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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].

REFERENCES

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  2. REFERENCES
  • 1
    Lawindy SM, Kurian T, Kim T et al. Important surgical considerations in the management of renal cell carcinoma (RCC) with inferior vena cava (IVC) tumour thrombus. BJU Int 2012 [Epub ahead of print]. DOI: 10.1111/j.1464-410X.2012.11174.x
  • 2
    Ciancio G, Vaidya A, Savoie M et al. Management of renal cell carcinoma with level III thrombus in the inferior vena cava. J Urol 2002; 168: 13747
  • 3
    Ciancio G, Livingstone AS, Soloway M. Surgical management of renal cell carcinoma with thrombus in the inferior vena cava: The University of Miami experience in using liver transplant techniques. Eur Urol 2007; 51: 98895
  • 4
    Shirodkar SP, Soloway MS, Ciancio G. Budd-Chiari syndrome in urology: Impact on nephrectomy for advanced renal cell carcinoma. Indian J Urol 2011; 27: 3516
  • 5
    Ciancio G, Vaidya A, Soloway M. Early ligation of the renal artery using the posterior approach: a basic surgical concept reinforced during resection of large hypervascular renal cell carcinoma with or without inferior vena cava thrombus. BJU Int 2003; 92: 4889
  • 6
    Ciancio G, Soloway M. The use of natural veno-venous bypass during surgical treatment of renal cell carcinoma with inferior vena cava thrombus. Am Surg 2002; 68: 48890
  • 7
    Ayyathurai R, Garcia-Roig M, Gorin MA et al. Bland thrombus association with tumour thrombus in renal cell carcinoma: analysis of surgical significance and role of inferior vena caval interruption. BJU Int 2012 [Epub ahead of print]. DOI: 10.1111/j.1464-410X.2012.11128.x
  • 8
    Ciancio G, Soloway M. Endoluminal occlusion of the inferior vena cava in renal cell carcinoma with retro- or suprahepatic caval thrombus. BJU Int 2006; 98: 915
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    Ciancio G, Soloway M. Renal cell carcinoma with tumor thrombus extending above the diaphragm: avoiding cardiopulmonary bypass. Urology 2005; 66: 26670
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    Cerwinka WH, Ciancio G, Salerno TA, Soloway M. Renal cell cancer with invasive atrial tumor thrombus excised off-pump. Urology 2005; 66: 1319.e91319e11
  • 11
    Ciancio G, Shirodkar SP, Soloway MS, Livingstone AS, Barron M, Salerno TA. Renal carcinoma with supradiaphragmatic tumor thrombus: avoiding sternotomy and cardiopulmonary bypass. Ann Thorac Surg 2010; 89: 50510