En-Bloc Resection of Renal Cell Carcinoma With Tumor Thrombus Propagating Into the Intrapericardial Inferior Vena Cava: Efficacy and Safety of Transabdominal Approach

Theodoros Sidiropoulos; Stavros Parasyris; Vassiliki Ntella; Ioannis Margaris; Spyridon Christodoulou; Kassiani Theodoraki; Panteleimon Vassiliu; Vassilios Smyrniotis; Nikolaos Arkadopoulos

doi:10.7759/cureus.42394

En-Bloc Resection of Renal Cell Carcinoma With Tumor Thrombus Propagating Into the Intrapericardial Inferior Vena Cava: Efficacy and Safety of Transabdominal Approach

Cureus. 2023 Jul 24;15(7):e42394. doi: 10.7759/cureus.42394. eCollection 2023 Jul.

Authors

Theodoros Sidiropoulos¹, Stavros Parasyris¹, Vassiliki Ntella¹, Ioannis Margaris¹, Spyridon Christodoulou¹, Kassiani Theodoraki², Panteleimon Vassiliu¹, Vassilios Smyrniotis¹, Nikolaos Arkadopoulos¹

Affiliations

¹ 4th Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC.
² 1st Department of Anesthesiology, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, GRC.

Abstract

Background: Renal cell carcinoma (RCC) is the most common primary kidney cancer. In up to 4-10% of patients, the tumor is complicated with a malignant thrombus extending to the inferior vena cava (IVC). Complete surgical excision of the RCC and the neoplastic thrombus can be curative. We aim to present a safe and feasible alternative transabdominal operative technique with the omission of thoracotomy, as applied in six patients diagnosed with RCC and IVC thrombus extending over the diaphragm.

Methods: This case series study was conducted in a tertiary university hospital in Athens, Greece. All six patients, who were operated on for RCC and a malignant thrombus exceeding in the intrapericardial IVC in our department from January 2009 until March 2020, were screened. Intraoperatively, the infrarenal and intrapericardial IVC were clamped simultaneously with the renal and liver blood inflow. Access to the intrapericardial IVC was obtained via the central tendon of the diaphragm. Intrathoracic extension of the tumor was confirmed by transesophageal or intraoperative ultrasonography. The intrathoracic IVC was exposed to direct vision and two finger palpation was applied to secure the clamping of the IVC above the tip of the thrombus. The tumor was resected through a longitudinal venotomy and the operation was completed on a standard radical nephrectomy.

Results: During the study period six patients presented with RCC and intrapericardial IVC thrombus. All patients, five female and one male, underwent radical nephrectomy combined with IVC thrombectomy, without the need for a thoracotomy. The mean age was 66 years old and the mean operative time was 122.5 minutes. Mean blood loss was 338 ml and only four of the patients were transfused with two units of RBC. Operative and hospital mortality was 0%. The hospital stay was seven (six to nine) days. Only one patient required readmission and reoperation 30 days later, due to intrapericardial herniation.

Conclusions: The proposed surgical technique may be curative in patients with advanced intracaval thrombus and helps reduce the associated morbidity, mortality, and the overall cost of more extended operations.

Keywords: neoplasmatic thrombus in intrapericardial ivc; radical nephrectomy with ivc thrombectomy; rcc with tumor thrombus in ivc; renal cell carcinoma; transabdominal approach.