title: Surgical strategy for treating renal cell carcinoma with thrombus extending into the inferior vena cava.
abstract: OBJECTIVE
  A surgical strategy for treating malignant renal tumors with thrombus extending into the inferior vena cava (IVC) was assessed.
  
  
  METHODS
  We retrospectively reviewed the records for all patients with renal cell carcinoma (RCC; n=30) or Wilms tumor (n=1) with tumor thrombus extending into the IVC who underwent surgical intervention at our institution between January 1980 and December 2001. Tumors were classified preoperatively according to the cephalad extension of thrombus, and intraoperative procedures were selected on the basis of degree of extension. Patients with RCC underwent radical nephrectomy and removal of thrombus with (n=11) or without (n=19) IVC resection. Partial normothermic cardiopulmonary bypass without cardiac arrest was used in 4 patients. The Pringle maneuver was performed in 8 patients. Infrarenal abdominal aortic cross-clamping was used in 8 patients to maintain systemic blood pressure. IVC cross-clamping and the Pringle maneuver were performed in 5 patients with suprahepatic thrombus extension. Temporary placement of a filter in the IVC or plication of the IVC above the hepatic vein was performed before hepatic mobilization, to decrease the risk for pulmonary embolism.
  
  
  RESULTS
  One patient died intraoperatively of pulmonary embolism. Postoperative complications occurred in 11 patients; all resolved with conservative therapy. The postoperative duration of survival in patients with RCC was 37 +/- 44 months (range, 4-180 months); the 5-year survival rate was 42%.
  
  
  CONCLUSIONS
  Aortic cross-clamping during IVC occlusion prevented hypotension and maintained hemodynamic stability that has required bypass in other series. This surgical treatment with the less extensive approach could result in long-term survival of patients with RCC in whom tumor thrombus extends into the IVC. We recommend that radical nephrectomy and tumor thrombectomy, with or without caval resection, be performed in these patients, with less invasive additional maneuvers.
authors.affiliation: Department of Surgery, Tokyo Medical and Dental University Graduate School, Japan. jibiki.srg1@tmd.ac.jp
authors.forename: Masatoshi
authors.initials: M
authors.lastname: Jibiki
authors.forename: Takehisa
authors.initials: T
authors.lastname: Iwai
authors.forename: Yoshinori
authors.initials: Y
authors.lastname: Inoue
authors.forename: Norihide
authors.initials: N
authors.lastname: Sugano
authors.forename: Kazunori
authors.initials: K
authors.lastname: Kihara
authors.forename: Nobuhiko
authors.initials: N
authors.lastname: Hyochi
authors.forename: Makoto
authors.initials: M
authors.lastname: Sunamori
mesh_terms: D000328:Adult; D000368:Aged; D002292:Carcinoma, Renal Cell / Q000150:complications / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D007680:Kidney Neoplasms / Q000150:complications / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D009392:Nephrectomy / Q000379:methods*; D012189:Retrospective Studies; D017131:Thrombectomy / Q000379:methods*; D014656:Vascular Surgical Procedures / Q000379:methods; D014682:Vena Cava, Inferior / Q000601:surgery*; D020246:Venous Thrombosis / Q000209:etiology / Q000601:surgery*