free survival in this series.

Conclusions:

This case series illustrates our experience of IVC resection without reconstruction as an acceptably safe procedure. This should be considered as an alternative to graft reconstruction, particularly as minimal invasive approaches are being adopted.

Level of Evidence:

3

Resection of abdominal inferior vena cava without graft interposition: Considerations in preserving renal function

The management of tumors involving or infiltrating the inferior vena cava (IVC) constitutes a great surgical challenge, since radical resection affords patients the only possibility for long-term survival. These tumors can be resected without graft interposition, provided that there is adequate collateral circulation and that the renal function can be secured. Meanwhile, ligation of the left renal vein may be possible due to the existence of collateral circulation through the adrenal and gonadal veins. We briefly present our experience on renal outflow preservation through implantation of the right renal vein into the IVC stump or through diversion of the left renal vein into the inferior mesenteric vein.

Adult Wilms tumor with inferior vena cava thrombus and distal deep vein thrombosis - a case report and literature review

BACKGROUND

Adult Wilms tumor (WT, nephroblastoma) is a rare, but well-described renal neoplasm. Although inferior vena cava tumor thrombosis is present in up to 10% of Wilms tumors in childhood, only few cases of this clinical manifestation in adults have been reported. To the best of our knowledge, this is the first case of adult WT infiltrating into inferior vena cava (IVC) with concomitant distal deep vein thrombosis.

CASE PRESENTATION

A 28-year-old male patient with gross hematuria and right flank pain was diagnosed with right kidney tumor penetrating to IVC. Preoperatively, acute distal thrombosis in inferior vena cava and lower extremities veins occurred. Right radical nephrectomy with tumor thrombectomy via cavotomy was performed. In order to prevent pulmonary embolism, IVC was ligated below left renal vein level. Histopathological examination revealed a triphasic nephroblastoma without anaplastic features. Postoperatively, patient was diagnosed with metastatic liver disease, which was treated with two lines of chemotherapy followed by radiotherapy with achievement of complete response.

CONCLUSIONS

Adult WT occurs usually in young patients, under 40 years of age. Neoadjuvant chemotherapy proved to be effective in children, resulting with tumor shrinkage and venous tumor thrombus regression. Therefore, percutaneous biopsy should be always considered in young patients presenting with renal tumor invading venous system. IVC ligation is a safe treatment option in the event of complete inferior vena cava occlusion due to distal thrombosis concomitant to tumor thrombus, provided collateral venous pathways are well-developed.

Venous resection in urological surgery

PURPOSE

Complete removal of retroperitoneal and pelvic tumors may require resection or ligation of major retroperitoneal, pelvic and mesenteric venous structures. We provide an overview of venous anatomy and collateral drainage, and review the veins that can be safely resected.

MATERIALS AND METHODS

We reviewed major anatomical texts, and performed a directed MEDLINE literature search of retroperitoneal, pelvic and mesenteric venous anatomy. Resection and reconstruction of these vessels were also reviewed with an emphasis on collateral blood flow and post-resection sequelae.

RESULTS

The infrarenal inferior vena cava, iliac veins, left renal vein, lumbar veins, inferior mesenteric vein and splenic vein may be resected or ligated without reconstruction. Resection of the right renal vein results in renal demise in the majority of instances. The portal vein may not be resected without reconstruction. Venous reconstruction may be performed with autologous or synthetic graft material.

CONCLUSIONS

Most major veins in the body can be safely resected or ligated with minimal sequelae. However, it is imperative to understand venous anatomy and collateral blood flow to minimize intraoperative and postoperative complications.