Surgical technique for the treatment of renal cell carcinoma with inferior vena cava tumor thrombus: tips, tricks and oncological results

Vital Hevia, Gaetano Ciancio, Victoria Gómez, Sara Álvarez, Víctor Díez-Nicolás, Francisco Javier Burgos, Vital Hevia, Gaetano Ciancio, Victoria Gómez, Sara Álvarez, Víctor Díez-Nicolás, Francisco Javier Burgos

Abstract

Renal cell carcinoma represents 3 % of all cancers. Around 4-10 % of cases present with inferior vena cava involvement, generally with tumor thrombus. Clinical and preoperative stage will be classified depending of the thrombus extension. A high quality preoperative workup is essential to properly plan surgical approach. Complete surgical resection of the tumor is potentially the only curative treatment, although it supposes a real challenge due to operative difficulty, potential for massive bleeding or tumor pulmonary thromboembolism. Surgery includes techniques derived from transplantation surgery and, in some cases, cardiovascular intervention with cardiopulmonary bypass. Long-term oncological outcomes after complete removal of the entire tumor burden are acceptable. In this report we describe step-by-step surgical maneuvers depending on the thrombus lever, and focusing in complete abdominal approach for the complete excision of the tumor. Moreover, a recent literature review about oncological results is reported.

Keywords: Inferior vena cava; Renal cell carcinoma; Surgical management; Tumor thrombus.

Figures

Fig. 1
Fig. 1
CT scan showing a large right renal cancer with IVC thrombus above hepatic veins but below diaphragm (IIIc)
Fig. 2
Fig. 2
Subclassification of level III thrombus. IIIa: below hepatic veins. IIIb: reaching hepatic veins. IIIc: above hepatic veins. IIId: above diaphragm (from Ciancio et al. 2002)
Fig. 3
Fig. 3
Chevron incision with Rochard retractor, enabling correct exposure of upper abdominal quadrants
Fig. 4
Fig. 4
Early access and ligation of the renal artery during a left radical nephrectomy and IVC thrombectomy. The artery is dissected outside Zuckerkandl’s fascia and prior to perform the kidney’s anterior surface dissection
Fig. 5
Fig. 5
Piggy-back maneuver. Liver mobilization off the IVC, remaining attached by suprahepatic veins in their confluent with suprahepatic IVC
Fig. 6
Fig. 6
Complete liver mobilization and circumferential IVC dissection, gaining total vascular control. Minor hepatic veins draining from right and caudate hepatic lob are ligated
Fig. 7
Fig. 7
Supradiaphragmatic and intrapericardial IVC dissection, which will be necessary for level IIId and IV thrombus
Fig. 8
Fig. 8
cavotomy and complete thrombectomy. Closure of the IVC is done with 4-0 non-absorbable running suture
Fig. 9
Fig. 9
placement of a PTFE prosthesis after IVC resection, with end-to-side anastomosis to left renal vein

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