Update on Surgical Management of Renal Cell Carcinoma with Venous Extension

Abstract

Intravenous extension of renal cell carcinoma remains one of the most intense debate topics in urologic oncology. In the absence of effective alternative treatment, complete surgical removal of the primary tumor with its extension along the vena cava is the only hope for a potential cure. For this reason, an aggressive approach has been established as the mainstay of treatment. Recent advances in the understanding of the biology of intravascular tumor invasion and the considerable progress in the fields of diagnosis and treatment of this entity, with innovative surgical and systemic strategies, have completely redefined the management of these patients. A PubMed-MEDLINE search was conducted to identify relevant articles on the preoperative assessment and surgical management of renal cell carcinoma with intravenous tumor extension to provide updated knowledge on this always challenging topic.

Renal artery embolization prior to nephrectomy for locally advanced renal cell carcinoma

“…8,9 It has been proposed that PRAE may reduce blood loss by allowing earlier ligation of the vein and minimization of bleeding from kidney and associated tumour blood supply during pedicle dissection and kidney mobilization. This in turn could lead to reduce intra-and post-operative complications.…”

“…One explanation for this could be the use of Gelfoam (Pfizer, New York, NY, USA) (absorbable) as embolic materials along with delay between PRAE and nephrectomy. In the majority of PRAE cohort, surgery was delayed by 2-3 days (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12). The influence of delay between PRAE and surgery on operative time and blood loss has not been evaluated but we speculate that delay beyond 3 days could make the surgery more challenging, owing to oedema and inflammation association renal infarction.…”

Multi-disciplinary surgical approach to the management of patients with renal cell carcinoma with venous tumor thrombus: 15 year experience and lessons learned

“…RCC has the propensity to extend into the renal vein, inferior vena cava (IVC) and up to the right atrium in up to 23 %, 10 %, and 1 % of cases, respectively [ 2 , 3 ]. Refinements in clinical imaging, with CT and MRI, have improved accurate evaluation of primary tumors and the level of venous tumor thrombus (VTT) [ 2 , 4 ]. Radical nephrectomy (RN) and IVC thrombectomy (IVCT) is challenging, particularly with a high VTT level [ 3 – 5 ].…”

Preoperative hypoalbuminemia and anemia as predictors of transfusion in radical nephrectomy for renal cell carcinoma: a retrospective study

“…Renal cell carcinoma accounts for 2 % to 3 % of malignancies in adults, as well as being the third most frequent and the most lethal form of genitourinary cancer [ 1 , 10 ]. The only curative therapeutic strategy is the complete removal of malignant renal tissue [ 3 ]. Clavien-Dindo complications of grade II or higher have been recorded in 14.2 % of patients undergoing radical nephrectomy, including a requirement for blood transfusion in 11.1 % [ 11 ].…”

“…Since radical nephrectomy for localized renal masses results in excellent long-term prognosis, there have been steady advances in surgical techniques that have dramatically improved the ability to safely remove these tumors [ 2 ]. However, despite improvements in preoperative diagnostic modalities, anesthetic management, and perioperative care, the morbidity and mortality rates remain high, primarily due to hemorrhage and pulmonary embolism [ 3 ]. Therefore, it is important to identify factors predicting hemorrhage and subsequent blood transfusion, which may be associated with postoperative outcomes.…”