Surgical technique for the treatment of renal cell carcinoma with inferior vena cava tumor thrombus: tips, tricks and oncological results

Renal cell carcinoma with an "uncoiling" tumor thrombus: intraoperative shift from level III to level IV

BACKGROUND

The gold standard treatment for renal cell carcinoma (RCC) with tumor thrombus (TT) is complete surgical excision. The surgery is complex and challenging to the surgeon, especially with large tumor thrombus extending into the inferior vena cava (IVC) and right atrium. Traditionally, these difficult cases required the use of cardiopulmonary bypass (CPB) with or without deep hypothermic cardiac arrest, but in recent years, different surgical techniques derived from the field of liver transplantation have been used in efforts to avoid CPB.

CASE PRESENTATION

We present a case of RCC with TT level IIIc (extending above major hepatic veins) that "uncoiled" intraoperatively into the right atrium after division of the IVC ligament, transforming into a level IV TT. Despite the new TT extension, the surgery was successfully completed exclusively through an abdominal approach without CPB and while using intraoperative transesophageal echocardiography (TEE) monitoring and a cardiothoracic team standby.

CONCLUSIONS

This case highlights the need for a multidisciplinary approach and the utility of intraoperative continous TEE monitoring which helped to visualize the change of the TT venous extension, allowing the surgical teamto modify their surgical approach as needed avoiding a catastrophic event.

Survival benefits after radical nephrectomy and IVC thrombectomy of renal cell carcinoma patients with inferior vena cava thrombus

Objective

The role of tumor thrombus as a predictor of survival in patients with renal cell carcinoma (RCC) is controversial. This study aims to evaluate surgical and oncological outcomes after surgery in RCC with inferior vena cava (IVC) tumor thrombus patients.

Materials and methods

A total of 58 patients (2002-2019) underwent radical nephrectomy and IVC thrombectomy at our institute, were retrospectively reviewed. Kaplan-Meier analysis was utilized to compare survival benefits between cohorts and Cox-regression to evaluate potential predictors of patient survival.

Results

There were 5(8.6%), 21(36.2%), 23(39.7%) and 9 (15.5%) patients with tumor thrombus level I, II, III and IV respectively. The major complications (Clavien 3-5) were observed in 15 patients (25.8%) and 12 patients (80%) were patients with high thrombus level (III-IV). There was 9%mortality (5patients): 2 intraoperatively and 3 postoperatively. Median follow-up was 15 months (IQR:5-41). Two-year overall survival (OS) was 80% and 75% in all patients and pN0M0 cohort, respectively. There was significant difference in OS among each IVC thrombus level cohort (p < 0.02). Two-year OS of metastatic RCC patients was 67% and not significantly different when compared to non-metastatic cohort (p = 0.12). On multivariate analysis, only sarcomatoid dedifferentiation was associated with OS(p = 0.04). Disease-free survival was not significantly different among thrombus-level cohorts (p = 0.65).

Conclusions

Our study suggested that surgical treatment for RCC with IVC thrombus provided substantial OS outcomes. Although survival was significantly reduced with higher IVC thrombus level cohort, the level of thrombus itself was not an independent factor. Only sarcomatoid dedifferentiation was a predictor for reduced OS after radical nephrectomy and tumor thrombectomy. Meticulous patient selection and prompt counselling are substantial step for the operation.

A Narrative Review on Robotic Surgery as Treatment for Renal Cell Carcinoma with Inferior Vena Cava Thrombus

Renal cell carcinoma (RCC) is a common diagnosis, of which a notable portion of patients present with an extension into the venous circulation causing an inferior vena cava (IVC) tumor thrombus. Venous extension has significant implications for staging and subsequent treatment planning, with recommendations for more aggressive surgical removal, although associated surgical morbidity and mortality is relatively increased. The methods for surgical removal of RCC with IVC thrombus remain complex, particularly surrounding the use of robot-assisted surgery. Robot assistance for radical nephrectomy in this context is recently emerging. Thrombus level has important implications for surgical technique and prognosis. Other preoperative considerations may include location, laterality, size, and wall invasion. The urology literature on treatment of such tumors is largely limited to case series and institutional studies that describe the feasibility of various surgical options for these complex tumors. Further understanding of the outcomes and patient-specific risk factors would shed increased light on the optimal treatment for such cases. This narrative review provides a thorough overview on the previously reported use of robot-assisted nephrectomy in RCC with IVC thrombus to inform further studies which may optimize outcomes and guide shared decision-making.

Migration of an Inferior Vena Cava Tumor Thrombus during Renal Cell Carcinoma Resection

Approximately 4%-10% of patients with renal cell carcinoma (RCC) have tumoral vascular invasion with resultant thrombi in the renal vein and in the inferior vena cava (IVC). The authors describe an interesting case of IVC tumor thrombus that migrated to the right cardiac chambers during RCC resection. The diagnosis was made by intraoperative transesophageal echocardiography (TEE), which revealed the presence of a free-floating thrombus between the right atrium (RA) and right ventricle (RV). The patient required an urgent sternotomy with cardiopulmonary bypass (CPB) for atrial thrombus removal prior to the completion of the nephrectomy. The patient made a full recovery and was discharged to a rehabilitation facility. These findings illustrate the importance of intraoperative TEE monitoring during nephrectomy and IVC thrombectomy. In this case, TEE allowed for the diagnosis of an unexpected complication necessitating prompt cardiac surgical management.

Technical Tips for Performing Suprahepatic Vena Cava Tumor Thrombectomy in Renal Cell Carcinoma without Using Cardiopulmonary Bypass

Radical nephrectomy with tumor thrombectomy for advanced renal cell carcinoma is an oncologically relevant approach that can achieve long-term survival even in the presence of distant metastases. However, the surgical techniques pose significant challenges. The objective of this clinical review was to present technical recommendations for tumor thrombectomy in the vena cava to facilitate surgical treatment. Transesophageal echocardiography is required to prepare for this procedure. Cardiopulmonary bypass should be considered when the tumor thrombus has invaded the cardiac chamber and clamping is not feasible because of the inability to milk the intracardiac chamber thrombus in the caudal direction. Prior to performing a cavotomy, it is crucial to clamp the contralateral renal vein and infrarenal and suprahepatic inferior vena cava (IVC). If the suprahepatic IVC is separated from the surrounding tissue, it can be gently pulled down toward the patient's leg until the lower margin of the atrium becomes visible. Subsequently, the tumor thrombus should be carefully pulled downward to a position where it can be clamped. Implementing the Pringle maneuver to reduce blood flow from the hepatic veins to the IVC during IVC cavotomy is simpler than clamping the hepatic veins. Sequential clamping is a two-stage method of dividing thrombectomy by clamping the IVC twice, first suprahepatically and then midretrohepatically. This sequential clamping technique helps minimize hypotension status and the Pringle maneuver time compared to single clamping. Additionally, a spiral cavotomy can decrease the degree of primary closure narrowing. The oncological prognoses of patients can be improved by incorporating these technical recommendations.

A rare co-occurrence of renal cell carcinoma, bilateral adrenal metastasis and inferior vena cava thrombus: A case report

INTRODUCTION

The incidence of ipsilateral adrenal metastasis from RCC varies between 1.1 and 10 %, on the other hand, the presence of bilateral adrenal metastasis from solitary RCC is extremely rare, with less than 20 reported cases in the literature.

CASE PRESENTATION

A 68-year-old man presented to the clinic with hematuria. Further investigations, contrast CT, showed mass at the right kidney and adrenal gland, a mass on the left adrenal gland and inferior cava thrombosis measuring 3*6 cm. The patient underwent, first, right nephrectomy and adrenalectomy with thrombectomy and IVC plasty. Microscopic examination showed clear cell renal cell carcinoma, while adrenal tissue showed metastatic renal cell carcinoma. The patient was followed up from the oncological, endocrinological and cardiac point of view. After 6 months he underwent left adrenalectomy. Subsequent follow-up showed body free of metastases.

CLINICAL DISCUSSION

The co-occurrence of renal cell carcinoma, bilateral adrenal metastasis, and inferior vena cava thrombus is a very rare phenomenon in the literature. Most patients with adrenal metastasis are asymptomatic, and the adrenal function is typically preserved even when malignancy affects bilateral adrenal glands. In addition, patients with adrenal ipsilateral metastases typically have primary renal tumors with poor prognosis.

CONCLUSION

The Diagnosis and management are a surgical challenge. Contrast-enhanced CT scan is the preferred imaging modality for renal cell carcinoma. The surgical intervention is mandatory if it can increase survival rate.

Renal cell carcinoma with intracardiac tumor thrombus extension: Radical surgery yields 2 years of postoperative survival in a single-center study over a period of 30 years

Background

Renal cell carcinoma (RCC) with tumor thrombus extension into the right atrium (level IV) is a rare life-threatening clinical condition that can only be managed by means of a combined urological and cardiac surgical approach. The early and late outcomes of this radical treatment were analyzed in a large single-institution series over a period of 30 years.

Methods

In 37 patients with RCC and intracardiac tumor thrombus extension, nephrectomy was performed followed by the extraction of the intracaval and intracardiac tumor thrombus under direct visual control during deep hypothermic circulatory arrest (DHCA). Recently, in 13 patients, selective aortic arch perfusion (SAAP) was instituted during DHCA.

Results

In all patients, precise removal of the tumor thrombus was accomplished in a bloodless field. The mean duration of isolated DHCA was 15 ± 6 min, and 31.5 ± 10.2 min in the case of DHCA + SAAP, at a mean hypothermia of 22.7 ± 4°C. In-hospital mortality was 7.9% (3 patients). In Kaplan-Meier analysis, the estimated median survival was 26.4 months whereas the 5-year cancer-related survival rate was 51%.

Conclusions

Despite its complexity, this extensive procedure can be performed safely with a generally uneventful postoperative course. The use of cardiopulmonary bypass with DHCA, with the advantage of SAAP, allows for a safe, precise, and complete extirpation of intracaval and intracardiac tumor mass. Late outcomes after radical surgical treatment in patients with RCC and tumor thrombus reaching up in the right atrium in our series justify this extensive procedure.

Current Approaches in Surgical and Immunotherapy-Based Management of Renal Cell Carcinoma with Tumor Thrombus

Renal cell carcinoma (RCC) accounts for 2-3% of all malignant disease in adults, with 30% of RCC diagnosed at locally advanced or metastatic stages of disease. A form of locally advanced disease is the tumor thrombus (TT), which commonly grows from the intrarenal veins, through the main renal vein, and up the inferior vena cava (IVC), and rarely, into the right cardiac chambers. Advances in all areas of medicine have allowed increased understanding of the underlying biology of these tumors and improved preoperative staging. Although the development of several novel system agents, including several clinical trials utilizing immune checkpoint inhibitors and combination therapies, has been shown to lower perioperative morbidity and increase post-operative recurrence-free and progression-free survival, surgery remains the mainstay of therapy to achieve a cure. In this review, we provide a description of specific surgical approaches and techniques used to minimize intra- and post-operative complications during radical nephrectomy and tumor thrombectomy of RCC with TT extension of various levels. Additionally, we provide an in-depth review of the major developments in neoadjuvant and adjuvant immunotherapy-based treatment and the impact of ongoing and recently completed clinical trials on the surgical treatment of advanced RCC.

Renal Cell Carcinoma with Supradiaphragmatic Tumor Thrombus: Avoiding Sternotomy and Cardiopulmonary Bypass

Renal cell carcinoma (RCC) accounts for 2-3% of all malignant disease in adults and has a propensity to infiltrate the surrounding adjacent structures with a biologic predisposition for vascular invasion. This tropism for the venous system facilitates propagation into the renal vein and inferior vena cava (IVC) in up to 25% of patients with RCC. Surgical resection remains the mainstay treatment for RCC with venous tumor thrombus (TT) extension and the only hope for a potential cure. Higher thrombus levels correlate with more advanced stages of disease and thus poorer survival rates. Although CPB with circulatory arrest has been successfully performed during resection of these tumors, its use remains controversial due to the risk of coagulopathy, platelet dysfunction, and central nervous system complications. Complete intraabdominal surgical excision of level III thrombi can be achieved without sternotomy and CPB by utilizing hepatic mobilization maneuvers. The purpose of this review is to provide an update on the surgical management of these difficult cases of RCC with supradiaphragmatic tumor thrombi, including a description of transplant-based techniques that avoid sternotomy and cardiopulmonary bypass (CPB), minimizing intra- and post-operative complications.

Large left moiety renal tumor with renal vein thrombus in a horseshoe kidney

Background

Management of large renal tumors in a horseshoe kidney has received little attention due to the highly infrequent occurrence. Surgical management for tumors in horseshoe kidney is challenging due to complex aberrant vascular anatomy, relative fixity of the renal moieties and other associated conditions such as ectopia and malrotation. An added component of a renal vein thrombus in this scenario often adds to the surgical conundrum. Inadequate peri-operative management may cause devastating complications and increased morbidity and mortality. Careful pre-operative planning and meticulous intra-operative dissection limits blood loss and thereby complications.

Case presentation

We present the peri-operative management of a large renal tumor with a renal vein thrombus in a horseshoe kidney moiety as a case report with literature review focusing on the intra-operative surgical approach that may be adopted for these tumors. A 12 cm × 10 cm left renal moiety mass with renal vein thrombus with no distant metastasis was diagnosed. After confirmation of thrombus extent with CT as well as MRI Abdomen, the patient underwent left moiety radical nephrectomy with renal vein thrombectomy. Careful intra-operative dissection and division of the vascular supply of the left renal moiety was performed. Vessel stapler was used for division of isthmus that resulted in minimal blood loss, complete oncologic clearance and minimal post operative morbidity.

Conclusions

Large renal tumor with renal vein thrombus in horseshoe kidneys is an uncommon condition. Pre operative cross-sectional imaging and intra-operative use of vessel sealants like Ligasure, harmonic scalpel and vessel staplers contribute to minimizing blood loss and thereby result in excellent patient outcomes. We report a case of a large left renal moiety tumor with renal vein thrombus successfully managed with open radical left moiety nephrectomy and isthmectomy with tumor thrombectomy.

Renal cell carcinoma with inferior vena cava tumor thrombus initially misdiagnosed as bland thrombus due to hypercoagulable state

Renal cell carcinoma with inferior vena cava tumor thrombus can be misdiagnosed as an inferior vena cava thrombosis if not evaluated carefully with imaging. We describe a case of renal cell carcinoma with inferior vena cava tumor thrombus that was initially misdiagnosed as an inferior vena cava thrombosis due to a possible hypercoagulable state. After 7 months of anticoagulation therapy with no improvement, a right radical nephrectomy and thrombectomy was performed without cardiopulmonary bypass, and a diagnosis of papillary renal cell carcinoma with a level-IIId tumor thrombus was confirmed with no presence of a bland thrombus. We demonstrate the complexity of identifying and treating renal cell carcinoma with venous tumor thrombus and the importance of differentiating between a malignant thrombus and a bland thrombus.

Robot-Assisted Laparoscopic IVC Treatment Strategy in Retroperitoneal Tumors

Objectives

To show the practice of robot-assisted laparoscopic inferior vena cava (IVC) treatment strategies in patients with retroperitoneal tumors.

Patients and Methods

From October 2020 to July 2021, 17 patients with retroperitoneal tumors successfully underwent robot-assisted laparoscopic tumor resection with IVC management. The patient details, tumor characteristics, intraoperative data, pathological features and severe complications were assessed. The IVC treatment strategies were divided into 4 ways: ①local resection and primary repair of the IVC; ②IVC ligation; ③ IVC reconstruction by bovine pericardial grafts; and ④ IVC transection and anastomosis.

Results

In terms of IVC management, 5 cases had conventional total occlusion of the IVC and its branches, 3 cases had delayed occlusion of the proximal IVC technique, 2 cases had IVC resection by Satinsky clamp, 5 cases had IVC ligation, 1 case had IVC reconstruction by bovine pericardial grafts and 1 case had IVC transection and anastomosis. The median operation time was 151 min, and blood loss was 500 ml. There was no severe complication perioperatively. The follow-up time of 17 patients was 8 to 17 months (median: 12 months). No local recurrence or overall death was found during follow-up.

Conclusions

These robot-assisted laparoscopic IVC treatment strategies were considered to be safe and feasible in experienced centers, as well as helpful to completely remove the tumor for better oncological prognosis and restore the blood reflux of IVC as much as possible to ensure fewer postoperative complications.

Preoperative stereotactic body radiotherapy combined with surgical treatment for renal cell carcinoma and inferior vena cava tumour thrombus: study protocol for a single-arm cohort trial

INTRODUCTION

Although surgery is currently the first choice for patients with renal cell carcinoma and vena cava tumour thrombus, the surgery is difficult, with many complications, and the prognosis of patients is not ideal. Renal cell carcinoma is not sensitive to traditional radiotherapy, but the development of stereotactic ablative body radiotherapy (SABR) technology with the characteristics of high precision, dose and conformity has made the radiotherapy of renal cell carcinoma reexamined.

METHODS AND ANALYSIS

STUDY DESIGN: This trial is a single-arm cohort study sponsored by Peking University Third Hospital.

STUDY TREATMENT

Preoperative stereotactic ablative radiotherapy combined with surgical treatment. PRIMARY ENDPOINTS: (1) Adverse reactions after 4-6 weeks of SABR. (2) Mayo staging of tumour thrombus. (3) The length of the tumour thrombus from the corresponding anatomical mark. (4) Invasion of the inferior vena cava wall. (5) Recurrent-free survival rate of the tumour. (6) Cancer-specific survival rate. (7) Overall survival rate. (8) Perioperative indicators including operation time, intraoperative bleeding volume and postoperative complications. SECONDARY ENDPOINTS: (1) The longest diameter of the tumour and (2) Lymph node condition.

MAIN INCLUSION CRITERIA

Patients with renal cell carcinoma and inferior vena cava tumour thrombus graded from Mayo II to IV and eligible for radical nephrectomy and inferior vena cava thrombectomy.

MAIN EXCLUSION CRITERIA

Patients with previous targeted therapy, chemotherapy or other interventions, or who cannot tolerate SABR or surgery.

PLANNED SAMPLE SIZE

20 patients.

ETHICS AND DISSEMINATION

The trial protocol and the informed consent of the subjects were submitted and approved by the Peking University Biomedical Ethics Committee.

TRIAL REGISTRATION NUMBER

ChiCTR1800015118.

Hypofractionated radiotherapy for renal cell carcinoma with inferior vena cava tumour thrombus

Renal cell carcinoma (RCC) constitutes about 3% of all malignant neoplasms in adults. Clear cell carcinoma is the most frequent type, accounting for about 65% of cases. It tends to invade the veins and form tumour thrombi in inferior vena cava (IVC-TT), occasionally reaching the right atrium. Nephrectomy and thrombectomy are standard therapeutic procedures performed in RCC-IVC-TT. Despite proven effectiveness of surgery, this entity in IVC-TT is associated with poor outcome. The role of palliative radiotherapy in this entity is undetermined. We present a case of a 43-year-old female patient after right-sided nephrectomy due to advanced RCC which invaded the IVC, hepatic veins, and right atrium. The patient has been treated with postoperative, hypofractionated radiotherapy on the residual disease.

Influence of tumor size in the progression of venous tumor thrombus in renal cell carcinoma: A 7-year single-center experience

OBJECTIVE

The objective of the study is to describe the perioperative outcomes, disease-specific, and overall survival status in patients diagnosed with renal cell carcinoma with inferior vena cava (IVC) tumor thrombus.

PATIENTS AND METHODS

We did a retrospective analysis of all patients who underwent radical nephrectomy along with IVC thrombectomy from the year 2013 to 2020. Mayo's classification was used to stratify the level of IVC thrombus. Demographic, perioperative, histopathology data, complications, and survival status were analyzed.

RESULTS

Total number of patients included in the study was 39, (Male: Female = 84.6%: 15.4%). Median age of patients was 58 (interquartile range [IQR] 50-63) years. Median size of renal tumor (in cms) was 9.5 (IQR 7.5-12), 8 (IQR 7-11.5), 8.5 (IQR 7-11.75), and 11 (IQR 9.5-11) (P = 0.998) in level 1,2,3, and 4 tumors, respectively. Clear cell variant was seen in 32 patients (82%) with R0 resection in 17 patients. Twelve patients (30.7%) had systemic metastasis on presentation. The overall mean survival time was 66.4 months with 95% confidence interval (CI) (52.4-80.5 months). Mean recurrence-free survival is 76 months with (63-90) CI of 95%. Mean survival in patients who presented with metastasis is 47 months with 95% CI (52.4-80.5). Perioperative mortality rate was 5.12% in this study.

CONCLUSION

The tumor size does not have an influence on the progression of tumor thrombus into IVC. Significant difference in survival was observed between different levels of thrombus with high mortality in level four tumors.

Outcomes in Renal Cell Carcinoma with Inferior Vena Cava Thrombus Treated with Surgery

Introduction. Renal cell carcinoma can invade through the renal vein into the inferior vena cava, and can extend intraluminally, with tumor-thrombus formation. Methods: Retrospective study from January 2003 to August 2016. Surgical outcomes were analyzed. Neves classification was used for patient categorization. Kaplan Meier and Log-Rank test were used for survival analysis. Results: A total of 134 patients were included, 69 males (51.4%) and 65 females (49%), M:F ratio 1.06:1. Tumor size, bleeding and surgical time were higher in level IV thrombi (mean 16.1cm, 3 064ml and 6.5hrs, respectively), compared to level I (8.5cm, 1033ml and 3.1hrs, respectively). A higher frequency of positive lymph nodes was observed in levels III and IV compared with levels I and II (49% vs. 17.7%, p=0.0001). Distant metastases were observed in 36 pts. (27%). Overall surgical mortality was 4.5%. 5-year overall survival was 63%. We observed a 5-year survival in patients with level I-II 82% and level III and IV 46%. Conclusions: Our results suggest the benefit for the patient of an aggressive surgical approach with an acceptable mortality and 5-year survival rate. The results obtained justify an aggressive surgical approach to these tumors.

First Resection of a Cavoatrial Renal Tumor Thrombus in a Pediatric Patient in Central America Based on a Multistage Surgical Safety Strategy Combining Liver Transplant Techniques and Cardiac Surgery

We herein report the challenging evaluation and planning process involved in performing the first successful surgical resection of a renal tumor with extensive inferior vena cava tumor thrombosis reaching the right atrium in a pediatric patient within the Central American region. In November 2018, the Oncology Department of the National Children's Hospital in Costa Rica consulted our Center for Liver Transplantation and Hepatobiliary Surgery for the evaluation of a clinical case involving a 6-year-old female patient with progressive Budd-Chiari syndrome caused by a Wilms' tumor of the right kidney with tumor thrombosis of the inferior vena cava reaching the right atrium. A multistage surgical safety strategy combining liver transplant techniques and cardiac surgery was thereafter designed and implemented, achieving complete excision of the tumor thrombus from the inferior vena cava with right nephrectomy. Postoperatively, the patient exhibited complete clinical resolution of Budd-Chiari syndrome and has remained tumor free with excellent quality of life while pursuing her second grade of primary school education 22 months after the successful implementation of this multistage surgical safety strategy. The combination of liver transplantation techniques and cardiac surgery based on a multistage surgical safety strategy minimized the occurrence of unexpected intraoperative events and allowed for complete renal tumor resection and level IV thrombectomy for the first time in a pediatric patient of a public health system in a developing country within the Central American region.

Current Trends in Management of Renal Cell Carcinoma with Venous Thrombus Extension

PURPOSE OF REVIEW

To review the evidence regarding the current trends in surgical management of renal cell carcinoma (RCC) with inferior vena cava (IVC) thrombosis. Recent published series have shown the role of minimally invasive surgery in IVC thrombectomy. This review article evaluates the present RCC with venous extent literature to assess the role of open and minimally invasive surgery in this scenario.

RECENT FINDINGS

Robotic urological surgery has shown to have known benefits in radical prostatectomy, partial nephrectomy, and pyeloplasty. Recent published series showed feasibility of robotic IVC thrombectomy even for level IV cases. With growing number of robot-assisted and laparoscopic surgeries worldwide, there is a current tendency to treat this complex and challenging pathology with a minimally invasive approach, without compromising oncological outcomes.

Management of Pediatric Tumors With Vascular Extension

Background: Pediatric tumors can present with vascular extension to the inferior vena cava and right atrium, which impacts the surgical strategy and can be challenging during surgical treatment. Wilms tumor (WT) is the most common retroperitoneal tumor that can present with vascular extension, but also adrenal tumors, clear cell tumors from the kidney, and hepatoblastomas can present with this situation. Surgical aims include obtaining complete tumor resection without risk for patients, to avoid severe bleeding, cardiac arrest, and embolization, and to avoid cardiac bypass if possible. Objective: To describe and discuss the surgical strategies to deal with pediatric tumors with vascular extension and propose a protocol. Method: Retrospectivly review the experience of treating patients with vascular extension in a single institution, describing different scenarios and a decision making fluxogram based on the preoperative evaluation regarding the surgical techniques and the need for cardiac bypass that are adequate for each situation. Image studies are important to guide the surgical strategy. Depending on the quality of image available, computerized tomography (CT) or magnetic resonance imaging (MRI) can be enough to give the information needed for surgical decisions. Ultrasonography (US) with Doppler is helpful to confirm diagnosis and describes factors to guide the adequate surgical strategy, like the upper level extension and presence or absence of blood flow around the thrombus. Neoadjuvant chemotherapy is indicated in most cases, in order to reduce the upper level of extension (and avoid the need for cardiac bypass) and to lower the risk of embolization. The approach is based on the upper level of the thrombus and can include cavotomy or cavectomy, sometimes with cardiac bypass and cardiac arrest with hypothermia, when the thrombus reaches the diaphragmatic level or above. Pathology analysis of the thrombus can guide staging and the need for radiotherapy postoperatively. Results: A decision making fluxogram protocol is presented focusing on the surgical treatment of such condition. Conclusion: Surgery strategy is highly impacted by the presence of vascular extension in pediatric tumors. Surgeons should be aware of potential complications and how to prevent them. Such cases should be treated in reference centers.

Surgical Tips for Inferior Vena Cava Thrombectomy

PURPOSE OF REVIEW

The aim of this review is to describe the preoperative evaluation, surgical techniques, and postoperative management of patients with renal cell carcinoma (RCC) undergoing radical nephrectomy (RN) and inferior vena cava (IVC) thrombectomy.

RECENT FINDINGS

RN and IVC thrombectomy remains the standard management option in non-metastatic RCC patients with IVC thrombus. A comprehensive preoperative workup, including high-quality imaging, blood works, and appropriate consultations are required for all patients. The aim of the surgery is complete resection of all tumor burden, which requires a skillful surgical team for such a challenging procedure and is inherently associated with a high rate of perioperative morbidity and mortality. Preoperative CT or MRI is essential for surgical planning. The surgical approach is mainly determined by the level of the tumor thrombus. The open approach has been the standard, though minimally invasive and robotic techniques are emerging in selected cases by experienced surgeons.

A Predictive Model for Tumor Invasion of the Inferior Vena Cava Wall Using Multimodal Imaging in Patients with Renal Cell Carcinoma and Inferior Vena Cava Tumor Thrombus

Purpose

Developed a preoperative prediction model based on multimodality imaging to evaluate the probability of inferior vena cava (IVC) vascular wall invasion due to tumor infiltration.

Materials and Methods

We retrospectively analyzed the clinical data of 110 patients with renal cell carcinoma (RCC) with level I-IV tumor thrombus who underwent radical nephrectomy and IVC thrombectomy between January 2014 and April 2019. The patients were categorized into two groups: 86 patients were used to establish the imaging model, and the data validation was conducted in 24 patients. We measured the imaging parameters and used logistic regression to evaluate the uni- and multivariable associations of the clinical and radiographic features of IVC resection and established an image prediction model to assess the probability of IVC vascular wall invasion.

Results

In all of the patients, 46.5% (40/86) had IVC vascular wall invasion. The residual IVC blood flow (OR 0.170 [0.047-0.611]; P = 0.007), maximum coronal IVC diameter in mm (OR 1.203 [1.065-1.360]; P = 0.003), and presence of bland thrombus (OR 3.216 [0.870-11.887]; P = 0.080) were independent risk factors of IVC vascular wall invasion. We predicted vascular wall invasion if the probability was >42% as calculated by: {Ln [Pre/(1 - pre)] = 0.185 × maximum cornal IVC diameter + 1.168 × bland thrombus-1.770 × residual IVC blood flow-5.857}. To predict IVC vascular wall invasion, a rate of 76/86 (88.4%) was consistent with the actual treatment, and in the validation patients, 21/26 (80.8%) was consistent with the actual treatment.

Conclusions

Our model of multimodal imaging associated with IVC vascular wall invasion may be used for preoperative evaluation and prediction of the probability of partial or segmental IVC resection.

A modified sequential vascular control strategy in robot-assisted level III-IV inferior vena cava thrombectomy: initial series mimicking the open 'milking' technique principle

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.

Radical nephrectomy combined with removal of tumor thrombus from inferior vena cava under real-time monitoring with transesophageal echocardiography: A case report

RATIONALE

Renal carcinoma is a common malignant tumor of the urinary system, 4%-10% of which are complicated with tumor thrombi in the renal vein and the inferior vena cava; in about 1% of patients, the inferior vena cava tumor thrombus invades the right atrium. Surgery is the treatment of choice. Real-time monitoring with transesophageal echocardiography (TEE) has been widely used in various operations, including cardiac and non-cardiac operations for congenital heart diseases, coronary diseases, vascular heart diseases, and aorta diseases, etc. In this article, a case of a patient with right renal carcinoma complicated with an inferior vena cava tumor thrombus is reported.

PATIENT CONCERNS

A 52-year-old man who was admitted to our hospital for lumbar pain lasting for one month.

DIAGNOSIS

Right renal carcinoma complicated with an inferior vena cava tumor thrombus.

INTERVENTIONS

Radical nephrectomy of the renal carcinoma and removal of an inferior vena cava tumor thrombus under real-time monitoring with TEE were performed.

OUTCOMES

Radical nephrectomy was successfully performed within 5 minutes after the inferior vena cava was clamped, and then the inferior vena cava tumor thrombus was removed. On the second day after the operation, the patient's conditions improved; his consciousness was clear; he was transferred to a general ward. On the third day after the operation, the patient was able to get out of bed and was discharged on the sixth day after the operation.

LESSONS

Real-time monitoring with TEE played an important role in many aspects in the radical nephrectomy of the renal carcinoma and removal of the inferior vena cava tumor thrombus.

Non-Familial Synchronous Bilateral Renal Cell Carcinoma with Bilateral Synchronous Renal Vein Extension and Inferior Vena Cava Thrombus

Bilateral renal cell carcinoma with tumor thrombus extension into the renal vein and/or inferior vena cava - clinical stage T3a+ - is rare. The majority of these cases arise due to a genetic predisposition. We present a case report of a 47-year-old male with bilateral, synchronous renal cell carcinoma with bilateral renal vein and inferior vena cava tumor thrombi with no identifiable familial predisposition.

Frontiers in robot-assisted retroperitoneal oncological surgery

Robot assistance has been rapidly adopted by urological surgeons and has become particularly popular for oncological procedures involving the retroperitoneal space. The wide dissemination of robot assistance probably reflects the limited amount of operating space available within the retroperitoneum and the advantages provided by robot-assisted approaches, including 3D imaging, wristed instrumentation and the shorter learning curve compared with that associated with the equivalent laparoscopic techniques. Surgical procedures that have traditionally been performed using an open or laparoscopic approach, such as partial nephrectomy, radical nephrectomy, retroperitoneal lymph node dissection, nephroureterectomy and adrenalectomy, are now often being performed using robot assistance. The frontiers of robot-assisted retroperitoneal oncological surgery are constantly expanding, with an emphasis on maintaining oncological and functional outcomes, while minimizing the level of surgical invasiveness.

Xeno-pericardial patch repair of the inferior vena cava for radical resection of renal cell carcinoma with tumor thrombus

Background and Objectives

For tumor thrombus in the inferior vena cava (IVC) complicated with kidney cancer, we built a surgical team to achieve (1) en bloc tumor resection; (2) xeno‐pericardial patch IVC repair; and (3) minimum organ damages. We reviewed outcome of the case series to verify rationale of this approach.

Methods

A consecutive series of 12 patients having the IVC tumor thrombus by renal cell carcinoma in the last 3 years was enrolled. Minimum kidney ischemia was induced in five cases (Procedure I), whereas liver and kidney ischemia was induced in five cases (Procedure II). Mild hypothermic extracorporeal circulation was used in two cases (Procedure III).

Results

There was no mortality or severe morbidities related to the surgery. Postoperative recovery was most prompt by the Procedure I. Liver and kidney ischemic time was longer in the Procedure III than the Procedure II, whereas organ function was not substantially impaired in either series. The resected IVC margin was free from the cancer in all cases, while local recurrence was not seen in any cases.

Conclusions

En bloc resection with xeno‐pericardial patch repair of the IVC was successfully performed in the tumor thrombus complicated with kidney cancer with minimum organ damage.

[Level IV inferior vena cava tumor thrombus : A rare diagnosis in patients with renal cell carcinoma]

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.

Lessons Still Being Learned: Acute Pulmonary Tumor Embolus During Renal Cell Carcinoma Resection

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.