Surgical management of renal cell carcinoma with level II thrombus through a transabdominal approach

Abstract

Purpose. Surgery is still the mainstay of treatment for renal cell carcinoma (RCC) with extension into the inferior vena cava (IVC). However controversy still exists over the correct surgical management of tumors which extend into the retrohepatic IVC (level II). Herein, we report our experience of RCC with level II thrombus extension and discuss the application of a transabdominal approach without use of cardiopulmonary bypass or intraoperative anticoagulation. Method. Between 1999 and 2003, there were seven patients who presented with RCC and level II thrombus extension. All charts were retrospectively reviewed. All level II tumors were resected via a transabdominal approach. The liver was completely freed from its ligamentous attachments and mobilized off of the IVC, leaving the hepatic veins as the only attachments between the liver and IVC. Tumor thrombus was resected en bloc with the involved renal vein via an anterior cavotomy. The cavotomy was then closed primarily with a running monofilament suture. There was no use of any intraoperative anticoagulation or cardiopulmonary bypass. Results. In this study, there were six males and one female with a median age of 71 years (59–76). All tumors were located retrohepatic and classified as level II tumors. Six of seven tumors were right sided. The median estimated blood loss was 3300 ml (2000–14,000), and the median number of PRBC units transfused in the operating room was 7 (4–28). There were no intraoperative deaths and one postoperative death from myocardial infarction. Of seven patients, four had complications: two myocardial infarctions, one pneumonia, and one cerebral vascular accident. The median ICU stay was 3 days (2–6) and median time for ventilatory support was 2 days (1–3). Total median hospital stay was 11 days (5–21). Discussion. We conclude that the transabdominal approach is an acceptable operation for RCC with level II thrombus extension and that the thoracic cavity does not need to be entered for this operation. Furthermore, we believe that intraoperative anticoagulation or cardiopulmonary bypass is not necessary for this type of procedure.