Articles

Surgery in Motion

Liver Transplantation Techniques for the Surgical Management of Renal Cell Carcinoma with Tumor Thrombus in the Inferior Vena Cava: Step-by-Step Description

By: Gaetano Ciancioa b, Javier Gonzalezc lowast , Samir P. Shirodkarb, Javier C. Anguloc and Mark S. Solowayb

European Urology, Volume 59 Issue 1, March 2011, Pages 401-406

Published online: 01 March 2011

Keywords: Renal cell carcinoma, Surgical technique, Caval thrombus, Tumor thrombus, Radical nephrectomy

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Abstract

Background

Renal cell carcinoma (RCC) with tumor thrombus in the inferior vena cava (IVC) poses a challenge to the surgeon given the operative difficulty, potential for massive hemorrhage, and possibility of tumor thromboemboli.

Objective

To determine the applicability of a self-developed technique based on orthotopic liver transplantation procedures for safe resection of these tumors.

Design, setting, and participants

From August 1997 to February 2008, 68 consecutive patients underwent resection of RCC with suprahepatic and/or retrohepatic (level 3 and 4) tumor thrombus in a single referral institution.

Surgical procedure

A triradiate incision over the upper abdomen permits the placement of a Rochard retractor. Early vascular control of the renal artery is achieved by creating a posterior plane of dissection. Venous collateral decompression permits development of a bloodless anterior plane by mobilizing the liver in a “piggy-back” fashion and the spleen–pancreas en bloc to the midline. Thrombus extraction requires circumferential control at the renal veins, hepatic hilum, and IVC before cavotomy. The central tendon of the diaphragm may be opened for cranial control and gentle traction over the right atrium performed. Repositioning of the proximal clamp and Pringle release avoid veno-venous bypass and cardiopulmonary bypass (CPB) in most cases.

Measurements

The extent of the tumor thrombus was retrohepatic in 56 patients and suprahepatic/intra-atrial in 12 patients.

Results and limitations

Mean operative time was 5h 32min. Mean estimated blood loss (EBL) was 2112±3834ml (range: 100–25 000), with a mean transfusion being 4.2±4.1 U (range: 0–30). Five patients (7.3%) required CPB. Three patients (4.4%) died in the immediate postoperative period. All had complete tumor resection. No patient developed intraoperative thromboembolism.

Conclusions

This surgical approach provides excellent exposure and control of the IVC in cases with level 3 and 4 tumor thrombus, avoiding CPB except in rare circumstances.

Take Home Message

Management of tumor thrombus is challenging. The application of orthotopic liver transplantation techniques for resection of these tumors through a transabdominal approach avoids cardiopulmonary bypass except in rare circumstances and provides excellent exposure and safe vascular control.

Keywords: Renal cell carcinoma, Surgical technique, Caval thrombus, Tumor thrombus, Radical nephrectomy.

Footnotes

a Department of Surgery, Division of Transplantation, University of Miami Miller School of Medicine, Miami, Florida, USA

b Department of Urology, University of Miami Miller School of Medicine, Miami, Florida, USA

c Servicio de Urología, Hospital Universitario de Getafe, Getafe (Madrid), Spain

lowast Corresponding author. Servicio de Urología, Hospital Universitario de Getafe, Ctra. De Toledo Km 12,500, 28905 Getafe (Madrid), Spain. Tel. +34 916839360 ext. 6381; Fax: +34 916247309.

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