Assessing the Evidence for the Surgical Management of Renal Cell Carcinoma with Venous Tumor Thrombus: Room to Grow

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Renal cell carcinoma (RCC) with venous tumor thrombus (VTT) represents a provocative oncologic paradox: The primary tumor has grossly demonstrated capacity for hematogenous invasion, yet with surgical resection, durable survival can be achieved in a substantial proportion of patients [1]. Accordingly, radical nephrectomy with inferior vena cava (IVC) thrombectomy is the mainstay of management for RCC with IVC VTT; however, surgery is associated with increased risks of perioperative morbidity and mortality. Consequently, efforts have focused on strategies to improve perioperative outcomes, and some interventions may even have implications for oncologic outcomes. Given the rarity of RCC with VTT, the quality of available evidence is poor. To this end, Lardas and colleagues provided a systematic review of the surgical management of VTT in nonmetastatic RCC in this month’s issue of European Urology [2]. The authors conducted a rigorous evaluation of studies reporting on the surgical management of VTT. Primary end points included both perioperative outcomes, such as complication rates and blood loss, and oncologic outcomes. The authors identified 10 nonrandomized comparative studies examining a variety of interventions and four case series with at least 50 participants each. Interventions evaluated included minimally invasive thoracic access techniques, preoperative renal artery embolization, noncardiopulmonary bypass approaches, and placement of IVC filters. Overall, the level of evidence was low due to the retrospective nature of the studies, patient heterogeneity, and attendant risk of bias. The authors appropriately concluded that the general approach to management of RCC with VTT should be guided by sound oncologic principles with technical considerations dictated by the level of tumor thrombus. Still, several findings warrant emphasis. The authors observed that minimally invasive thoracic access techniques appear to be associated with improved perioperative outcomes, although, perhaps logically, not with oncologic outcomes. It seems reasonable to use minimally invasive thoracic access approaches if feasible. In addition, preoperative renal artery embolization has been associated with increased perioperative morbidity. In our practice, we do not routinely use preoperative renal artery embolization but rather emphasize early arterial ligation intraoperatively. Likewise, little evidence supports preoperative IVC filter placement to reduce risk of embolization. Moreover, filter placement cephalad to tumor thrombus is to be discouraged, given the propensity for tumor incorporation into the filter and subsequently increased difficulty of resection [3].