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Keywords:

  • venous tumour thrombus;
  • surgical management;
  • outcomes
Abbreviations
VTT

venous tumour thrombus

TEE

trans-oesophageal echocardiography

IVC

inferior vena cava

CPB

cardiopulmonary bypass

HCA

hypothermic circulatory arrest.

INTRODUCTION

  1. Top of page
  2. INTRODUCTION
  3. PREOPERATIVE EVALUATION
  4. SURGICAL MANAGEMENT
  5. RESULTS
  6. COMPLICATIONS
  7. FUTURE DIRECTIONS AND CONCLUSIONS
  8. CONFLICT OF INTEREST
  9. REFERENCES

RCC is associated with a particular biological propensity for vascular invasion, with up to 10% of patients having associated venous tumour thrombus (VTT) involving the renal vein or inferior vena cava (IVC) [1], and ≈ 1% having a tumour thrombus that extends into the right atrium. The presence of a VTT, with its associated risks of venous congestion and distal embolism, adds immediacy to the management of such patients for the urologist. In addition, the often associated parasitic vasculature and collaterals that develop as a result of vena caval occlusion increase the technical difficulty of nephrectomy. Nevertheless, previous reports have shown that aggressive surgical resection of these lesions can produce long-term freedom from disease [2–10].

At the same time, recent advances in cross-sectional imaging have led to a more precise delineation of what are not infrequently massive primary tumours, and have improved the ability to detect the extent of the VTT, thereby aiding the planning of the optimal management approach. Also, improved support before and during surgery now allows more patients to be considered for aggressive surgery [11,12]. At our centre, the above factors have led to a gradual increase over time in the number of patients treated surgically for RCC with IVC VTT. The aim of this review is to outline key points in the assessment and management of these complex patients, and to discuss outcomes after surgical resection.

PREOPERATIVE EVALUATION

  1. Top of page
  2. INTRODUCTION
  3. PREOPERATIVE EVALUATION
  4. SURGICAL MANAGEMENT
  5. RESULTS
  6. COMPLICATIONS
  7. FUTURE DIRECTIONS AND CONCLUSIONS
  8. CONFLICT OF INTEREST
  9. REFERENCES

While RCC can present in a wide variety of clinical scenarios, ranging from incidental detection to local or metastatic manifestations, most patients with VTT are symptomatic at the time of presentation [13,14]. Symptoms can result from local tumour growth, e.g. flank pain or haematuria, be constitutional, including fatigue, weight loss, or various paraneoplastic syndrome, or be the result of thrombus-related occlusion of the IVC, including lower extremity oedema, new-onset varicocele, or, in the case of thrombus dislodgement, pulmonary embolus.

Paramount to the appropriate preoperative evaluation of these patients are well-performed cross-sectional imaging studies. Although CT is frequently the initial imaging method leading to the diagnosis of these tumours, MRI has been established as the study of choice to determine the extent of VTT, the degree of IVC occlusion, and the presence of bland thrombus in the infra-renal IVC [15]. Moreover, we have noted a rapid progression rate for IVC VTT, exceeding the reported rates for primary renal tumours; therefore, recent imaging studies must be obtained before proceeding with surgical resection. If VTT is found to extend into the right atrium or if pulmonary emboli are suspected, further preoperative assessments including trans-oesophageal echocardiography (TEE) or CT-angiography of the pulmonary vasculature might be considered.

Based on these imaging studies, several different staging strategies have been proposed for patients with VTT. For example, according to the 2002 TNM system, patients are classified as T3b with infra-diaphragmatic VTT and T3c with supra-diaphragmatic VTT [16]. We prefer the classification scheme proposed by Montie et al.[7], listed in Table 1, which is more specific for the level of VTT, particularly as the level of involvement of the vena cava has implications for the surgical approach.

Table 1.  Classification by tumour thrombus level
Tumour thrombus levelDefinition
0Thrombus limited to the renal vein, detected clinically or during assessment of  the pathological specimen
IThrombus extending into IVC, <2 cm above renal vein
IIThrombus extending >2 cm above the renal vein but below the hepatic veins
IIIThrombus at the level of or above the hepatic veins, but below the diaphragm
IVThrombus extending above the diaphragm

In addition, patients with evidence of bland thrombus on preoperative imaging are started on systemic anticoagulation to prevent the propagation of the bland thrombus, which can cause contralateral renal vein thrombosis, and which serves as a nidus for distal embolization. The use of i.v. heparin in this setting allows close monitoring of anticoagulation values, and rapid withdrawal immediately before surgery.

Moreover, some institutions favour angio-embolization of the kidney before surgery, which has been variably suggested to decrease intraoperative blood loss, facilitate an early approach to the renal hilum, and result in partial regression of the VTT. Nevertheless, reports supporting this are scarce to date, and we do not routinely use angio-embolization before nephrectomy with planned tumour thrombectomy.

SURGICAL MANAGEMENT

  1. Top of page
  2. INTRODUCTION
  3. PREOPERATIVE EVALUATION
  4. SURGICAL MANAGEMENT
  5. RESULTS
  6. COMPLICATIONS
  7. FUTURE DIRECTIONS AND CONCLUSIONS
  8. CONFLICT OF INTEREST
  9. REFERENCES

The goal of surgery for patients with RCC involving the vena cava is to resect the entire tumour burden. In addition to nephrectomy with caval thrombectomy, this might require caval resection and/or reconstruction, resection of retroperitoneal lymph nodes, or metastectomy. Moreover, nephrectomy for these cases most often involves radical nephrectomy. Partial nephrectomy has been attempted in patients with a solitary kidney and associated VTT, but was associated with a need for radical nephrectomy in four of 22 patients, and oncological success was reported in only a third of patients [17].

For the surgical approach, we use an anterior subcostal or midline abdominal incision when a bypass is unlikely, while if cardiopulmonary bypass (CPB) is clearly planned before surgery we favour a midline abdominal incision with extension to sternotomy. A minimal-access approach, involving cannulation of the right subclavian artery through an infraclavicular incision and the right atrium through a small right parasternal incision, was recently described as an alternative to the median sternotomy for establishing CPB with hypothermic circulatory arrest (HCA) [18]. This approach was associated with faster surgery, shorter hospital stay, and less requirement for mechanical ventilation and transfusion [18]. In addition, for patients who have had previous cardiac surgery, a right thoraco-abdominal incision can be used. Laparoscopic approaches to radical nephrectomy with vena caval VTT have been described [19], but currently are only applicable to selected cases with a low-level thrombus, and even then only in expert hands.

Once the kidney and anterior surface of the great vessels have been exposed, the operation proceeds in three steps: (i) ligation of the renal artery; (ii) vena caval tumour thrombectomy; and then (iii) nephrectomy. Indeed, we consider that these cases should be thought of as an operation on the IVC and then an operation on the kidney. Our first step here is early ligation of the renal artery, as it reduces bleeding from venous collaterals and often causes the VTT to shrink. For tumours arising in the right kidney, the artery is usually approached in the inter-aortocaval space to minimize manipulation of the right renal vein and IVC [13].

The IVC tumour thrombectomy is approached according to the extent of the VTT. Level 0 or I tumours can be treated in a similar fashion, as level 1 thrombi by definition extend minimally into the IVC, and are therefore frequently reducible into the renal vein and can usually be encompassed within an appropriately shaped vascular clamp placed so as not to occlude IVC flow. The ostium of the renal vein is circumscribed, allowing removal of the tumour thrombus in continuity with the kidney and the renal vein. The caval defect is oversutured using continuous 4/0 polypropylene suture.

Level II tumours often necessitate extensive mobilization of the IVC, including in some cases ligation and division of lumbar veins, to gain control of the IVC proximal and distal to the VTT. However, in most cases vascular bypass is not necessary for level II tumours. Once adequate exposure has been obtained, the IVC is occluded by placing clamps or Rummel tourniquets sequentially on the suprarenal IVC above the thrombus, which can be identified within the cava by gentle palpation, then on the contralateral renal vein, and lastly on the infrarenal IVC. Accessory hepatic veins from the caudate lobe to the IVC might need to be ligated and divided to facilitate cephalad exposure of the cava and clamp placement. After ensuring vascular control, the IVC is opened in an ‘L’ shape, from the renal ostium cephalad over the tumour [13]. The thrombus is gently dissected away from the wall of the IVC, and the ostium of the renal vein is circumscribed and removed with the kidney. The lumen of the IVC is flushed and inspected, and residual tumour thrombus is removed; caval resection or biopsies can sometimes be indicated to achieve negative surgical margins. The cavotomy is closed as described for Level I tumours, taking care to expel clot and air as the last suture is tightened, by releasing the infrarenal clamp and allowing back-bleeding. The remaining clamps on the contralateral renal vein and suprarenal IVC are then also released.

Level III tumours can be the most challenging, both to accurately identify (given their retrohepatic nature, and the proximity of the confluence of the hepatic veins with the right atrium) and to approach (given the difficulty of IVC exposure at this level); thus a single management strategy cannot be applied to all patients with a level III thrombus [20]. The decision on the optimal management is made based on both preoperative imaging features of the IVC, specifically the degree of occlusion, extent of associated bland thrombus, together with intraoperative monitoring using TEE. Resection in many of these cases can be completed intra-abdominally, as described for level II tumours, with the addition of liver transplant techniques such as mobilization of the right lobe of the liver, which exposes the retrohepatic and suprahepatic IVC to allow clamping above the cephalad extent of the thrombus [12,14]. Ideally with this approach, the thrombus can be milked below the hepatic venous confluence, allowing the IVC to be clamped below the entry of the hepatic veins and thereby avoiding liver congestion [14]. If this is not possible, use of the Pringle manoeuvre is common to control hepatic inflow. However, even in this case an abdominal approach, which avoids the morbidity of a sternotomy and the need for vascular bypass, is preferred where feasible.

However, vascular bypass is not infrequently required for the safe and complete resection of level III tumours. In particular, vascular bypass is indicated in cases where the patient is thought not to be able to tolerate cross-clamping and the subsequent decrease in cardiac output without significant resulting hypotension, and in cases where cross-clamping is noted to result in extensive haemorrhage from venous collaterals. To avoid these situations, we routinely observe the effects of cross-clamping before proceeding with cavotomy [13]. Once the need for a bypass is established, several options remain. Traditionally, vascular bypass for tumour thrombus cases has consisted of CPB with hypothermic (to 18 °C) HCA. With hypothermic arrest, a relative bloodless field is available for cavotomy and thrombectomy, but the cooling and re-warming process, together with the need for anticoagulation that accompanies CPB, increases operative times, anaesthesia times, and the risk of postoperative coagulopathy.

Recently therefore we have begun to use veno-venous vascular bypass for most level III tumour thrombus cases, as well as for the few level II thrombi that require a bypass for resection. Veno-venous bypass allows the surgeon to avoid the hypotension that can occur during vena caval occlusion, while performing an unhurried inspection and repair of the IVC. Veno-venous bypass is initiated after adequate mobilization of the IVC by placing a 20 F venous cannula through a purse-string suture in the IVC, well-below the caudal extent of the thrombus. A 8–14 F venous cannula is then introduced into the right atrium or right brachial vein to provide venous return. Each cannula is connected to an electromagnetic centrifugal pump via modified heparin-bonded Gott aneurysm shunt tubing, and the bypass is initiated. With veno-venous bypass we have previously reported a peri-operative complication rate of 17%, compared to 31% for CPB with HCA [13]. Our updated surgical outcomes by thrombus level are reported in Table 2.

Table 2.  Surgical characteristics by tumour thrombus level for patients with IVC VTT
CharacteristicVTT level
IIIIIIIV
  1. NA, not available.

Number of patients73 93 35 32
N (%):
Intraoperative TEE 0  2 (2.2) 10 (28.6) 24 (75.0)
Type of incision
 abdominal73 (100) 84 (90.3) 27 (77.1)  1 (3.1)
 thoracoabdominal 0  9 (9.7)  7 (20.0)  2 (6.3)
 abdominal/mediastinal 0  0 (0.0)  1 (2.9) 29 (90.6)
Resection of IVCNA  8 (8.6)  4 (11.4)  11 (34.4)
Occluded IVC
 partial73 (100) 69 (74.2) 24 (68.6) 28 (87.5)
 complete 0 24 (25.8)  11 (31.4)  4 (12.5)
IVC clips used 0  9 (9.7)  6 (17.1)  7 (21.9)
Liver mobilized 0  7 (7.5)  9 (25.7)  2 (6.3)
Pringle manoeuvre 0  7 (7.5)  6 (17.1)  3 (9.4)
Extra-corporeal circulation
 none73 (100) 90 (96.8) 27 (77.1)  2 (6.3)
 CPB 0  0 (0.0)  0 (0.0)  6 (18.8)
 CPB/HCA 0  1 (1.1)  6 (17.1) 15 (46.9)
 venous 0  2 (2.2)  2 (5.7)  9 (28.1)
Median (range) duration, min, of:
 CPBNANA 60 (20–123) 75 (11–214)
 HCANA 29 (23–35) 18 (15–28) 18 (13–38)
 surgeryNA241.5 (155–378)270 (186–497)325 (178–535)
 anaesthesiaNA288.5 (212–446)331 (230–548)396 (245–568)

We usually approach the resection of level IV tumours in conjunction with the cardiothoracic surgeons, using CPB and HCA. However, recently we have also used a veno-venous bypass for level IV tumours, particularly when the TEE shows a free-floating thrombus that can easily be reduced below the diaphragm. Alternatively, a completely intra-abdominal approach has been described for level IV tumours [21]. The liver is completely mobilized in this technique, with division of the right and left triangular ligaments, and the right inferior and superior coronary ligaments. The central diaphragm tendon is dissected until the supradiaphragmatic, intrapericardial IVC is visualized. Through this exposure the authors report that they have been able to clamp the right atrium and perform caval thrombectomy without entering the chest.

A final technical point here is that, regardless of thrombus level, suspected invasion of the IVC wall necessitates partial or total resection. Subsequently, IVC reconstruction can entail placing a biological or synthetic patch or tube graft. Alternatively, a totally occluded IVC can safely be ligated using a vena caval clip or vascular stapler. Anticoagulation with coumadin is routine after surgery for patients who undergo caval ligation or extensive caval resection at the time of thrombectomy.

RESULTS

  1. Top of page
  2. INTRODUCTION
  3. PREOPERATIVE EVALUATION
  4. SURGICAL MANAGEMENT
  5. RESULTS
  6. COMPLICATIONS
  7. FUTURE DIRECTIONS AND CONCLUSIONS
  8. CONFLICT OF INTEREST
  9. REFERENCES

In updating our experience, currently with 659 patients with RCC and VTT, 614 (93.2%) were found to have clear cell RCC. Therefore, our subsequent review is restricted to the associated pathological features and clinical outcome in patients with clear cell RCC and associated VTT (Table 3, Fig. 1). About 40% of patients with a VTT had either distant metastases (28.5%) or regional lymph node involvement (11.7%) at the time of surgical resection. These findings portend a significantly worse prognosis, with a 5-year cancer-specific survival of 15–20% with either, and only 4% with both, compared to almost 60% in patients with neither adverse pathological feature (Fig. 1a). We also found that the conventional prognostic factors for RCC, e.g. tumour stage, grade, coagulative necrosis and sarcomatoid differentiation, were also associated with the outcome of patients with RCC and associated VTT (Table 3). Other investigators have similarly reported a predictive value for tumour stage and grade in patients with RCC and vena caval thrombus [14].

Table 3.  Pathological features and cancer-specific survival for 614 patients with clear cell RCC
FeatureN (%)5-year CSS, % (sem, no. at risk)P
2002 Primary tumour classification
 pT3b566 (92.2)44.6 (2.3, 171)<0.001
 pT3c 27 (4.4)47.4 (12.5, 6) 
 pT4 21 (3.4) 5.2 (5.0, 1) 
Regional lymph node involvement
 pNx/pN0542 (88.3)47.3 (2.4, 171)<0.001
 pN1/pN2 72 (11.7)14.2 (4.6, 7) 
Distant metastases
 pM0439 (71.5)55.4 (2.7, 163)<0.001
 pM1175 (28.5)13.3 (2.9, 15) 
Combination of N and M stage
 pN0/pNx, pM0397 (64.7)59.0 (2.8, 157)<0.001
 pN1/pN2, pM0 42 (6.8)22.7 (7.1, 6) 
 pN0/pNx, pM1145 (23.6)15.5 (3.4, 14) 
 pN1/pN2, pM1 30 (4.9) 3.7 (3.6, 1) 
Nuclear grade
 1 14 (2.3)92.3 (7.4, 12)<0.001
 2108 (17.6)67.3 (4.9, 57) 
 3380 (61.9)42.1 (2.9, 101) 
 4 112 (18.2)14.2 (4.0, 8) 
Coagulative tumour necrosis
 No277 (45.1)62.9 (3.2, 125)<0.001
 Yes337 (54.9)26.3 (2.8, 53) 
Sarcomatoid differentiation
 No558 (90.9)47.2 (2.3, 177)<0.001
 Yes 56 (9.1) 2.6 (2.6, 1) 
image

Figure 1. The estimated cancer-specific survival (sem, number still at risk) rates at 5 years for 614 patients with clear cell RCC: A , with pN0/pNx pm0, pN1/pN2 pm0, pN0/pNx pm1, and pN1/pN2 pm1 RCC; values were 59.0% (2.8%, 157), 22.7% (7.1%, six), 15.5% (3.4%, 14), and 3.7% (3.6%, one), respectively (P < 0.001); B , with level 0, I, II, III, and IV VTT; the rates were 48.9% (2.8%, 134), 34.6% (6.4%, 17), 24.8% (5.4%, 13), 37.3% (9.2%, eight), and 47.0% (12.2%, six), respectively (P = 0.004); and C , with level 0 or level I–IV VTT; the rates were 48.9% (2.8%, 134) and 33.5% (3.6%, 44), respectively (P < 0.001).

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One area of continued investigation for patients with RCC and VTT has been the identification of other pathological factors that might have prognostic value in these aggressive cancers. For example, we recently showed that patients with RCC and associated VTT who have peripheral perinephric or renal sinus fat invasion of the primary tumour are more likely to die from RCC than patients with RCC and a VTT who do not have perinephric or renal sinus fat invasion [22,23]. Based on this, we proposed a re-classification scheme for patients with pT3 RCC, incorporating fat invasion, which has been shown to better stratify patients risk of death from RCC than the current TNM classification (concordance index of 0.61 vs 0.55, respectively) [22].

Meanwhile, the prognostic value of VTT level remains controversial. We previously reported that patients with thrombus involvement of the IVC have a significantly lower cancer-specific survival than patients with a renal vein thrombus only (P = 0.002), but that there is no significant difference in outcome by thrombus level among patients with IVC VTT (P = 0.868) [13]. These results are supported in our updated series here (Fig. 1b,c). Consistent with our results, one recent investigation of 153 patients with T3b tumours reported no significant difference in 10-year cancer-specific survival for patients with level I–III tumours (P = 0.48), but found that the 10-year survival of patients with renal vein involvement only (66%) was significantly better than patients with level I tumours (29%; P = 0.001) [24]. However, Kim et al.[25] noted a similar disease-specific survival for patients with renal vein VTT vs IVC thrombus below the diaphragm (P = 0.536), but found that patients with a VTT that extended above the diaphragm (T3c) had a significantly worse survival rate on multivariate analysis (P = 0.02). Thus, the role of thrombus extent, compared to the features of the primary tumour, in determining the prognosis of these patients remains in debate.

COMPLICATIONS

  1. Top of page
  2. INTRODUCTION
  3. PREOPERATIVE EVALUATION
  4. SURGICAL MANAGEMENT
  5. RESULTS
  6. COMPLICATIONS
  7. FUTURE DIRECTIONS AND CONCLUSIONS
  8. CONFLICT OF INTEREST
  9. REFERENCES

Early complications (arising within 30 days of surgery) have been reported in up to 15% of patients undergoing nephrectomy with tumour thrombectomy, including a peri-operative mortality of 2–3%[13]. The updated early complication rates from our institutional series are summarized in Table 4. Not surprisingly, intraoperative blood loss and the need for transfusion during surgery and during hospitalization increased with the level of tumour thrombus (P < 0.001). With this there was a statistically significant increase in the incidence of any early surgical complication by VTT level (P < 0.001), with 46.9% of patients undergoing resection of a level IV thrombus having an early complication, compared to 12.4% of patients with level 0 thrombus. However, over time there was a decrease in peri-operative mortality, from 3.9% in 1970–1989 to 1.5% in 1990–2005, and a decrease in the patients’ length of hospitalization, from a median of 8 to 6 days (P < 0.001).

Table 4.  Early (<30 days) and late (30 days to 1 year) surgical complications by VTT level
VariableVTT level
0IIIIIIIV
  • *

    P < 0.001;

  • P = 0.056;

  • P < 0.191.

Number of patients42673933532
Early Complications, n (%):
Intraoperative death  2 (0.5) 0 3 (3.2) 2 (5.7) 1 (3.1)
Peri-operative death  4 (0.9) 1 (1.4) 0 2 (5.7) 3 (9.4)
Haemorrhage  4 (0.9) 1 (1.4) 3 (3.2) 4 (11.4) 8 (25.0)
Deep vein thrombosis  2 (0.5) 2 (2.7) 1 (1.1) 0 1 (3.1)
Pulmonary embolism  6 (1.4) 4 (5.5) 4 (4.3) 1 (2.9) 3 (9.4)
Myocardial infarction  2 (0.5) 1 (1.4) 1 (1.1) 3 (8.6) 0
Wound infection 12 (2.8) 1 (1.4) 2 (2.2) 0 2 (6.3)
Abscess  0 1 (1.4) 0 1 (2.9) 1 (3.1)
Sepsis  1 (0.2) 1 (1.4) 0 0 2 (6.3)
Acute renal failure  3 (0.7) 2 (2.7) 4 (4.3) 1 (2.9) 2 (6.3)
Dialysis  1 (0.2) 1 (1.4) 0 1 (2.9) 2 (6.3)
Additional surgery  9 (2.1) 3 (4.1) 4 (4.3) 2 (5.7) 6 (18.8)
Ileus 23 (5.4) 2 (2.7) 4 (4.3) 3 (8.6) 3 (9.4)
Pneumothorax  0 2 (2.7) 0 0 0
Any* 53 (12.4)13 (17.8)19 (20.4) 9 (25.7)15 (46.9)
Median (range):
 Hospitalization, days  7 (1–36) 7 (4–28) 8 (1–30) 8 (1–28) 9 (1–91)
 Blood loss during surgery, L*  0.5 (0.05–1.2) 1.0 (0.15–6) 1.4 (0.2–9.5) 2.5 (0.6–15) 1.95 (0.4–13)
Units of blood
 during surgery*  1 (0–31) 2 (0–16) 3 (0–35) 6 (0–36) 8 (0–42)
 during hospitalization*  1 (0–40) 3 (0–18) 4 (0–35) 9 (0–46)12 (0–54)
Late complications, n (%):
Chronic renal insufficiency 30 (7.0)12 (16.4)13 (14.0) 7 (20.0) 3 (9.4)
Proteinuria 73 (17.1) 11 (15.1)18 (19.4) 9 (25.7) 9 (28.1)
Wound hernia  4 (0.9) 0 (0.0) 1 (1.1) 1 (2.9) 2 (6.3)
Chronic renal failure  7 (1.6) 1 (1.4) 1 (1.1) 1 (2.9) 2 (6.3)
Dialysis  6 (1.4) 0 (0.0) 0 (0.0) 0 (0.0) 2 (6.3)
Other unspecified 14 (3.3) 4 (5.5) 7 (7.5) 0 (0.0) 5 (15.6)
Any104 (24.4)21 (28.8)31 (33.3)12 (34.3)12 (37.5)

Late complications (30 days to 1 year) after nephrectomy with tumour thrombectomy are also listed in Table 4. These consist primarily of chronic renal insufficiency (defined here as a serum creatinine level of >2 mg/dL) and proteinuria, in about a third of patients. Here the level of VTT was associated with a trend to more late complications (37.5% for level IV vs 24.4% for level 0), but this difference was not statistically significant (P = 0.19).

FUTURE DIRECTIONS AND CONCLUSIONS

  1. Top of page
  2. INTRODUCTION
  3. PREOPERATIVE EVALUATION
  4. SURGICAL MANAGEMENT
  5. RESULTS
  6. COMPLICATIONS
  7. FUTURE DIRECTIONS AND CONCLUSIONS
  8. CONFLICT OF INTEREST
  9. REFERENCES

Although a stage migration toward smaller renal masses has been reported in kidney cancer with the widespread use of abdominal imaging, urologists will nevertheless continue to encounter tumours with associated vena caval involvement as a result of the inherent biological behaviour of RCC. Moreover, the role of tumour thrombectomy as part of a cytoreductive nephrectomy for patients with advanced RCC will probably continue to expand, as a survival advantage for patients with metastatic RCC treated with nephrectomy before immunotherapy has been reported [26], while the medical therapies for patients with metastatic RCC [27] continue to improve. Thus, Goetzl et al.[28] recently reported outcomes from 33 patients with metastatic RCC who had nephrectomy with tumour thrombectomy. Patients who had thrombectomy as part of a cytoreductive nephrectomy had a greater complication rate but no lower overall survival than patients who had cytoreductive nephrectomy and no VTT. The feasibility of cytoreductive nephrectomy for RCC with VTT was also reported elsewhere [29]. Improvements in quality of life, as measured by performance status, have also been reported in patients with advanced RCC after nephrectomy with thrombectomy [30].

Overall, results from many institutions to date show that improvements in preoperative assessment, intraoperative monitoring and surgical technique have decreased the mortality and morbidity of treatment, and improved the outcome for patients with RCC and VTT. These advances have facilitated an aggressive surgical approach to these complex urological patients.

REFERENCES

  1. Top of page
  2. INTRODUCTION
  3. PREOPERATIVE EVALUATION
  4. SURGICAL MANAGEMENT
  5. RESULTS
  6. COMPLICATIONS
  7. FUTURE DIRECTIONS AND CONCLUSIONS
  8. CONFLICT OF INTEREST
  9. REFERENCES