Radical Nephrectomy in a Horseshoe Kidney with Endo-Caval Thrombosis: Infrahepatic Caval Vein Control with Piggy-Back Technique

Abstract

Introduction: Renal cell carcinoma with vascular invasion of vena cava is still a great challenge for uro-oncologists. The surgical approach to this clinical scenario is even more challenging when coupled with anatomical anomalies, like horseshoe kidney and the presence of abnormal vessels. Materials and Methods: In this video, we will show a case of a large left renal tumor in a horseshoe kidney with double renal vein and endo-caval thrombus that reaches the suprahepatic veins (T2b—third level). The video describes, step by step, the piggy-back surgical technique, which allows to completely expose the inferior infrahepatic vena cava, splitting it from the liver that remains connected just to the three suprahepatic veins. This technique, borrowed from the liver transplant, allows, without increasing the risk of intraoperative complications and maintaining a high oncologic efficacy, to have an excellent vascular control that, in cases like the presented one, may avoid recourse to the use of extracorporeal circulation and allows urological equipe to complete the operation, without the aid of cardiac surgeons. Moreover, the video shows how it is possible, on a horseshoe kidney, the presence of abnormal vessels, whose arterial component has to be preserved to maintain a proper blood flow in the residual renal parenchyma. Results: The postoperative course was uneventful, underlining the reliability of the chosen surgical approach. The patient died after 10 months from cardiopulmonary failure. Conclusions: The video shows how it is possible to surgically approach an advanced left kidney cancer on a horseshoe kidney with abnormal vessels and an associated endo-caval thrombus that reaches the suprahepatic veins, without recurring to extracorporeal circulation. The piggy-back technique allows in this case a better exposure of the infrahepatic vena cava, allowing the procedure to be effectively performed. No competing financial interests exist. Runtime of video: 6 mins 54 secs Video technique employed: The video has been shot by one of the surgeons, using a full HD handy cam. The camera has been covered to be sterile and to be used over the field. Video editing has been made using Adobe Premiere and Adobe photoshop (for overlay graphics). Smithmicro POSER and Autodesk 3D studio MAX have been used for tridimensional patient images. A high-end computer has been used to finally render the video in full HD.