Vascular stapling of the inferior vena cava: further refinement of techniques for the excision of extensive renal cell carcinoma with unresectable vena-caval involvement

Abstract

Objectives: To present our experience with a novel technique of tumor removal: en bloc resection of the tumor, thrombus, and inferior vena cava (IVC) via vascular staple ligation and excision, and to excise all tumor, which may include a portion of the IVC when invasion is present. Management of renal cell carcinoma (RCC) with IVC thrombus presents a challenge. Options for tumor excision include thrombectomy with or without cardiopulmonary bypass, replacement of the cava with synthetic or venous graft, or caval excision without replacement.

Methods: Six patients with extensive RCC with IVC thrombus were evaluated. All patients underwent preoperative imaging that depicted completely obstructing IVC thrombus of varying cranial extension with apparent invasion of the caval wall. None had lower extremity edema. Patients underwent IVC staple ligation and en bloc resection of tumor and thrombus. Pre-, intra-, and postoperative as well as pathological factors were measured. These included estimated blood loss, transfusions, and procedure length. Inpatient factors including duration of intubation, length of intensive care unit stay, and overall length of stay were recorded. Tumor-free status was evaluated.

Results: All patients had Fuhrman Grade 4 RCC. No perioperative deaths occurred. Mean estimated blood loss was 6350 mL (range 900-25 000). Length of intubation averaged 1.5 days. Mean intensive care unit stay was 4.3 days. Overall length of stay averaged 9.3 days.

Conclusions: Complete excision of a portion of the IVC, using a vascular stapler in conjunction with radical nephrectomy is a satisfactory method to remove RCC with IVC invasion. Sufficient collateral circulation exists for venous return from the lower extremities.