Inferior vena cava interruption in renal cell carcinoma with tumor thrombus: surgical strategy and perioperative results

Abstract

Background To analyze the influence of inferior vena cava (IVC) interruption for perioperative and oncological results in patients with renal cell carcinoma and tumor thrombus and summarize the surgical strategies of IVC interruption for different situations. Methods We retrospectively analyzed the clinical and pathological data of 103 patients in our center. Patients were divided into two groups with 32 cases (31.1%) underwent IVC interruption (Group 1) while 71 cases (68.9%) did not. For comparison of continuous variables, the Mann–Whitney U test was used. For comparison of categorical variables, Chi-square tests were used. A propensity score based matching method was used to eliminate possible bias. Kaplan–Meier plots were performed to evaluate the influence of IVC interruption on overall survival and cancer specific survival. All the statistical analyses were performed using SPSS 24. A P value < 0.05 was considered statistically significant. Results Among the 32 patients who underwent IVC interruption, the median age was 61 years and the median tumor size was 7.7 cm. There were 28 males and 23 tumors were on the right side. We successfully matched 29 patients who underwent IVC interruption to 29 patients without this procedure in 1:1 ratio. No significant differences existed in baseline characteristics between the groups. The comparison of perioperative data showed that patients who underwent IVC interruption had significantly longer median postoperative hospital stays (13 vs 9 days, P = 0.022) and a higher overall postoperative complication rate (79.3 vs 51.7%, P = 0.027). According to the side and shape of tumor thrombus, it could be divided into four categories. There were 15 cases (46.9%) with right filled-type tumor thrombus (RFTT), 8 cases (25.0%) with right non-filled-type tumor thrombus (RNFTT), 1 case (3.1%) with left filled-type tumor thrombus (LFTT) and 8 cases (25.0%) with left non-filled-type tumor thrombus (LNFTT). According to different categories, different surgical procedures were adopted. Conclusions IVC interruption will increase the incidence of overall postoperative complications, but not the risk of major postoperative complications. Tumor thrombus should be divided into four categories, and different sides and shapes of renal tumor thrombus need different operative procedure of IVC interruption.

Resection of retroperitoneal tumors with inferior vena cava involvement without caval reconstruction

“…3,7 Estimated incidence rates for lymphedema range from 2% to 16% for IVC-Reconstruction and 14% to 60% for IVC-Ligation. 2,5,7,8,15,23,24 Similarly, in our series, IVC-Ligation had a significantly higher chance of lymphedema development (35%) than the IVC-Reconstruction (0%) cohort. Although the rates of lymphedema with IVC-Ligation are higher, most episodes appear to resolve within a few weeks with minimal impact on patient quality of life.…”

“…This is a potential sequela of large retroperitoneal tumor resection, which can be very painful and debilitating for the patient 3,7 . Estimated incidence rates for lymphedema range from 2% to 16% for IVC‐Reconstruction and 14% to 60% for IVC‐Ligation 2,5,7,8,15,23,24 . Similarly, in our series, IVC‐Ligation had a significantly higher chance of lymphedema development (35%) than the IVC‐Reconstruction (0%) cohort.…”

“…Conversely, postoperative thromboembolic events have been a deterrent against performing IVC‐Reconstruction 4 . Previous analyses have reported VTE rates ranging from ~0% to 25% for both IVC‐Reconstruction and IVCL‐Ligation 2,4,5,8,14,15,23,25 . Similarly, in this cohort, observed VTE rates were 10% and 17% for IVC‐Ligation and IVC‐Reconstruction, respectively.…”

“…Another major concern regarding IVC‐Ligation is the compromise of blood flow to the remaining kidney as it could lead to a decline in renal function. Interestingly, the reported need for postoperative dialysis after IVC‐Ligation is ~3.5% with several case series reporting no need for it 3,4,8,15,24 . Only two patients in our IVC‐Ligation cohort required postoperative dialysis.…”

“…IVC‐Ligation without reconstruction is not routinely performed as it requires the presence of venous collaterals often established by prolonged tumor compression or invasion of the IVC. Additionally, there is a postoperative concern for side effects that include decreased renal function, lymphedema, and chylous ascites 2,7,8,15 . However, data suggest that IVC‐Ligation without reconstruction can be performed without significant long‐term effects on renal function, chronic lymphedema, complication rate, or survival, particularly in RCC with IVC involvement 7–9,15,16 .…”