IMPORTANT SURGICAL CONSIDERATIONS IN THE MANAGEMENT OF RENAL CELL CARCINOMA (RCC) WITH INFERIOR VENA CAVA (IVC) TUMOUR THROMBUS

Authors


Sir,

Lawindy et al. [1] described a comprehensive review of radical nephrectomy with inferior vena cava (IVC) thrombectomy. We would like to add several comments.

They described the surgical team: a vascular surgery team for a level ≥II IVC tumour thrombus, a hepatobiliary team for a level III thrombus, and a cardiovascular team for any level IV thrombus. From our experience, we suggest that having an urologist with experience in multi-organ transplantation in the team makes it more efficient because of the better understanding of the pathophysiology of RCC with tumour thrombus. We have required the presence of a cardiothoracic team only if there was a large right atrial tumour thrombus, severe Budd-Chiari syndrome, or the presence of pulmonary arterial emboli [2–4].

We agree with the authors that preoperative arterial embolization should be avoided. We advocate en bloc mobilisation of the right colon, kidney, and liver, and en bloc mobilisation of the left colon, kidney, pancreas, and spleen for right and left renal tumours, respectively. This approach facilitates early access and control of the renal artery during the procedure. This step helps in reducing bleeding from the tumour vasculature and collaterals. Moreover, in some cases early control of the renal artery reduces the size and level of tumour thrombus [5].

We prefer to use a pulmonary arterial catheter (PAC) in cases with level III thrombus. In these cases, we place an introducer initially and place the PAC later when necessary. We have minimised the use of a PAC in cases with level IV tumour thrombus due to potential iatrogenic pulmonary emboli. We have routinely used intraoperative transoesophageal echocardiography in cases with level ≥III tumour thrombus.

In patients with near complete or complete obstruction of the cava we do not use veno-veno bypass. From our experience, clamping the cava in these cases does not cause haemodynamic compromise due to the presence of multiple collaterals [5–7].

In patients with tumour thrombus in the supradiaphragmatic IVC, a sternotomy is usually performed for access in most centres. In our centre, we access the supradiaphragmatic IVC without performing a sternotomy. The central tendon of the diaphragm is dissected until the intrapericardial IVC is identified. We carry out this dissection circumferentially, so that the intrapericardial IVC can be encircled at its confluence with the right atrium. The right atrium is gently mobilised beneath the diaphragm for access and control [9–11].

Finally, it is important to highlight that the use of transplantation techniques, e.g. mobilisation of the liver off the IVC (‘piggyback’ mobilisation), aid in the resection of RCC with level III and IV tumour thrombus and eliminate the need for a thoracoabdominal approach, sternotomy, cardiopulmonary bypass with or without hypothermic circulatory arrest, or veno-venous bypass [2–11].

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