Article first published online: 6 SEP 2012
© 2012 BJU INTERNATIONAL
Volume 110, Issue 7, page E328, October 2012
How to Cite
Spiess, P. E. and Buethe, D. (2012), REPLY. BJU International, 110: E328. doi: 10.1111/j.1464-410X.2012.10975_2.x
- Issue published online: 6 SEP 2012
- Article first published online: 6 SEP 2012
The editorial comment by Ayyathurai et al. highlights several important issues pertaining to the intraoperative management of inferior vena cava (IVC) tumour thrombus in the setting of RCC. While we concur with the stated strategies of real-time haemodynamic monitoring by means of a pulmonary arterial catheter with intraoperative transoesophageal echocardiography, which we have also adopted, we differ from our colleagues in our preferential surgical approach. We applaud their efforts to gain supradiaphragmatic IVC control without use of a sternotomy; however, we feel that this can result in potentially disastrous sequelae if the tumour thrombus is adherent to the atrial wall. Similarly, in patients with a significant atrial tumour thrombus burden, formal cardiopulmonary bypass (CPBP) with right atriotomy is well advised to ensure complete thrombus removal in a controlled surgical setting while on bypass. Our standard approach in such cases is a chevron incision extended in the midline by a sternotomy, when deemed necessary. Sparingly, a thoracoabdominal approach has been used for larger upper pole renal or adrenal tumours, although this has been infrequently used due to the excellent exposure and versatility of the chevron approach.
As depicted in our review, we adhere to the principle of progressive involvement of vascular, hepatobiliary, and cardiothoracic surgical teams as directed by the degree of cephalad extension of the tumour thrombus. We feel that there is significant utility to be gained from partnership within a multidisciplinary surgical team. The not uncommon need for caval grafting , either in the form of a patch or complete segmental interposition, and the potential necessity for an autologous vein harvesting and venous bypass is best facilitated by the expertise of a vascular surgeon, particularly as it pertains to the management of its imparted complications. For the management of level III IVC tumour thrombi, the benefit of applying liver transplantation techniques is pivotal, as has been well studied and reported . Clearly the presence of a urologist with multi-organ transplantation inclusive of hepatic transplantation experience/skills could obviate the need for a designated hepatobiliary team, but such a valuable individual is an infrequent commodity and in our ever increasing highly contentious medicolegal professional milieu, practicing within the realm of our specialty is to be strongly encouraged. The frequently stated analogy that ‘simply because you can do it, doesn't mean you should do it’ truly applies in this regard.
Lastly, up to 50% of patients with renal tumours involving the IVC warrant cardiothoracic involvement at time of extirpative measures , with just over a quarter of such tumours reaching the level of the right atrium, which highlights the necessity for preoperative planning inclusive of a cardiothoracic team [4,5]. Despite conflicting assertions by our colleagues, 12% of patients do not tolerate clamping of the IVC due to haemodynamic instability and necessitating veno-venous bypass (VVBP) or CPBP at time of caval thrombectomy . Of these two measures, which allow for a relatively ‘bloodless’ field and optimised achievement of negative surgical margins, VVBP eliminates the need for systemic anticoagulation and has been shown to yield: less haemorrhage and shorter bypass and operative times; with resulting fewer complications than with CPBP .