Resection of Large Urological Tumors With or Without Inferior Vena Cava Extension in Jehova's Witnesses.

Gaetano Ciancio,Javier Gonzalez

doi:10.3389/fsurg.2020.622110

Abstract

Background: Renal and adrenal tumors with/without tumor thrombus in the inferior vena cava (IVC) pose a challenge to the surgeon due to the potential for massive hemorrhage and tumor thromboemboli. The situation would be more critical for Jehovah's Witness (JW) patients which refuse blood transfusion. A transplant-based (TB) approach to these tumors in JWs would result a safe surgical method, providing limited blood loss and perioperative complications. We report our experience using a TB surgical approach in JW harboring large adrenal/renal tumors with/without tumor thrombus trying to determine its usefulness in this setting.Patients and Methods: From 2003 to 2011, 7 patients underwent resection of renal/adrenal tumors with/without tumor thrombus in the IVC by means of a TB approach. Thrombus level was renal (n = 2), retrohepatic (n = 1), and suprahepatic (n = 1). The remaining 3 patients did not present thrombus. No pre-operative optimization or cell-saver were used. Estimated blood loss, perioperative complications (Clavien-Dindo and cause), hemoglobin/hematocrit loss, and length of stay were considered main outcomes.Results: The intervention was successfully completed without transfusion in all cases. Operative time and blood loss were 2.5 h (range: 1.83–5.75) and 150 cc (range: 100–750), respectively. No major post-operative complications were registered. However, minor complications were detected in 57% of the patients included. Median hemoglobin loss was 1.13 mg/dL, which translated a median hematocrit loss of 2.3%. Patients were discharged in a median of 7 days (range 5–20).Conclusions: A TB-surgical approach provides enhanced retroperitoneal exposure and optimal vascular control, thus limiting operative blood loss or major complication development, thus resulting useful in JWs.

Highlights

Renal and adrenal tumors infrequently extend into the inferior vena cava (IVC) [1, 2]
The transplantbased (TB) surgical approach includes the rotation of the visceral contents of the right and left of the abdomen (Mattox and CattellBraasch maneuvers), control of the main renal artery through a posterior plane of dissection, complete mobilization of the liver, full circumferential dissection of the IVC, and tumor thrombus safe control in its cranial end by means of relocation below the major hepatic veins entrance, two-step sequential thrombus withdrawal, or abdominalization of the right atrium through the diaphragm [5]
Main outcome variables considered were: post-operative complications occurred in the first 30-day post-operative period, estimated blood loss (EBL) during the procedure, pre-operative and post-operative hemoglobin (Hb) and hematocrit (Hct) levels and their respective delta values (i.e., Hb and Hct loss), and length of hospital stay

Summary

Introduction

Renal and adrenal tumors infrequently extend into the inferior vena cava (IVC) [1, 2]. The surgical technique has to provide adequate exposure and optimal vascular control to avoid perioperative complications, including massive hemorrhage and death. In this context, we routinely apply the surgical principles and maneuvers derived from transplantation surgery. TB techniques help us to remove large renal or adrenal tumors safely, with a lower perioperative complication rate [including estimated blood loss (EBL) and transfusion requirements] even in the presence IVC tumor thrombus, and in most instances through a single abdominal approach [3, 4]. Renal and adrenal tumors with/without tumor thrombus in the inferior vena cava (IVC) pose a challenge to the surgeon due to the potential for massive hemorrhage and tumor thromboemboli. We report our experience using a TB surgical approach in JW harboring large adrenal/renal tumors with/without tumor thrombus trying to determine its usefulness in this setting

Methods

Results

Discussion

Conclusion