ABSTRACT
Background: Renal cell carcinoma (RCC) presents with inferior vena cava (IVC) thrombus in 10%�% cases and surgical management forms the mainstay of the treatment. The objective of this study is to assess the outcomes of the patients undergoing radical nephrectomy with IVC thrombectomy. Methods: A retrospective analysis of patients undergoing open radical nephrectomy with IVC thrombectomy between 2006 till 2018 was done. Results: A total of 56 patients were included. The mean (眘tandard deviation) age was 57.1 (�.2) years. The number of patients with levels I, II, III, and IV thrombus were 4, 29,10, and 13, respectively. The mean blood loss was 1851.8 mL, and the mean operative time was 303.3 minutes. Overall, the complication rate was 51.7%, while the perioperative mortality rate was 8.9%. The mean duration of hospital stay was 10.6 � 6.4 days. The majority of the patients had clear cell carcinoma (87.5%). There was a significant association between grade and stage of thrombus (P = 0.011). Using Kaplan朚eier survival analysis, the median overall survival (OS) was 75 (95% confidence interval [CI] = 43.5�6.5) months, and the median recurrence-free survival (RFS) was 48 (95% CI = 33.1�.3) months. Age (P = 0.03), presence of systemic symptoms (P = 0.01), radiological size (P = 0.04), histopathological grade (P = 0.01), level of thrombus (P = 0.04), and invasion of thrombus into IVC wall (P = 0.01) were found to be significant predictors of OS. Conclusion: The management of RCC with IVC thrombus poses a major surgical challenge. Experience of a center along with high-volume and multidisciplinary facility particularly cardiothoracic facility provides better perioperative outcome. Though surgically challenging, it offers good overall-survival and recurrence-free survival
ABSTRACT
The mainstay of treatment for renal cell carcinoma with inferior vena cava (IVC) thrombus is complete surgical excision, which can be facilitated by appropriate preoperative evaluation and detailed planning. The level of tumor thrombus, the presence or absence of thrombus and the invasion of vein wall are important variables affecting surgery. For cases complicated with adherent or invasive tumor thrombus, en bloc resection of the IVC with or without venous reconstruction represents a special decision-making. This review will describe the evolving surgical techniques and key points of robotic-assisted radical nephrectomy with IVC thrombectomy.
ABSTRACT
Objective: To report the first clinical case of robotic-assisted laparoscopic nephrectomy(right) combined with inferior vena caval thrombectomy for level II tumor thrombus in China. Methods: A 73-year-old female patient presented with "gross hematuria and flank discomfort for 4 months" was admitted to our hospital. Preoperative CT scans revealed a 4.9 cm×4.7 cm right renal cancer, grossly extending into the inferior vena cava (IVC, length of the IVC tumor thrombus: 4.6 cm). After three months of neoadjuvant targeted molecular therapies (TKIs), the tumor size reduced to 4.3 cm×4.4 cm on CT and the IVC tumor thrombus length reduced to 3.3 cm. IVC filter was placed cephalad 2 days before surgery under DSA intervention. The patient was placed in recumbent position during the operation; a 12-mm optical port was placed to the right of the rectus abdominis at 2 cm above the umbilicus. Two 8-mm robotic ports and three 12-mm assistant ports were placed percutaneously under direct visualization through a stab incision. The robotic system was then docked, with the colon reflected medially and the duodenum kocherized. The IVC sheath was opened, and the IVC was dissected circumferentially above and below the insertion of the right renal vein to the extent dictated by the length of the thrombus. With the right renal artery dissected and transected, the vessel loops were used to create modified-Rummel tourniquets. The vena cava below and above tumor thrombus, and the left renal vein were cross-clamped. With the vessel loops cinched down completely and secured by hem-o-lok clips, the wall of the IVC was then incised longitudinally for approximately 5 cm. The tumor thrombus was delivered intact along with the invaded IVC wall. The IVC was closed and tourniquet was loosened. After adequate hemostasis was achieved, the specimen was placed into an entrapment sac and incisions were closed by layers. Results: The procedure was smoothly completed. The total operating time was 363 min and the total IVC cross-clamp time was 47 min. The estimated blood loss was 1 200 mL. The amount of intraoperative transfusion was 1 200 mL and 1 000 mL postoperative blood transfusion was required for a low level of hemoglobin. The bowel function recovered at day 3 after operation and drainage was maintained for 3 days. The patient was discharged 16 days after operation. Conclusion: We successfully completed the first clinical case of robotic-assisted laparoscopic nephrectomy combined with inferior vena caval thrombectomy for level II tumor thrombus in China; it is a safe and feasible procedure, but has great technical difficulty, so the patients should be chosen with great care.
ABSTRACT
Intraoperative pulmonary embolism can result in severe hemodynamic instability, including cardiac arrest. Therefore, immediate diagnosis and proper treatment are required. We report a case of the acute cardiac and pulmonary embolisms during radical nephrectomy and inferior vena cava (IVC) thrombectomy in a patient with renal cell carcinoma with thrombus in the IVC. We diagnosed the cardiac embolism intraoperatively using the transesophageal echocardiogram, and performed emergent cardiac and pulmonary embolectomies immediately. After the surgery, the patient was discharged without any complication.
Subject(s)
Humans , Carcinoma, Renal Cell , Diagnosis , Embolectomy , Embolism , Heart Arrest , Hemodynamics , Nephrectomy , Pulmonary Embolism , Thrombectomy , Thrombosis , Vena Cava, InferiorABSTRACT
Renal cell Carcinoma is an unusual cancer with the propensity to invade not only the renal vein but to propagate into the inferior vena cava(IVC) as a tumor thrombus. No tumor thrombus extending to the IVC was seen in a renal cell carcinoma less than 4.5 cm in the greatest diameter among 431 consecutive patients in the Mayo Clinic from January 1976 to January 1992. The present case was a 3.5 cm in size small renal cell carcinoma on the right upper pole which had a tumor thrombus which extended to the inferior vena cava.