Circumferential Inferior Vena Cavectomy Without Caval Replacement in the Management of Renal Cell Carcinoma with Tumor Thrombus

Abstract

Purpose of review: Renal cell carcinoma presents a unique proclivity for vascular involvement giving rise to a peculiar form of locally advanced disease so-called tumor thrombus. To date, the only curative strategy for these cases remains surgery, which should aim to remove every vestige of macroscopic disease. Most of the preexisting literature advocates opening the vena cava to allow tumor thrombus removal and subsequent venous suture closure. However, inferior vena cava circumferential resection (cavectomy) without caval replacement is possible in the majority of cases since progressive occlusion facilitates the development of a collateral venous network aimed at maintaining cardiac preload.

Recent findings: Radical nephrectomy with tumor thrombectomy remains a surgical challenge not exempt of operative complications even in experienced hands. In opposition to what traditional cavotomy and thrombus withdrawal can offer, circumferential cavectomy without caval replacement would provide comparable or even better oncologic control, decrease the likelihood of operative bleeding, and prevent the development of perioperative pulmonary embolism. This review focuses on the rationale of circumferential IVC resection without caval replacement and the important technical aspects of this approach in cases of renal cell carcinoma with vascular involvement. We also include an initial report on the surgical outcomes of a contemporary series of patients managed under this approach at our center.

Keywords: Caval replacement; Circumferential cavectomy; Inferior vena cava; Renal cell carcinoma; Surgery; Tumor thrombus.

Fig. 1

A Inferior vena cava exhibiting a completely occlusive tumor thrombus (white arrow). B Stapling the left renal vein. C Stapling the inferior vena cava cranial to upper tumor thrombus limit. D Inferior vena cava has been removed en bloc with the nephrectomy specimen, the remaining infrarenal vena cava is shown. E Right renal cell carcinoma removed en bloc with the inferior vena cava. F Left renal cell carcinoma removed en bloc with the inferior vena cava