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INDICATIONS

  1. Top of page
  2. INDICATIONS
  3. METHODS
  4. SURGICAL TECHNIQUE
  5. COMPARISON WITH OTHER METHODS
  6. ADVANTAGES AND DISADVANTAGES
  7. REFERENCES

Significant bleeding during radical nephrectomy may occur for several reasons. The kidney is extremely vascular; when tumour is present, new vessels can augment the baseline vascularity and the engorged veins readily bleed [1]. These venous collaterals tend to concentrate toward the hilum anteriorly for a right-sided renal cancer. The usual plane between the ascending colon, duodenum and Gerota's fascia often contains many varices. Although this seems more common in patients with an inferior vena cava (IVC) thrombus, those with large hypervascular tumours with no IVC extension can have similar collaterals [2] (Fig. 1) .

image

Figure 1. A renal tumour with a tumour thrombus extending into the IVC showing aberrant collateral circulation mainly at the level of the renal hilum.

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For decades there has been a debate on the advantages of preoperative embolization of the renal artery to facilitate a subsequent radical nephrectomy [3]. The rational for embolization was: (i) decreasing the size of the primary tumour; (ii) decreasing the venous collaterals; and (iii) decreasing the size of the IVC thrombus. Preoperative embolization is not without risks, including: (a) a systemic reaction to embolization consisting of pain and fever and leucocytosis [4–6]; (b) embolization of other than the target organ [7–10]; and (c) tumour embolization from the devascularized IVC thrombus [11].

The emphasis of the present report is twofold, i.e. to propose and reaffirm early surgical ligation of the renal artery as opposed to preoperative embolization, and to describe a posterior approach to the renal artery as the first step in the dissection, as opposed to developing a plane between the colon and Gerota's fascia to access the hilum. This manoeuvre allows the collateral circulation to decrease without compromising the haemodynamic status of the patient, especially when the IVC is involved with tumour thrombus.

METHODS

  1. Top of page
  2. INDICATIONS
  3. METHODS
  4. SURGICAL TECHNIQUE
  5. COMPARISON WITH OTHER METHODS
  6. ADVANTAGES AND DISADVANTAGES
  7. REFERENCES

Between May 1997 and October 2002, 82 patients (50 men and 32 women, mean age 60 years, range 25–83) with a preoperative clinical diagnosis of RCC underwent surgery; 42 had a tumour thrombus in the IVC at various levels.

SURGICAL TECHNIQUE

  1. Top of page
  2. INDICATIONS
  3. METHODS
  4. SURGICAL TECHNIQUE
  5. COMPARISON WITH OTHER METHODS
  6. ADVANTAGES AND DISADVANTAGES
  7. REFERENCES

A right or left subcostal incision was made ≈ 4 cm below the costal margin, extending laterally to the mid-axillary line. This incision was extended to the left as far laterally as required and in the midline vertically up to the xiphoid process. A Rochard self-retaining retractor was placed during this procedure. This instrument elevates the costal margins and splays them laterally toward the axillae. The everted costal margin tends to flatten the diaphragm. This exposure enables easier liver mobilization or en bloc mobilization of stomach, pancreas and spleen, and access to the retrohepatic space [12,13]. The main principle of surgical treatment included resection of Gerota's fascia and its content, with an early ligation of the renal artery. The kidney mobilization begins laterally and posteriorly with special attention to the perirenal collateral circulation. This posterior approach of renal artery ligation encounters fewer varices or collaterals than the more traditional anterior approach. The kidney is mobilized medially and the renal artery identified, ligated and divided (Fig. 2) . Once the renal artery is ligated the collateral circulation collapses, making the rest of the dissection easier. In all the patients this manoeuvre was used with no complications, allowing early vascular control. There was no intraoperative mortality, re-operations or postoperative complications and no patients had a pulmonary embolus during or after the surgical resection.

image

Figure 2. Mobilization of the kidney medially showing the posterior approach. The renal artery is ligated and ready to be cut.

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COMPARISON WITH OTHER METHODS

  1. Top of page
  2. INDICATIONS
  3. METHODS
  4. SURGICAL TECHNIQUE
  5. COMPARISON WITH OTHER METHODS
  6. ADVANTAGES AND DISADVANTAGES
  7. REFERENCES

Transcatheter arterial embolization (TAE) of the renal blood supply is another method for collapsing the collateral circulation, introduced by Almgård et al.[14] to cause artificial necrosis and improve the management of renal tumour. TAE was used to facilitate radical nephrectomy, decrease operative blood loss and cause oedema in tissue planes [15]. At present this procedure is used as preoperative or palliative treatment in the management of RCC, but it remains controversial [16].

Effective TAE renders the tumour thrombus necrotic with the resulting risk of embolization [11]. Hirota et al.[17] preferred the prophylactic placement an IVC filter to prevent tumour emboli after TAE. The current approach of early ligation of the renal artery has the same outcome as TAE without increasing the risk of pulmonary tumour emboli. Another disadvantage of TAE is the postinfarction syndrome, with flank pain, fever and impaired general condition [3–5]. More serious complications are the consequences of unintentional embolization of other than target organs, e.g. large bowel, spinal cord, or the contralateral kidney. Tubular necrosis, renal abscess and alteration in blood pressure have also been reported [6–9].

ADVANTAGES AND DISADVANTAGES

  1. Top of page
  2. INDICATIONS
  3. METHODS
  4. SURGICAL TECHNIQUE
  5. COMPARISON WITH OTHER METHODS
  6. ADVANTAGES AND DISADVANTAGES
  7. REFERENCES

Chronic occlusion of the suprarenal IVC is associated with an aberrant systemic venous drainage, and this collateral circulation is usually carried by the vena azygos, by means of its extensive communication with the lumbar and renal veins, or through extensive perirenal collateral circulation. Staehler et al.[18] favoured preoperative embolization of the renal supply. Occlusion of the renal supply before surgery causes collapse of many of these veins and facilitates mobilization of the renal tumour. We did not use embolization before surgery in the present patients but the primary goal at the beginning of the surgery was to ligate the renal artery, causing the same effect of collapsing the collateral circulation. This was achieved by mobilising the kidney and ligating the renal artery from behind the renal vein. There are no apparent disadvantages of this manoeuvre, which is part of the surgery for radical nephrectomy.

REFERENCES

  1. Top of page
  2. INDICATIONS
  3. METHODS
  4. SURGICAL TECHNIQUE
  5. COMPARISON WITH OTHER METHODS
  6. ADVANTAGES AND DISADVANTAGES
  7. REFERENCES
  • 1
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  • 2
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  • 3
    Smith RB. Complications of renal surgery. In SmithRB, EhrlichRM eds, Complications of Urologic Surgery: Prevention and Management. Philadelphia: WB Saunders, 1990: 12859
  • 4
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    Bono AV, Caresano A. The role of embolization in the treatment of kidney carcinoma. Eur Urol 1983; 9: 3347
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    Wallace S, Chuang VP, Swanson D et al. Embolization of renal carcinoma. Radiology 1981; 138: 56370
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    Ciancio G, Hawke C, Soloway M. The use of liver transplant techniques to aid in the surgical management of urological tumors. J Urol 2000; 164: 66572
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    Ciancio G, Vaidya A, Savoie M, Soloway M. Management of renal cell carcinoma with level III thrombus in the inferior vena cava. J Urol 2002; 168: 13747
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    Almgård LE, Fernström I, Haverling M, Ljungquist A. Treatment of renal adenocarcinoma by embolic occlusion of the renal circulation. Br J Urol 1973; 45: 4749
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    Kalman d Varenhorst e. The role of arterial embolization in renal cell carcinoma. Scand J Urol Nephrol 1999; 33: 16270
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    Zielinski H, Szmigielski S, Petrovich Z. Comparison of preoperative embolization followed by radical nephrectomy with radical nephrectomy alone for renal cell carcinoma. Am J Clin Oncol 2000; 23: 612
  • 17
    Hirota S, Matsumoto S, Ichikawa S et al. Suprarenal Inferior Vena Cava filter placement prior to transcatheter arterial embolization (TAE) of a renal cell carcinoma with large renal vein tumor thrombus: Prevention of pulmonary tumor emboli after TAE. Cardiovasc Intervent Radiol 1997; 20: 13941
  • 18
    Staehler G, Brkovic D. The role of radical surgery for renal cell carcinoma with extension into the vena cava. J Urol 2000; 163: 6715
Abbreviations
IVC

inferior vena cava

TAE

transcatheter arterial embolization.