Surgical resection of a renal cell carcinoma involving the inferior vena cava: the role of the cardiothoracic surgeon

Abstract

BackgroundThe techniques for the resection of renal tumors with IVC extension are based on the experience of individual units. We attempt to provide a logical approach of the surgical strategies in a stepwise fashion.MethodsOver 6-years 9 patients with renal cell carcinoma invading the IVC, underwent surgery. There were 6 males. The extension was at level IV in 4 and III in 5 cases. CPB used in 8 and hypothermia and circulatory arrest in all patients with level IV disease. The results and an algorithm of the plan of action, as per level of extension are presented.ResultsPlan of action: For level I-II disease: No Cardiothoracic involvement, For level III: Cardiopulmonary Bypass (CPB) & control of the cavo-atrial junction. For level IV: use of brief periods of Circulatory Arrest & repair of the Cavotomy with a pericardial patch. Postoperative morbidity: prolonged ICU stay, 3 patients (33.3%); tracheostomy, 1 (11.1%); Sepsis, 2 (22.2%); CVA 1, (11.1%). Mortality: 2 patients (22.2%)ConclusionsTotal clearance of the IVC from an adherent tumor is important, therefore extensive level IV disease presents a surgical challenge.We recommend CPB for level III and brief periods of Total Circulatory Arrest (TCA) for level IV disease.

Renal tumor with tumor thrombus in inferior vena cava and right atrium: the report of five cases with long-term follow-up

“…On the other hand, hypothermic CPB increases the operative time, cardiorespiratory complications, postoperative bleeding, and the onset of coagulopathies [16]. Parassis reported long operative time (from 232 to 576 min) in patients with Level IV disease, using total hypothermic circulatory arrest, with significant complication rate and 22.2% mortality rate [17]. Sweeney reported 36% early complication rate and 15% perioperative mortality rate.…”

Surgical Resection of Malignancies Invading Inferior Vena Cava Level I and II. Issues Still Need to Be Discussed

“…In light of recent oncological and diagnostic advancement, an increasing number of cases undergo surgical resection, still with significant morbidity and mortality. It is important to note that only few studies address some technical and clinical issues that need to be further discussed (3)(4)(5).…”