BERKELEY, CA (UroToday.com) - Renal cell carcinoma remains a rare but aggressive tumor. Cytoreductive surgery in the setting of metastatic disease has been shown to have benefit. Direct tumor invasion into the second portion of the duodenum was initially described this year by Schlussel et al., and since its publication there have been no further case reports identified in the literature. In addition to direct invasion into the duodenum, this specific tumor also consisted of an inferior vena cava thrombus, which complicated the operative planning.
By understanding the tumor biology of renal cell carcinoma, the senior hepatobiliary/liver transplant and urologic surgeon’s put forth an operative plan that was safe and well executed. Due the rare nature of this case and the potential for such a high risk of morbidity and mortality, we found there were multiple aspects of the pre-, intra-, and post-operative management that were critical to this patient’s successful outcome. The technical skills and experience of the surgeon is mandatory. Since the tumor’s invasion involves so many organ systems, we feel the involvement of a liver transplant /hepatobiliary surgeon in conjunction with a urologist is the optimal combination. The liver transplant surgeon is well trained in venovenous bypass and vena cava repair, and the hepatobiliary skills provide a well-executed reconstruction following a pancreaticoduodenectomy. Intraoperatively, the key to this surgery was continued direct and good communication between all members of the operating room team to include surgeons, anesthesiologists, nursing, and operating room staff. Removal of the vena cava thrombus was a critical portion of this operation. We used a modified veno-venous bypass due to the size of the thrombus and the extent of the venotomy that was required. As stated in the methods, a 17-French catheter was used for the bypass which was inserted in the left femoral vein; blood was returned to the internal jugular vein at a rate of 1.5L/min, and the patient tolerated this method well for the time the vena cava was cross clamped. Although this portion of the case could be performed without bypass, the surgeon must be intimately familiar with the technique in the event there is uncontrolled bleeding from the vena cava. The pancreatic and biliary enteric reconstruction was without complication and performed in a standard fashion.
Postoperatively the patient was monitoring in an intensive care unit that was familiar with the care of patients with similar postoperative physiology. The patient recovered well and he has now been receiving adjuvant chemotherapy. This patient’s tumor was aggressive. However, with appropriate operative planning, knowledge of disease biology, and sound oncologic techniques, the patient had a successful operation that had never been described before.
Andrew T. Schlussel, DOa and Linda L. Wong, MDb 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 General Surgery, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, HI 96859, USA
bDepartment of Surgery, University of Hawaii School of Medicine, 550 South Beretania Street, Suite 403, Honolulu, HI 96813, USA