title: Laparoscopic management of advanced renal cell carcinoma with level I renal vein thrombus.
abstract: OBJECTIVE
  To present our series of laparoscopic radical nephrectomy in patients with level I tumor thrombus. The existence of renal vein tumor thrombus presents a technical challenge in securing hilar control during the resection of a renal mass. To our knowledge, this experience represents one of the largest series of laparoscopic nephrectomy for renal cell carcinoma associated with a macroscopic renal vein thrombus.
  
  
  METHODS
  From April 2002 to June 2004, 12 patients (8 men and 4 women) were diagnosed with renal masses. In addition to computed tomography, cavography and magnetic resonance imaging were used to determine the levels of tumor thrombi preoperatively in those who had suspicious involvement of the renal vein on computed tomography.
  
  
  RESULTS
  Laparoscopic nephrectomy was performed in a standard fashion. Hand-assisted laparoscopic nephrectomy was used in 6 cases involving large tumors with bulky hilar adenopathy. All renal veins were stapled using an endoscopic vascular stapler. Intraoperative laparoscopic ultrasonography was used to delineate the extent of the vein thrombus in 4 cases to enable proper stapler positioning. No intraoperative complications occurred, and 2 cases were electively converted to open nephrectomy. The postoperative narcotic requirements and hospitalization times were low. Pathologic examination of the tumor specimens demonstrated negative resection margins in all patients.
  
  
  CONCLUSIONS
  In carefully selected patients, laparoscopic resection of renal masses with level I renal vein thrombi is feasible. Because of technical considerations that may be identified intraoperatively, early conversion to open nephrectomy should be anticipated. Long-term results regarding oncologic control continue to be assessed.
authors.affiliation: Division of Urology, Department of Surgery, McMaster University, Hamilton, Ontario, Canada. kapoor4@mcmaster.ca
authors.forename: Anil
authors.initials: A
authors.lastname: Kapoor
authors.forename: Christopher
authors.initials: C
authors.lastname: Nguan
authors.forename: Tariq F
authors.initials: TF
authors.lastname: Al-Shaiji
authors.forename: Abdullatif
authors.initials: A
authors.lastname: Hussain
authors.forename: Luke
authors.initials: L
authors.lastname: Fazio
authors.forename: Mohammed
authors.initials: M
authors.lastname: Al Omar
authors.forename: Patrick P W
authors.initials: PP
authors.lastname: Luke
mesh_terms: D002292:Carcinoma, Renal Cell / Q000473:pathology / Q000556:secondary / Q000601:surgery*; D005260:Female; D006801:Humans; D007680:Kidney Neoplasms / Q000473:pathology / Q000601:surgery*; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D009360:Neoplastic Cells, Circulating; D012082:Renal Veins; D012189:Retrospective Studies