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Background: The aim of this study was to investigate the application value of laparoscopic ultrasound (LU) in retroperitoneal radical nephrectomy for renal cell carcinoma with Type II inferior vena cava tumor thrombectomy (RRN-RCC-TII-IVCTT). Methods: The clinical data (operative time, length of tumor thrombus, tumor length, intraoperative bleeding, clinical stage, histological type, residual tumor tissue, and postoperative follow-up) of 6 patients who underwent LU-guided RRN-RCC-TII-IVCTT were retrospectively analyzed, and the intraoperative experience of LU was also summarized. Results: All 6 patients recovered well with liver and kidney functions returning to normal, and no tumor recurrence, metastasis, or vena cava tumor thrombus. Conclusions: LU-guided RRN-RCC-TII-IVCTT is a feasible treatment option, which locates the tumor accurately by retroperitoneal approach and provides the additional benefit of reduced intraoperative bleeding and shortened operative time, also achieving the much sought-after goal of precision.
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Primary liver cancer is a common malignant tumor. Early liver cancer is suitable for surgical resection, local ablation, liver transplantation and other radical treatment, and the prognosis is better. Patients with advanced liver cancer often have tumor thrombosis in hepatic vein and inferior vena cava. With high rates of recurrence and metastasis, the prognosis is poor. Chinese guidelines recommend multidisciplinary treatment to patients with hepatic vein thrombosis and inferior vena cava thrombosis including local treatment, systematic anti-tumor drug treatment, surgical resection and other treatment. This article reviewed the progress in diagnosis and treatment of primary liver cancer with tumor thrombosis in hepatic vein and inferior vena cava in the past decade.
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【Objective】 To compare the clinical efficacy of robot-assisted and open surgery in the treatment of renal carcinoma with inferior vena cava cancer thrombus, and to analyze the safety and feasibility of robot-assisted radical nephrectomy. 【Methods】 Clinical data of 55 patients surgically treated for renal carcinoma with Mayo Ⅰ-Ⅲ inferior vena cava tumor thrombus during Dec.2015 and Dec.2021 were retrospectively analyzed. Based on the operation methods, the patients were divided into the robotic surgery group (n=36) and open surgery group (n=19). The perioperative data, oncological results and survival of the two groups were compared. 【Results】 All operations were successful. The median operation time was 176 (IQR:137-234) min, and grade Ⅲ and above complications occurred in 9(16.4%) cases. The robotic surgery group had lower intraoperative blood loss [300 (IQR:200-625) mL vs.1 000 (IQR:600-1 184) mL] and blood transfusion ratio [(20/36) vs. (18/19)] than the open surgery group, but higher postoperative hemoglobin level[109(98-120) g/L vs. 90(84-100) g/L]. During a median follow-up of 26 (IQR:19-39) months, 19(34.5%) patients developed new metastases and 12(21.8%) patients died. The postoperative tumor-specific survival (HR=0.39, 95%CI:0.13-1.16, P=0.090) and overall survival (HR=0.71, 95%CI:0.22-2.23,P=0.554) were not significantly different between the two groups. 【Conclusion】 There are no significant differences in the incidence of postoperative complications, tumor-specific survival and overall survival between robot-assisted and open surgery for Mayo Ⅰ-Ⅲ inferior vena cava tumor thrombus, but the intraoperative blood loss in robotic group is lower than that in the open surgery group.
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Objective:To explore the clinical efficacy and safety of different surgical procedures of Mayo level Ⅳ inferior vena cava tumor thrombus(IVC-TT).Methods:The clinical and pathological data of 36 patients with Mayo level Ⅳ tumor thrombus were collected in three large clinical centers in China, including 18 cases in PLA General Hospital, 7 cases in Nanfang Hospital, and 11 cases in Renji Hospital. There were 25 males and 11 females.The median age was 56.5 years (53-67 years old). The average body mass index was 24.18±2.55 kg/m 2. The average diameter of renal tumors was 8.24±3.25 cm. The average length of inferior vena cava tumor thrombus was 12.89±2.50 cm. Mayo level Ⅳ tumor thrombus were divided into level Ⅳa and level Ⅳb (301 classification) based on the criterion of whether the proximal end of the thrombus has invaded the right atrium. Among them, level Ⅳa patients underwent robot-assisted inferior vena cava thrombectomy without cardiopulmonary bypass(CPB-free group, 6 cases). Level Ⅳb patients underwent robot-assisted inferior vena cava thrombectomy with cardiopulmonary bypass(CPB group, 12 cases) or cardiopulmonary bypass with deep hypothermic circulatory arrest assisted inferior vena cava thrombectomy(CPB/DHCA group, 18 cases). The baseline data of the three groups of patients were comparable. The perioperative results and long-term survival data after surgery were compared with different surgical methods for grade Ⅳcancer thrombosis. Results:All operations were successfully completed. Compared with the CPB group, the CPB-free group had a shorter first portal blocking time[17.5(15-36)min vs. 36.5(12-102)min, P=0.044], less intraoperative bleeding [2 350(1 000-3 000)ml vs. 3 500 (1 500-12 000)ml, P=0.043] and a lower allogeneic blood transfusion [1 250(500-2 000)ml vs. 2 185(700-5 800)ml, P=0.049]. Compared with the CPB/DHCA group, the CPB-free group had an advantage in reducing intraoperative allogeneic blood transfusion [1 250(500-2 000)ml vs. 2 700(1 200-10 000)ml, P=0.003]. There were no significant differences between groups in terms of duration of surgery and postoperative hospital stay. Among the 36 patients in this group, 23(64%) developed major complications (level Ⅲ or above), including 9 (25%) grade Ⅲ, 12 (33%) grade Ⅳ, and 2 (6%) grade Ⅴ. The CPB-free group had a relatively low complication rate of grade Ⅳ or above [ 17% (1/6) vs.42% (5/12) vs.44% (8/18)]. There were no statistical differences in median progression-free survival (16.4 vs.12.3 vs.18.0 months, P=0.695) and overall survival (30.1 vs.30.2 vs.37.7 months, P=0.674) between the groups. Conclusions:Robot-assisted inferior vena cava thrombectomy without cardiopulmonary bypass has the advantages of short ischemia time of organs, less intraoperative bleeding, and low incidence of major complications, which can be used as a safe and feasible surgical strategy for selected level Ⅳ tumor thrombus.
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Objective:To explore the feasibility and safty of robot assisted trans-diaphragmatic intropericardial inferior vena cava occlusion and thrombectomy in treatment of Ⅳa grade tumor thrombus without cardiopulmonary bypass and thoracotomy.Methods:The clinical data of 4 patients with renal cell carcinoma and Ⅳa grade tumor thrombus by robot assisted trans-diaphragmatic intropericardial inferior vena cava occlusion and thrombectomy from January 2013 to June 2019 were retrospectively analyzed. The median age was 53.5 (53-70) years. The average body mass index was 23.25 (20.7-26.3) kg/m 2. The tumors were located on the right side in 2 cases. The average maximum diameter of the tumor was 8.1 (3.6-11.2) cm.Preoperative tumor thrombus of all patients was classified as Ⅳa. The average preoperative length of tumor thrombus in vena cava was 12.3 (11.8-18.0) cm. All the operations were performed under multidisciplinary cooperation of urology, hepatobiliary, cardiovascular, ultrasound and anesthesiologist team. Surgical procedure: Robot assisted liver mobilization was used to expose the inferior vena cava. Under the guidance of intraoperative ultrasound, the central tendon and pericardium of diaphragm were dissected until the inferior vena cava and right atrium in the superior pericardium were exposed. The first porta hepatis and inferior vena cava were blocked in turn.The vena cava thrombectomy and inferior vena cava reconstruction were performed. Results:All the operations were completed without conversion. The median operation time was 553.5 (338-642) minutes, and the median time of the first porta hepatis occlusion was 18.1 (14-32)minutes. The median blood loss was 1 900(1 000-2 600)ml. All patients were transferred to ICU after operation. The median length of stay in ICU was 7(4-8) days, and the median time of indwelling drainage tube was 8(4-12) days. The average postoperative hospital stay was 13(11-20) days. There were 1 case of grade Ⅱ and 3 cases of grade Ⅲ complications (Clavien classification). One case had paroxysmal supraventricular tachycardia, one case had lymphatic fistula, one case had pleural effusion with atelectasis, and one case had hepatic and renal insufficiency and lymphatic fistula. The complications were improved after treatment. There was no perioperative death.Conclusions:Robot assisted trans-diaphragmatic intropericardial inferior vena cava occlusion and thrombectomy is an alternative method for the treatment of Ⅳa grade inferior vena cava tumor thrombus. Using this method, Ⅳa grade tumor thrombus can be treated without cardiopulmonary bypass and thoracotomy, with controllable complications and zero perioperative mortality.
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Objective To explore the feasibility of robot-assisted laparoscopic inferior vena cava (IVC) thrombectomy in treating renal tumor with Mayo level Ⅲ-Ⅳ inferior vena cava thrombus.Methods From November 2014 to January 2017,5 cases of renal tumor with Mayo level Ⅲ-Ⅳ inferior vena cava tumor thrombus were treated with robot-assisted surgery.There were 4 males and 1 female with the median age of 59 years (range 54-71 years).Four cases had the renal tumor on the right side and one on the left side.The mean tumor size was 6.8 cm (range 5-9 cm) with 3 cases of T3b and 2 cases of T3c.There were 4 cases of level Ⅲ and 1 case of level Ⅳ inferior vena cava thrombus with the median length of 9 cm (range 7-11 cm).The surgical procedure for Mayo level Ⅲ inferior vena cava thrombus included mobilization of both left and right robes of liver,subsequently controlling the suprahepatic infradiaphramatic IVC and first porta hepatis simultaneously.The surgical procedure for Mayo level Ⅳ inferior vena cava thrombus included cardiopulmonary bypass by multi-disciplinary cooperation among urologists,hepatobiliary and cardiovascular surgeons.The procedures included live mobilization,control of the superior vena cava and first porta hepatis and remove thrombus in the atrium and IVC respectively.Results All operations were completed successfully.The median operative time was 440 min (320-630 min).The blood recovery device was used and the intraoperative estimated blood loss was 2 500 ml (500-6 000 ml) and all cases required intraoperative blood transfusion.The median time of intraoperative occlusion of IVC was 35 min (25-50 min).All patients were transferred to the intensive care unit for median of 4 days (2-8 days) after surgery.The median time to remove the postoperative drainage tube was 9 days (7-12 days).Postoperative pathological diagnosis revealed 5 cases of clear cell carcinoma.Postoperative renal dysfunction occurred in 3 patients and liver dysfunction occurred in 2 patients who improved after medical therapy.During median 19.6 months (12-48 months) of follow-up,1 patient died and 1 patient progressed.Conclusions Despite the high risk of surgery,robot-assisted laparoscopic IVC thrombectomy for renal tumor with Mayo level Ⅲ-Ⅳ thrombus is feasible for experienced surgeons in selected patients.However,the oncological outcomes need further investigation.
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Objective To study the diagnosis and surgical outcomes of renal cell carcinoma with inferior vena cava tumor thrombus.Methods The clinical data from 31 cases of renal cell carcinoma with inferior vena cava tumor thrombus were retrospectively reviewed from January 2000 to December 2014.Among them,21 cases were male and 10 cases were female.The mean age ranged from 38 to 79 years,mean 57 years.The location of tumor included right renal in 29 cases and left renal in 2 cases.The distribution of the tumor thrombus was recorded as follow:level Ⅰ in 20 cases,level Ⅱ in 8 cases and level Ⅲ in 3 cases.All patients received radical nephrectomy and tumor thrombectomy.Ipsilateral subcostal oblique incision was chosen in 20 cases.Transrectus incision was chosen in 10 cases.And abdominal transperitoneal L shaped incision was chosen in 1 case.Three patients were given neoadjuvant molecular targeted therapies before operation.Results All patients accepted the operation successfully.There was no death during perioperative period.The pathological diagnosis showed clear cell carcinoma in 30 cases and chromophobe cell tumor in 1 case.The Fuhrman grading showed that 17 cases were grade Ⅱ,8 cases were grade Ⅲ and 5 cases were grade Ⅳ.Among them,the lymphatic metastasis in the renal hilum was found in 5 cases.After operation,16 patients received molecular targeted therapies,including sorafenib in 10 cases and sunitinib in 6 cases.Six patients were given autologous tumor lysate-pulsed dendritic cells co-cultured with cytokine induced killer cells treatment.The median overall survival was 44 months (range 4-60 months).The 1-,3-,and 5-year overall survival rates for all patients were 100％,52％,and 39％,respectively.There were significant differences of the overall survival rates between level Ⅰ / Ⅱ and level Ⅲ tumor thrombi(81.5％ vs 0) (P =0.012).Similar difference was noticed between Fuhrman grade Ⅱ and grade Ⅲ/Ⅳ (94.1％ vs 46.2％)(P =0.003).There was also significant difference between those with or without lymph node metastases (40.0％ vs 80.8 ％) (P =0.0 1 6).Conclusions Radical nephrectomy and tumor thrombectomy could improve the survival of patients of renal cell carcinoma with inferior vena cava tumor thrombus.The overall survival rate might be related to the tumor thrombus level,tumor grade,and local lymph node metastasis.
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Objective To assess the safety and feasibility of pure laparoscopic surgery for renal cell carcinoma with inferior vena cava tumor thrombus.Methods We retrospectively analyzed 6 cases of renal cell carcinoma with inferior vena cava tumor thrombus from December 2010 to October 2014.The patients were all male.Their age ranged from 50 to 69 years and the body mass index ranged from 21.6 to 30.9 kg/ m2.Clinical manifestations included painless hematuria in 4 cases,low back pain in 1 cases and physical examination noticing in 1 cases.Imaging suggested the right renal tumor in 4 cases and left renal tumor in 2 cases.The tumor size ranged from 4.0 to 10.6 cm.The inferior vena cava tumor thrombus was found in all patients,including type Ⅰ thrombus in 3 cases and type Ⅱ thrombus in 3 cases.The length of type Ⅱ tumor thrombus ranged from 4.0 to 4.2 cm.We completed pure laparoscopic nephrectomy and inferior vena cava tumor thrombectomy in all patients.We chose retroperitoneal laparoscopic surgery to treat right renal tumor with inferior vena cava thrombus and chose retroperitoneal combined with transperitoneal laparoscopic surgery to treat left renal tumor with inferior vena cava thrombus.Results All surgery were successful.Cancer embolus defluxion didn't occur during the opearation.The operation time was 224-873 min and the intraoperative blood loss was 200-5 000 ml.There were 4 patients get transfusion,which the transfusion volume ranged from 400 to 2 800 ml.For 1 case of left renal cell carcinoma with level Ⅱ inferior vena cava tumor,the operation time was 873 min,the blood loss was 5 000 ml,and the transfusion volume was 2 800 ml.Postoperative hospital stay was 7-14 days.And the pathological results were all renal clear cell carcinoma.In those patients,the Fuhrman grade classification was Ⅱ-Ⅲ.All patients were treated by targeted medicine to control tumor recurrence and metastasis.During the 6-48 months following up,no recurrence and metastasis were reported.Conclusions Pure laparoscopic surgery for right renal cell carcinoma with inferior vena cava tumor thrombus and left renal cell carcinoma with level Ⅰ inferior vena cava tumor thrombus is safe and feasible.However,long learning curve should be necessary for performing the left renal cell carcinoma with level Ⅱ inferior vena cava tumor thrombus.The effect of total laparoscopic surgery for renal cell carcinoma with inferior vena cava tumor thrombus is definite.
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The treatment of renal cacinoma with inferior vena cava tumor thrombus is priority to the surgery,because of serious tranma and high risk the traditional operative method.Surgical procedure has been developed and changes.The development and application of vascular intervcntional technique make operation more safe and convenient.This article summarizes the application of renal artery intervention,inferior vena cava filter,balloons and vascular endoscope in the treatment of renal carcinoma with inferior vena cave tumor thrombus.