Management of renal cell carcinoma with vena cava and atrial thrombus: minimal access vs median sternotomy with circulatory arrest

Abstract

To review our experience with approaches for managing renal cell carcinoma (RCC) with venous thrombi extension at and above the level of the hepatic veins, comparing surgery and peri-operative outcomes in patients with cardiopulmonary bypass (CPB) with deep hypothermic cardiac arrest (DHCA) either by minimal access (MA) or traditional median sternotomy (TMS). From 1986 to 2005, 50 radical nephrectomies with inferior vena cava (IVC) thrombectomies were performed at our institution using TMS (22 patients) and MA (28) techniques. Patient demographics were compared using Student's t-, Fisher's exact and Pearson chi-square tests. The duration of surgery, CPB, DHCA, mechanical ventilation, length of stay, and peri-operative transfusion requirements, were compared using the Mann-Whitney U-test. Estimates of survival were constructed using Kaplan-Meier curves and analysed with the log-rank test. Subgroups were analysed excluding TMS patients undergoing concurrent coronary revascularization. There were no significant differences in patient demographics or comorbidities between the MA and TMS group. There were significant decreases in the MA vs the TMS group (P < 0.05) in the duration of surgery, mechanical ventilation, length of stay and peri-operative transfusion requirements. When patients with coronary revascularization were excluded, the MA group had significant decreases (P < 0.05) in duration of surgery, hospital stay and transfusion requirements. Peri-operative mortality was not statistically different between the TMS (14%) and MA (4%) patients. Overall and organ system-specific complications also were not statistically different. The overall median survival in the TMS and MA groups was 0.62 and 2.84 years, respectively (P = 0.06, hazard ratio 2.02; 95% confidence interval, CI, 0.97-4.72). Patients with tumour thrombus extending into the right atrium had a median survival of 1.02 years, vs 2.84 years with no intracardiac extension (P = 0.15, hazard ratio 1.82, 95% CI 0.81-4.0). MA surgical techniques in conjunction with DHCA for the treatment of RCC with extensive tumour thrombus provides quicker surgery and a shorter hospital stay. In addition there was less requirement for mechanical ventilation and transfusion than with TMS. Our findings suggest that MA techniques provide significant advantages over TMS.