Management of renal cell carcinoma with level I tumor thrombi using a combined retroperitoneoscopic and transperitoneal laparoscopic technique, "Beyond the Abstract," by Oner Sanli and Abubekir Boguk

BERKELEY, CA ( - Involvement of the venous system in RCC may result in significant consequences:

  1. Development of large parasitic veins which may lead to significant bleeding due to obstruction of the renal vein.
  2. Dislocation of the tumor thrombus that may cause tumor embolism, while releasing the kidney with the aid of antegrade flow of the renal artery.

A major solution for both life-threatening conditions is early ligation of the renal artery. However, it is not an easy task, especially if the mass is large and enlarged lymphadenopathies exist in the renal hilum.

In the past, some institutions have preferred to coil the renal artery radiologically for this purpose. However, this technique has largely been abandoned because of its very limited contributions to surgical outcomes. Another approach, which is also the rationale of the present study, is early ligation of the renal artery with retroperitoneoscopic technique and with limited mobilization of the kidney.

The problem in the retroperitoneoscopic approach is the limited working space because it mostly disables full release of the kidney or extraction of the tumor thrombus. At this point, a rational idea for us was inclusion of a transperitoneal approach to the surgical technique with a larger working space for both mobilization of the kidney and extraction of the thrombus. Moreover, since the entire kidney is mobilized without antegrade arterial flow, milking of the small diameter thrombus (< 2 cm from the confluence of the renal veins) into the renal vein from the vena cava might be possible during laparoscopy.

In the present study, we applied this idea in 5 patients, 2 of whom had level 1 tumor thrombus. As detailed in the article, tumor thromboses in both patients were extracted successfully with acceptable intraoperative bleeding. Both patients did well after surgery, without significant complications. The only drawback of this technique is the use of 6 trocars for performing the full procedure. However, one should keep in mind that robotic surgeons insert at least 4 to 5 trocars for performing reconstructive renal surgeries such as pyeloplasty or ablative renal surgeries such as robotic partial nephrectomy. For this reason, we think that placement of 6 trocars is not a major concern for the patient, and also the technique is not counter to the rationale of minimally invasive surgery.

In conclusion, the approach that we defined is a rational concept that may have a role in RCC patients with renal vein or limited vena cava tumor thrombus.

Written by:
Oner Sanli and Abubekir Boguk as part of Beyond the Abstract on 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.

Department of Urology, Istanbul Faculty of Medicine, Istanbul University, Turkey

Use of a combined retroperitoneoscopic and transperitoneal laparoscopic technique for the management of renal cell carcinoma with level I tumor thrombi - Abstract

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