En Bloc Resection of Right Renal Cell Carcinoma and Inferior Vena Cava Tumor Thrombus Without Caval Reconstruction: Is It Safe to Divide the Left Renal Vein?

Abstract

Introduction: It has been suggested that inferior vena cava (IVC) reconstruction following resection of retroperitoneal tumors with IVC tumor thrombus (TT) is not required when adequate collateral circulation is present. There are no reports evaluating mid-term effects on renal function in these patients. The purpose of this study was to assess renal function after en bloc resection of right renal cell carcinoma (RCC) with obstructing IVC TT and the possible risks that may arise after left renal vein division.

Materials and methods: A bi-institutional retrospective review was performed over a 15-year period, assessing patients with right RCC and obstructing level II-IV TT. All patients underwent extensive evaluation and cardiology clearance, and informed consent was obtained for right radical nephrectomy and thrombectomy with or without IVC reconstruction with possible cardiopulmonary bypass (CPB). Patient demographics, tumor characteristics, intraoperative factors, complications, length of stay, and patient survival were evaluated. Preoperative creatinine was recorded, as was creatinine on the day of discharge and at 6 and 12 months postoperatively.

Results: Twenty-two patients were included in the study. Median age at surgery was 62.5 (range: 45-79) years, and 19 (86%) of the patients were men. One patient (5%) had a level II thrombus, 14 patients (64%) had a level III thrombus (IIIa, n = 3; IIIb, n = 6; IIIc, n = 3; IIId, n = 2), and seven patients (32%) had a level IV thrombus. Intraoperatively, median estimated blood loss was 1.35 (range: 0.2-25) L. The median length of hospital stay was 11 (range: 5-50) days. Median preoperative creatinine was 1.20 (range: 0.40-2.70) mg/dl, and postoperatively, median creatinine was 1.3 (range: 0.86-2.20) mg/dl. Median creatinine levels at 6 months and 12 months postoperatively were 1.10 (range: 0.5-1.8) mg/dl and 1.40 (range: 0.6-2.0) mg/dl, respectively. Four patients died (range: 0.1-1.3 years), and median postoperative follow-up among the 18 ongoing survivors (at last follow-up) was 1.5 (range: 0.5-7.0) years.

Conclusions: Resection of right RCC with an obstructing level II-IV TT without reconstruction of the IVC appears to not have a significant adverse effect on mid-term renal function after division of the left renal vein.

Keywords: inferior vena cava thrombectomy; nephrectomy; oncology; renal cell carcinoma; tumor thrombus extending to inferior vena cava.

Figure 1

Neves and Zincke Classification System was used for level II and IV thrombus. Level III thrombi were classified as level IIIa (retrohepatic), level IIIb (hepatic), level IIIc (suprahepatic, infradiaphragmatic), or level IIId (supradiaphragmatic, infra-atrial).

Figure 2

Tumor thrombus (TT) removal avoiding the use of cardiopulmonary bypass (CPB). The central tendon of the diaphragm is opened vertically, and the pericardium is exposed. If more exposure is required, the pericardium may also be opened. Circumferential control of the inferior vena cava (IVC) at a suprahepatic level facilitates TT removal (A). The right atrium may be pulled downward through the diaphragm and into the abdomen, and the cranial end of the TT was controlled under Pringle maneuver conditions by cross-clamping the IVC above this level. Simultaneous transesophogeal echocardiography provides visual guidance during the performance of these maneuvers (B). When the tumor thrombus can be milked down distal to the major hepatic vein orifices, an endo-GIA stapler may be utilized to staple the IVC proximally. Once the IVC is stapled, the liver vascular flow can be reestablished by releasing the Pringle maneuver. The procedure is completed by stapling the IVC distally and the left renal vein close to its entrance in the vena cava (C).

Figure 3

Tumor thrombus removal by means of cardiopulmonary bypass. Cannulae are placed in the aortic root and the right atrium. If cardiac arrest is required, a vascular clamp is placed at the aortic arch proximally, and an additional cannula is placed for plegic solution release. Pringle maneuver is initiated, a right atriotomy is performed, and the large component of the tumor thrombus occupying the right atrium is removed through the atriotomy (A). The remaining tumor thrombus in the right atrium and proximal inferior vena cava is pushed downward through the atriotomy in a caudal direction. A longitudinal cavotomy permits the removal of the remaining tumor thrombus under direct visual control, ensuring the patency of the major hepatic veins ostia at the same time (B). Once the cranial thrombus component is removed, the inferior vena cava is stapled below the entrance of the major hepatic veins, the atriotomy is sutured closed, and the Pringle maneuver is released to reestablish the vascular flow into the liver. The procedure is completed by stapling the inferior vena cava distally and the left renal vein close to its ostium (C).

Figure 4

The inferior vena cava (IVC) was stapled at the level of the major hepatic veins (black arrow). The IVC with tumor thrombus (TT) is under the surgeon’s hand (white arrow) (A). Surgical specimen of a large right renal tumor (white arrow) with the IVC completely stapled containing the TT (black arrow) (B).