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Keywords:

  • inferior vena cava;
  • renal tumour;
  • tumour thrombus;
  • renal surgery;
  • radical nephrectomy

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. CONFLICT OF INTEREST
  9. REFERENCES

OBJECTIVE

To describe our experience of excising the inferior vena cava (IVC) without a graft; en bloc resection of a renal cell carcinoma (RCC) with the renal vein and vena cava tumour thrombus and a segment of the entire abdominal IVC is technically feasible, but traditionally, after resection, attempts are made to restore continuity with the use of synthetic or homologous venous grafts.

PATIENTS AND METHODS

Between May 1997 and September 2004, 60 patients (mean age 62 years) underwent surgical resection of a renal tumour with a thrombus extending into the IVC. To resect the entire evident tumour, excision of the affected portion of the IVC was required in three patients (5%); the IVC was not reconstructed.

RESULTS

The three patients were aged 38, 39 and 74 years; the mean operative duration was 5.88 h, the mean (range) estimated blood loss was 833 (500–1000) mL, the mean number of blood units transfused was 3.3 (0–7) units, and the mean follow-up was 24 months. The course after surgery was uneventful; specifically, none of the patients had a venous thrombosis or a pulmonary embolus.

CONCLUSIONS

RCC has a propensity to invade the renal vein and IVC. Occasionally the thrombus invades the wall of the IVC and complete removal requires excision of a circumferential portion of the IVC; this can be done safely without a graft.


Abbreviations
IVC

inferior vena cava.

INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. CONFLICT OF INTEREST
  9. REFERENCES

A unique aspect of RCC is its ability to invade vessels and induce a tumour thrombus. Occasionally the tumour thrombus extends into the inferior vena cava (IVC) and the tumour may invade the wall of the IVC. It is difficult, if not impossible, to determine before surgery whether the thrombus invades the wall of the IVC. Thus the surgical team must be prepared for several scenarios in an attempt to remove the entire tumour.

Unfortunately, there is no effective systemic therapy for RCC [1]. The development of innovative surgical techniques, specifically the use of liver transplant and organ-procurement methods, have made a major impact in the ability to safely resect large renal and adrenal tumours [2,3]. In certain circumstances, when the RCC with tumour thrombus extends into the IVC, the IVC can be resected and repaired primarily, or the continuity can be restored with a synthetic or homologous venous graft [4,5]. We report our experience with IVC resection for RCC, without use of a graft.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. CONFLICT OF INTEREST
  9. REFERENCES

Between May 1997 and September 2004, 60 patients with a preoperative diagnosis of RCC and a tumour thrombus in the IVC underwent surgical resection and removal of the tumour thrombus. The cranial extent of the tumour was partly defined as suggested by Neves and Zincke [6], but for a level III thrombus we used our modified definition [3]. Ten patients had a level I thrombus (renal vein only), six had a level II thrombus (infrahepatic IVC), 38 had a level III thrombus according to our definition [3], and six had a level IV (intra-atrial) thrombus. The tumour thrombus was successfully resected from the IVC in 57 patients, some of them with extension above the diaphragm [3] and including into the major hepatic veins, causing Budd–Chiari syndrome [7]. However, the IVC could not be dissected free of thrombus in three patients; one had an IVC filter embedded into the cava and tumour thrombus (see surgical technique). The other two had tumour thrombus adherent to the wall and during the thrombectomy the IVC disintegrated. The three patients were two men and one woman, aged 38, 39 and 74 years (Table 1). The renal tumour was on the right in two and the left in one. All patients were staged as level IIIa (intrahepatic) [3].

Table 1.  The demographic, operative and pathological findings of the three patients
Patient/ age/sexThrombus levelClinical diagnosisAdjunctive surgeryEstimated blood loss, mLPathology findingsFollow-up, months
1/38/MIIIaLeft renal massMobilization of pancreas and spleen Mobilization of liver (piggyback) Removal of the IVC and IVC filter1000RCC granular type26
2/39/FIIIaRight renal massMobilization of liver (piggyback) Resection of IVC with tumour thrombus Oversuturing distal and proximal IVC and  left renal vein 500RCC clear type24
3/74/MIIIaRight renal massMobilization of liver (piggyback Resection of IVC with tumour thrombus Anastomosis end-to-end of left renal vein  and proximal IVC1000Poorly differentiated RCC22

The initial evaluation included analysis of serum electrolytes, creatinine, blood urea nitrogen, alkaline phosphatase, liver function tests, chest X-ray, ultrasonography, chest and abdominal CT, and selective use of MRI. The thrombus level was ascertained by CT, MRI and echocardiography; preoperative embolization was not used.

SURGICAL TECHNIQUE

Our technique for resecting these large renal tumours was described previously [2,3]. We prefer a modified chevron incision, commencing ≈ 4 cm below the right costal margin and extending laterally to the mid-axillary line. This incision is extended left or right as required. In the midline it is extended vertically to the xiphoid process. The costal margins are splayed laterally toward the axillae with a Rochard retractor.

The liver can be rotated to the midline, after incising the different ligaments, exposing the retrohepatic IVC, and providing access to the branches from the caudate lobe to the IVC, which are individually ligated and divided. The only remaining structural attachments are the hepatic veins and the porta hepatis (‘piggyback’ liver mobilization) [2,3]. Therefore, this gives vascular exclusion of the retrohepatic IVC. This manoeuvre allows the hepatic veins to drain into the IVC, so as not to compromise cardiac return, avoiding hypotension, hepatic congestion and possible postoperative dysfunction. This technique also allows hepatic venous drainage during the resection of the IVC. Natural collateral channels, such as the gonadal vein, ascending lumbar veins and the azygous/hemiazygous system, should not be ligated during dissection of the IVC. We think that these channels are important for providing a natural bypass and facilitating safe cross-clamping of the IVC [8].

The kidney mobilization begins laterally and posteriorly with special attention to the perirenal collateral circulation. A posterior approach to 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. Ligation of the renal artery collapses the collateral circulation and facilitates the rest of the dissection [9].

A plane is created between the IVC and posterior abdominal wall; the advantage of creating this plane is to facilitate circumferential control of the IVC. Vascular isolation of the IVC is achieved superiorly and inferiorly to the thrombus, including the left or right renal vein. The advantage of mobilizing the IVC from the posterior abdominal wall is realized at this point. The intra-abdominal IVC can be resected in a bloodless surgical field. In the first patient, the segment of the IVC was resected with the left renal vein and the IVC was oversutured proximally and distally (Fig. 1). The resection of the IVC and the tumour thrombus was a particular challenge in this patient, as he had an IVC filter which was placed at another hospital before referral to our centre (Fig. 2). The second patient had a right nephrectomy and the proximal and distal segment of the intra-abdominal IVC was also removed. The left renal vein, the distal and the proximal IVC at the level of the hepatic veins were oversutured (Fig. 3). The last patient had the same resection as the previous one, but in his case a large segment of the left renal vein was removed. The remaining left renal vein was anastomosed end-to-end to the proximal IVC to avoid renal dysfunction (Fig. 4).

image

Figure 1. Ligation of the IVC distal to the renal vein with maintenance of continuity of the right renal vein and the proximal inferior vena cava.

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image

Figure 2. Tumour thrombus growing into an IVC filter (arrow), which was placed to prevent pulmonary embolus.

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Figure 3. a, Reconstruction after resecting the tumour thrombus along with the whole wall of the IVC. A; The proximal IVC was oversutured almost at the level of the major hepatic veins. B, left renal vein. C, distal IVC. b, Illustration of the operative site after tumour, tumour thrombus and IVC resection.

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image

Figure 4. Ligation of the distal IVC with maintenance of venous drainage of the left kidney by end-to-end anastomosis between the proximal IVC and the left renal vein.

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RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. CONFLICT OF INTEREST
  9. REFERENCES

The three patients had a radical nephrectomy with complete extraction of tumour thrombus and resection of the abdominal IVC. The extensive mobilization provided a bloodless area in a deep retrohepatic field, to remove the primary tumour, the thrombus and the segment of the IVC. The level of the thrombus on CT or MRI correlated with intraoperative findings.

The mean (range) operative duration was 5.88 (6.11–8.08) h, the estimated blood loss was 833 (500–1000) mL, the mean number of blood units transfused during surgery was 3.3 (0–7) units and the size of the renal mass was 10 (8–14) cm. Pathological examination revealed RCC of the clear type in two patients; the third had a papillary RCC. The median hospital stay was 8 days and the mean follow-up 24 months; all patients are disease-free.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. CONFLICT OF INTEREST
  9. REFERENCES

Few renal tumours extend into the IVC and it is relatively rare for the tumour thrombus to invade the IVC. It is reported that when the IVC is chronically obstructed by a tumour thrombus, caval resection produces minimal postoperative morbidity [10]. In the present three patients, resection of the IVC caused no morbidity or mortality directly associated with the surgery. These three patients had complete occlusion of the IVC by the tumour thrombus, and adequate collateral vessels were presumed to be present. Before surgery the patients had no oedema of the lower extremities, and this did not occur after surgery. If collateral circulation is not present, resecting the IVC can be associated with severe oedema of the lower extremities [11]. In this setting, reconstructing the IVC should be considered and may be done with a PTFE graft [4], but the main concern with using prosthetic grafts for vein replacement is their tendency to thrombose or become infected, and therefore autologous vein graft [4] and pericardium [12] are the preferred graft materials. Resecting the IVC is not always necessary when the tumour thrombus extends into the caval lumen, when a cavatomy with removal of an intact specimen may be sufficient. When the tumour thrombus may be extensively invading or is densely adherent to the cava or there is an IVC filter that cannot be safely removed, as was found in the present patients, caval resection with no replacement seems a reasonable approach.

The patient in whom we resected the IVC and ligated the left renal vein had adequate renal function after surgery; the left kidney is drained by a rich collateral network, which is not the case with the right kidney [13].

Thus resection of the IVC en bloc with RCC and tumour thrombi can be done with no need for IVC reconstruction. Complete ‘piggyback’ liver mobilization [2,3] facilitates thrombectomy because cavotomy may be extended cranially to remove any adherent tumour thrombus. The excellent exposure provided with the piggyback mobilization facilitates complete tumour extraction and/or complete removal of the IVC. Although prosthetic grafts can be successfully placed in this setting, we have avoided them and the associated anticoagulant therapy, with success. Removing the RCC with tumour thrombus is a challenge, more so in situations where there is a need to remove the intra-abdominal IVC.

ACKNOWLEDGEMENTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. CONFLICT OF INTEREST
  9. REFERENCES

The authors thank Claudia Gutierrez for her expertise with the illustrations.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. CONFLICT OF INTEREST
  9. REFERENCES