BERKELEY, CA (UroToday.com) - Some urological malignancies can involve the inferior vena cava (IVC) and require its resection for surgical cure. In cases with a tumor thrombus invading the IVC wall, extensive resection of the caval wall to achieve negative surgical margins is necessary to improve survival. The development of innovative surgical techniques, specifically the application of liver transplant techniques and the adoption of cardiopulmonary bypass, have improved the safety and completeness of those challenging procedures. However, there is controversy regarding the necessity of reconstruction after IVC resection. IVC ligation or interruption may induce renal failure and lower extremity edema (LEE) in the event sufficient collaterals are lacking. For reconstruction, patch venoplasty or graft interposition is attempted via various procedures. In the current study, we detail our experience at our institute with IVC resection -- with and without reconstruction -- for patients with locally advanced renal tumors, bulky metastatic GCT and other retroperitoneal tumors, including adrenal carcinoma and sarcoma.
A total of 23 patients underwent caval resection concurrently with retroperitoneal tumor excision. Primary tumor histology was renal cell carcinoma in 19 patients, metastatic germ cell tumor in 2, and leiomyosarcoma and adrenal cancer in 1 each. Preoperatively, all patients underwent either computed tomography (CT) or magnetic resonance imaging (MRI) to assess the cephalic extent of the thrombus and determine whether complete or incomplete IVC obstruction was evident. The operations were carried out by urological and vascular surgeons. The IVC was exposed and secured with vessel loops superiorly and inferiorly to the thrombus. The renal vein and lumbar veins were also secured. Subsequently, patients underwent systemic heparinization. The procedure for resection and reconstruction of the IVC was chosen according to the clinical, radiological, and intraoperative findings from among partial wall resection with a direct running suture or prosthetic patch repair, circumferential cavectomy with graft replacement, and interruption without reconstruction.
Preoperative radiographical diagnoses revealed complete IVC obstruction in 8 patients. Partial caval wall resection was performed in 19 patients. IVC reconstruction was done with direct suture in 11, patch repair in 8 and graft replacement in 3. Interruption of the IVC was performed in one. Radiographic diagnoses accorded with intraoperative findings on the level of the tumor thrombus, but not on tumor invasiveness of the IVC wall. Therefore, the final decision for the surgical procedure was made based on intraoperative findings. After surgery, intracaval thrombosis was observed in four patients, of whom all underwent infrarenal IVC reconstruction. Of the 20 patients without distant metastasis at the time of surgery, complete resection was achieved in 14 patients, whereas 6 had positive margins. Although 9 patients developed distant metastases postoperatively, there was no local recurrence. The progression-free survival and cause-specific survival in those RCC patients without distant metastasis at the time of surgery were 47.0% and 60.4%, respectively, at 5-years.
For advanced urological malignancies with tumor thrombus extension into the IVC, complete resection may be an option for treatment. In this study, we demonstrated the safety and feasibility of radical surgery including IVC resection for patients with locally advanced urologic malignancies. Thus an aggressive surgical strategy should be considered for disease control and prolonged survival in patients with these malignancies.
Toshiaki Tanaka as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Dept of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
Resection of the inferior vena cava for urological malignancies: Single-center experience - Abstract
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