Radical nephrocapsulectomy and caval thrombectomy with extracorporeal circulation and deep hypothermic circulatory arrest in right anterior minithoracotomy: a minimally invasive approach.
OBJECTIVE
Radical nephrocapsulectomy and cavoatrial thrombectomy with median sternotomy and abdominal access, using extracorporeal circulation (ECC) and deep hypothermic circulatory arrest (DHCA), has become the gold standard treatment for renal cell carcinoma (RCC) with neoplastic thrombosis of the suprahepatic and intrapericardial inferior vena cava (IVC) and right atrium (RA). Any modification of surgical techniques should be compared with this therapeutic strategy.


METHODS
In our quest to identify a minimally invasive approach and to apply available technology to ensure patient safety, even in cases of RCC with suprahepatic IVC and RA thrombosis, we identified a therapeutic approach that foresees en bloc radical nephrocapsulectomy, with ECC and DHCA in right anterior minithoracotomy. Furthermore, to make surgery even safer, we made some modifications and used auxiliary maneuvers. We present the case of a 39-year-old man with a neoplasm that involved the right kidney and suprahepatic IVC thrombosis, undergoing radical nephrocapsulectomy and thrombectomy with ECC and DHCA in right anterior minithoracotomy.


CONCLUSIONS
Radical nephrocapsulectomy and thrombectomy of the suprahepatic and intrapericardial IVC and/or of the RA with ECC and DHCA in right anterior minithoracotomy for RCC is a valid minimally invasive alternative to standard surgical techniques. Compared with standard median sternotomy access, right anterior minithoracotomy allows a more rapid functional recovery, a reduction in risk of infection of the wound, and a reduction in pain during postoperative convalescence, and has considerable esthetic advantages, without limiting surgical therapeutic chances, regardless of the cranial extension of the thrombus.
Bertini
Roberto
R
Department of Urology, Vita-Salute University San Raffaele, San Raffaele Hospital, Milan, Italy. bertini.roberto@hsr.it
Roscigno
Marco
M
Lapenna
Elisabetta
E
Pasta
Alessandra
A
Petralia
Giovanni
G
Strada
Elena
E
Naspro
Richard
R
Da Pozzo
Luigi
L
Colombo
Renzo
R
Rigatti
Patrizio
P
D000328:Adult; D000368:Aged; D002292:Carcinoma, Renal Cell / Q000556:secondary* / Q000601:surgery*; D050792:Circulatory Arrest, Deep Hypothermia Induced; D005112:Extracorporeal Circulation; D006801:Humans; D007680:Kidney Neoplasms / Q000473:pathology* / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D009360:Neoplastic Cells, Circulating; D012077:Renal Artery; D013908:Thoracotomy; D017131:Thrombectomy / Q000379:methods*; D014682:Vena Cava, Inferior