Liver transplantation techniques for the surgical management of renal cell carcinoma with tumor thrombus in the inferior vena cava: Step-by-step description

Gaetano Ciancio, Javier Gonzalez, Samir P. Shirodkar, Javier C. Angulo, Mark S. Soloway

Research output: Contribution to journalArticle

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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 5 h 32 min. Mean estimated blood loss (EBL) was 2112 ± 3834 ml (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.

Original languageEnglish
Pages (from-to)401-406
Number of pages6
JournalEuropean Urology
Volume59
Issue number3
DOIs
StatePublished - Mar 1 2011

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Inferior Vena Cava
Renal Cell Carcinoma
Liver Transplantation
Thrombosis
Cardiopulmonary Bypass
Neoplasms
Renal Veins
Liver
Thromboembolism
Traction
Renal Artery
Operative Time
Decompression
Diaphragm
Heart Atria
Postoperative Period
Tendons
Abdomen
Blood Vessels
Dissection

Keywords

  • Caval thrombus
  • Radical nephrectomy
  • Renal cell carcinoma
  • Surgical technique
  • Tumor thrombus

ASJC Scopus subject areas

  • Urology

Cite this

Liver transplantation techniques for the surgical management of renal cell carcinoma with tumor thrombus in the inferior vena cava : Step-by-step description. / Ciancio, Gaetano; Gonzalez, Javier; Shirodkar, Samir P.; Angulo, Javier C.; Soloway, Mark S.

In: European Urology, Vol. 59, No. 3, 01.03.2011, p. 401-406.

Research output: Contribution to journalArticle

Ciancio, Gaetano ; Gonzalez, Javier ; Shirodkar, Samir P. ; Angulo, Javier C. ; Soloway, Mark S. / Liver transplantation techniques for the surgical management of renal cell carcinoma with tumor thrombus in the inferior vena cava : Step-by-step description. In: European Urology. 2011 ; Vol. 59, No. 3. pp. 401-406.
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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 5 h 32 min. Mean estimated blood loss (EBL) was 2112 ± 3834 ml (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.",
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T2 - Step-by-step description

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AU - Gonzalez, Javier

AU - Shirodkar, Samir P.

AU - Angulo, Javier C.

AU - Soloway, Mark S.

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AB - 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 5 h 32 min. Mean estimated blood loss (EBL) was 2112 ± 3834 ml (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.

KW - Caval thrombus

KW - Radical nephrectomy

KW - Renal cell carcinoma

KW - Surgical technique

KW - Tumor thrombus

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