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Abstract

We agree that most bleeding during radical nephrectomy with inferior vena cava (IVC) thrombectomy is venous in origin and does not appear to be decreased by renal (arterial) angioinfarction. We also agree that radical nephrectomy with IVC thrombectomy is primarily a vena caval operation, and thus the initial steps of the operation should be directed toward obtaining control of the vena cava (both above and below the level of the tumor thrombus and of any significant tributaries). We do not advocate occluding the vena cava at this time but simply obtaining circumferential control for subsequent clamping. We also proceed with renal artery ligation after IVC control. From this point, however, we do not always favor the approach described by the reviewer for several reasons. The radiographic and intraoperative findings enable the surgeon to determine the extent to which the tumor thrombus adheres to the vena caval wall and thus dictates the operative sequence. In our experience, a large proportion of vena caval thrombi (particularly those that fill the entire IVC lumen) are quite adherent to the IVC intima. These thrombi are unlikely to become dislodged during kidney tumor manipulation. In this setting, we generally proceed with radical nephrectomy before IVC thrombectomy. We believe this is an important step in the operative sequence, because removing the kidney enables the surgeon to perform additional dissection on the posterior vena cava, which is necessary to allow for mobility in the posterior caval wall after tumor thrombectomy. We find that with the kidney in place, the posterior IVC is less exposed and less mobile for reapproximation during closure of the vena cavotomy. In some cases, the tumor thrombus may appear to be “loosely attached” or incompletely filling the IVC lumen, and mobilization and removal of the kidney tumor might promote distal embolization. In such situations, we would proceed with IVC thrombectomy before radical nephrectomy or remove the kidney tumor and IVC thrombus in an en bloc manner. Utility of Preoperative Renal Artery Embolization for Management of Renal Tumors With Inferior Vena Caval ThrombiUrologyVol. 74Issue 1PreviewTo review our experience with radical nephrectomy and inferior vena cava thrombectomy (RNIVCT) to determine the utility of preoperative embolization. Preoperative embolization has been used as an adjunctive procedure to facilitate surgical resection of complex renal tumors. Full-Text PDF Editorial CommentUrologyVol. 74Issue 1PreviewThese authors from a large kidney surgery center report their experience with preoperative renal artery embolization before radical nephrectomy and inferior vena cava (IVC) tumor thrombectomy during a 17-year period. Although not done using a prospective protocol, it appears these surgeons systematically used preoperative arterial embolization for advanced level 3-4 kidney cancers in 58% (135/231) of patients with IVC tumor thrombus, making this a large and unique data set. In brief, this retrospective analysis found patients with preoperative embolization did worse or no better than those with upfront radical nephrectomy in perioperative mortality, transfusion, and morbidity, and the authors have recommended abandoning its use. Full-Text PDF