title: Systematic Review of Surgical Management of Nonmetastatic Renal Cell Carcinoma with Vena Caval Thrombus.
abstract: Overall, 4-10% of patients with renal cell carcinoma (RCC) present with venous tumour thrombus. It is uncertain which surgical technique is best for these patients. Appraisal of outcomes with differing techniques would guide practice.
  
  
  
  To systematically review relevant literature comparing the outcomes of different surgical therapies and approaches in treating vena caval thrombus (VCT) from nonmetastatic RCC.
  
  
  
  Relevant databases (Medline, Embase, and the Cochrane Library) were searched to identify relevant comparative studies. Risk of bias and confounding assessments were performed. A narrative synthesis of the evidence was presented.
  
  
  
  The literature search identified 824 articles. Fourteen studies reporting on 2262 patients were included. No distinct surgical method was superior for the excision of VCT, although the method appeared to be dependent on tumour thrombus level. Minimal access techniques appeared to have better perioperative and recovery outcomes than traditional median sternotomy, but the impact on oncologic outcomes is unknown. Preoperative renal artery embolisation did not offer any oncologic benefits and instead resulted in significantly worse perioperative and recovery outcomes, including possibly higher perioperative mortality. The comparison of cardiopulmonary bypass versus no cardiopulmonary bypass showed no differences in oncologic outcomes. Overall, there were high risks of bias and confounding.
  
  
  
  The evidence base, although derived from retrospective case series and complemented by expert opinion, suggests that patients with nonmetastatic RCC and VCT and acceptable performance status should be considered for surgical intervention. Despite a robust review, the findings were associated with uncertainty due to the poor quality of primary studies available. The most efficacious surgical technique remains unclear.
  
  
  
  We examined the literature on the benefits of surgery to remove kidney cancers that have spread to neighbouring veins. The results suggest such surgery, although challenging and associated with high risk of complications, appears to be feasible and effective and should be contemplated for suitable patients if possible; however, many uncertainties remain due to the poor quality of the data.
authors.affiliation: Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK.
authors.forename: Michael
authors.initials: M
authors.lastname: Lardas
authors.affiliation: Academic Urology Unit, University of Aberdeen, Aberdeen, UK.
authors.forename: Fiona
authors.initials: F
authors.lastname: Stewart
authors.affiliation: Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK.
authors.forename: Duncan
authors.initials: D
authors.lastname: Scrimgeour
authors.affiliation: Department of Urology, Sunderby Hospital, Sunderby, Sweden.
authors.forename: Fabian
authors.initials: F
authors.lastname: Hofmann
authors.affiliation: Department of Urology, Coimbra University Hospital, Coimbra, Portugal.
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Marconi
authors.affiliation: Department of Urology, Skåne University Hospital, Malmö, Sweden.
authors.forename: Saeed
authors.initials: S
authors.lastname: Dabestani
authors.affiliation: Department of Urology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
authors.forename: Axel
authors.initials: A
authors.lastname: Bex
authors.affiliation: Division of Urology, Maggiore della Carita' Hospital, University of Eastern Piedmont, Novara, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Volpe
authors.affiliation: Division of Urology, University of Texas Medical School at Houston, Houston, TX, USA.
authors.forename: Steven E
authors.initials: SE
authors.lastname: Canfield
authors.affiliation: Department of Urology, Ludwig-Maximilians University, Munich, Germany.
authors.forename: Michael
authors.initials: M
authors.lastname: Staehler
authors.affiliation: Department of Urology, Faculty Hospital and Faculty of Medicine in Pilsen, Charles University in Prague, Prague, Czech Republic.
authors.forename: Milan
authors.initials: M
authors.lastname: Hora
authors.affiliation: The Royal Free NHS Trust and Barts Cancer Institute, Queen Mary University of London, London, UK.
authors.forename: Thomas
authors.initials: T
authors.lastname: Powles
authors.affiliation: Department of Urology, University Hospital Schleswig-Holstein, Lübeck, Germany.
authors.forename: Axel S
authors.initials: AS
authors.lastname: Merseburger
authors.affiliation: Department of Urology and Urologic Oncology, Hannover Medical School, Hannover, Germany.
authors.forename: Markus A
authors.initials: MA
authors.lastname: Kuczyk
authors.affiliation: Department of Urology, University of Rennes, Rennes, France.
authors.forename: Karim
authors.initials: K
authors.lastname: Bensalah
authors.affiliation: Department of Urology, Radboud University Medical Centre, Nijmegen, The Netherlands.
authors.forename: Peter F A
authors.initials: PF
authors.lastname: Mulders
authors.affiliation: Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå University, Umeå, Sweden.
authors.forename: Börje
authors.initials: B
authors.lastname: Ljungberg
authors.affiliation: Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK; Academic Urology Unit, University of Aberdeen, Aberdeen, UK. Electronic address: thomasbllam@abdn.ac.uk.
authors.forename: Thomas B L
authors.initials: TB
authors.lastname: Lam
mesh_terms: D002292:Carcinoma, Renal Cell / Q000150:complications / Q000473:pathology; D006801:Humans; D007680:Kidney Neoplasms / Q000150:complications / Q000473:pathology; D009367:Neoplasm Staging; D020379:Risk Adjustment; D013514:Surgical Procedures, Operative / Q000009:adverse effects / Q000379:methods; D019043:Vascular Neoplasms / Q000209:etiology / Q000473:pathology / Q000601:surgery; D014684:Venae Cavae / Q000473:pathology / Q000601:surgery
keywords: Circulatory bypass and preoperative embolisation; Nonmetastatic renal cell carcinoma; Surgical management of tumour thrombus; Systematic review; Thrombectomy; Vena caval thrombus