BERKELEY, CA (UroToday.com) - Renal cell carcinoma has a propensity to invade the inferior vena cava in more advanced stages, which can pose a technical challenge for surgical extirpation. We reviewed the literature and reported our own experience on the use of liver transplant techniques for removal of renal masses in the event of IVC invasion in an effort to avoid sternotomy, and cardiopulmonary (CPB), or veno-venous bypass (VVB). This technique utilizes self-retaining retractors, such as the Rochard retractor, a chevron incision, piggy-back liver mobilization, and en-bloc mobilization of the pancreas and spleen for left sided tumors. These liver transplant techniques are specifically useful for level III and IV tumors to improve exposure and aid in hepatic mobilization, which are essential in exposing the retrohepatic IVC.
At the University of Miami/Jackson Memorial Hospital, we sub-classify level III tumor in to IIIa-IIId, based on the cranial extent of tumor thrombus to the hepatic veins. This perioperative planning is important as the specific tumor level dictates the specific surgical technique. Level IIIa extends to below the major hepatic veins, level IIIb extends to the ostia of the hepatic veins, level IIIc reaches above the hepatic veins and below the diaphragm, and level IV thrombus extends above the diaphragm and below the right atrium. An intraoperative trans-esophageal echocardiogram (TEE) is routinely used to confirm the cephelad extent of tumor thrombus.
Tumors with level III thrombus and above routinely require piggy-back liver mobilization for adequate IVC exposure. Once the renal artery is ligated posteriorly, the liver is circumferentially freed of its attachments so it is only tethered by the major hepatic veins and arteries. Clamping of the IVC below the major hepatic veins is performed for tumor thrombus that are level IIIa and below. We attempt to milk level IIIb and level IIIc tumors to below the major hepatic veins to avoid clamping them, therefore preserving blood flow from the liver into the IVC. If the thrombus cannot be milked below the hepatic veins, a Pringle maneuver is performed and the clamp is placed above the hepatic veins and tumor thrombus, under TEE visualization.
Our group has reported the outcome of treating 68 renal cell carcinoma tumors with level III or IV tumor thrombus involvement, the largest series to date at the time of publication. Using these techniques, only five patients required CPB (7.3%), and three (4.4%) patients experienced Clavien 3 or 4 complications. We reviewed the available literature at the time of publication from other groups using similar transplant techniques for RCC with IVC invasion at all levels. Based on our experience and that of the authors reviewed, we feel the use of transplant techniques eliminates the routine use of VVB and CPB, and our experience is reproducible with the use of a multidisciplinary team approach.
- Gorin MA, Gonzalez J, Garcia-Roig M, Ciancio G. Transplantation techniques for the resection of renal cell carcinoma with tumor thrombus: A technical description and review. Urol Oncol 2012;.
- Ciancio G, Vaidya A, Savoie M, Soloway M. Management of renal cell carcinoma with level III thrombus in the inferior vena cava. J Urol 2002;168:1374-7.
- 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;89:505-10.
Michael Garcia-Roig, MDa and Gaetano Ciancio, MDa, b 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.
aDepartment of Urology, University of Miami Miller School of Medicine, Miami, FL, USA
a, bDepartment of Surgery, Division of Transplantation, University of Miami Miller School of Medicine, Miami, FL, USA