Cava Resection Research Articles

Technique and Outcomes of Concomitant Aortic and Caval Resection and Reconstruction for Retroperitoneal Tumors

Major vascular involvement is often considered a contraindication to resection of malignant tumors, but in highly selected patients it can be performed safely, with results that are highly dependent upon the tumor biology. Resection of both the aorta and inferior vena cava (IVC) is a rare undertaking, requiring both favorable tumor biology and a patient fit for a substantial surgical insult; nevertheless, it provides the possibility of a cure. Patients requiring resection and reconstruction of both the aorta and IVC from 2009 through 2019 at two university medical centers were included. Patient characteristics, operative technique, and outcomes were retrospectively collected. We identified nine patients, all with infrarenal reconstruction or repair of the aorta and IVC. All cases were performed with systemic heparinization and required simultaneous aortic and caval cross-clamping for tumor resection. No temporary venous or arterial bypass was used. Since arterial reperfusion with the IVC clamped was poorly tolerated in one patient, venous reconstruction was typically completed first. Primary repair was performed in one patient, while eight required replacements. In two patients, aortic homograft was used for replacement of both the aortoiliac and iliocaval segments in contaminated surgical fields. In the remaining six, Dacron was used for arterial replacement; either Dacron (n=2) or PTFE (n=4) were used for venous replacement. Patients were discharged after a median stay of 8 days (range: 5-16). At median follow up of 17 months (range 3-79 months), two patients with paraganglioma and one patient with Leydig cell carcinoma had cancer recurrences. Venous reconstructions occluded in three patients (38%), though symptoms were minimal. One patient presented acutely with a thrombosed iliac artery limb and bilateral common iliac artery anastomotic stenoses, treated successfully with thrombolysis and stenting. Patients with tumor involving both the aorta and IVC can be successfully treated with resection and reconstruction. En bloc tumor resection, restoration of venous return before arterial reconstruction, and most importantly, careful patient selection, all contribute to positive outcomes in this otherwise incurable population.

Postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) for seminoma: Limitations of surgical intervention after first-line chemotherapy.

Patients with relapsed seminoma after first-line chemotherapy can be treated with salvage chemotherapy or postchemotherapy retroperitoneal lymph node dissection (PC-RPLND). Based on prior experience, surgical management can have worse efficacy and increased morbidity compared to nonseminomatous germ cell tumor. Our aim was to characterize the surgical efficacy and difficulty in highly selected patients with residual disease after first-line chemotherapy. The Indiana University testis cancer database was queried to identify men who underwent PC-RPLND for seminoma between January 2011 and December 2021. Included patients underwent first-line chemotherapy and had evidence of retroperitoneal disease progression. We identified 889 patients that underwent PC-RPLND, of which only 14 patients were operated on for seminoma. One patient was excluded for lack of follow-up. Out of 13 patients, only 3 patients were disease free with surgery only. Median follow up time was 29.9 months (interquartile ranges : 22.6-53.7). Two patients died of disease. The remaining 8 patients were treated successfully with salvage chemotherapy. During PC-RPLND, 4 patients required nephrectomy, 1 patient required an aortic graft, 2 patients required a partial ureterectomy, and 3 patients required partial or complete caval resection. The decision between salvage chemotherapy and PC-RPLND as second-line therapy can be challenging. Salvage chemotherapy is effective but is associated with short and long-term morbidity. Surgical efficacy in this setting seems to be limited, but careful selection of patients may lead to surgical success without affecting the ability to receive any systemic salvage therapies if necessary or causing life-threating morbidity.

MP50-08 POST-CHEMOTHERAPY RETROPERITONEAL LYMPH NODE DISSECTION (PC-RPLND) FOR SEMINOMA: IS SURGERY EFFECTIVE?

You have accessJournal of UrologyCME1 Apr 2023MP50-08 POST-CHEMOTHERAPY RETROPERITONEAL LYMPH NODE DISSECTION (PC-RPLND) FOR SEMINOMA: IS SURGERY EFFECTIVE? Isamu Tachibana, Andre Alabd, Rumeal Whaley, Jacob Mcfadden, Alex Piroozi, Sean Kern, Nabil Adra, Richard Foster, Lawrence Einhorn, Clint Cary, and Timothy Masterson Isamu TachibanaIsamu Tachibana More articles by this author , Andre AlabdAndre Alabd More articles by this author , Rumeal WhaleyRumeal Whaley More articles by this author , Jacob McfaddenJacob Mcfadden More articles by this author , Alex PirooziAlex Piroozi More articles by this author , Sean KernSean Kern More articles by this author , Nabil AdraNabil Adra More articles by this author , Richard FosterRichard Foster More articles by this author , Lawrence EinhornLawrence Einhorn More articles by this author , Clint CaryClint Cary More articles by this author , and Timothy MastersonTimothy Masterson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003298.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patients with relapsed seminoma after first-line chemotherapy can be treated with salvage chemotherapy or post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND). Based on prior reported experience, surgical management can have worse efficacy and increased morbidity compared to non-seminomatous germ cell tumor. Our aim was to characterize the surgical efficacy and difficulty in a specific cohort of patients with definite progression but minimal disease burden. METHODS: The Indiana University testis cancer database was queried to identify men who underwent PC-RPLND for seminoma between January 2011 to December 2021. Included patients only underwent first-line chemotherapy and could not have any evidence of non-seminomatous elements on orchiectomy or have elevated serum alpha-fetoprotein (AFP). All patient demonstrated high suspicion of retroperitoneal disease prior to PC-RPLND was based on increasing size of tumor on standard CT imaging, progression of FDG avidity on PET imaging, or elevated tumor markers. RESULTS: We identified 889 patients that underwent PC-RPLND, of which only 14 patients were operated on for seminoma. One patient was excluded for lack of meaningful follow-up. Out of 13 patients, only 3 patients were disease free with surgery and did not have to undergo salvage chemotherapy. Median follow up time was 29.9 months (IQR: 22.6-53.7). Two patients died due to testicular cancer. The remaining 8 patients were treated successfully with salvage chemotherapy. For additional procedures, 4 patients required a nephrectomy, 1 patient required an aortic graft, 2 patients required a partial ureterectomy, and 3 patients required partial or complete caval resection CONCLUSIONS: The decision between salvage chemotherapy and PC-RPLND as second-line therapy can be challenging. Salvage chemotherapy is effective but is associated with short and long-term morbidity. Surgical efficacy in this setting seems to be limited, but careful selection of patients may lead to surgical success without life threatening morbidity or adjunctive procedures that may compromise the ability to receive salvage chemotherapy. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e687 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Isamu Tachibana More articles by this author Andre Alabd More articles by this author Rumeal Whaley More articles by this author Jacob Mcfadden More articles by this author Alex Piroozi More articles by this author Sean Kern More articles by this author Nabil Adra More articles by this author Richard Foster More articles by this author Lawrence Einhorn More articles by this author Clint Cary More articles by this author Timothy Masterson More articles by this author Expand All Advertisement PDF downloadLoading ...

Outcomes of Arterial and Caval Resection During Post-Chemotherapy Retroperitoneal Lymph Node Dissection in Metastatic Testicular Cancer

Background/Objective:In the United States, testicular cancer is the most common solid tumor in men aged 15 to 34. Fortunately, testicular cancer has a cure rate greater than 90% and a 97% five-year survival rate. For the men not cured, a relapse to the retroperitoneum (RP) is most common. Of the patients with RP metastases, a minimal number may require post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) with resection of the aorta, external iliac, or inferior vena cava (IVC). We hypothesized this procedure would yield reasonable cure rates with acceptable levels of postoperative complications to warrant the indication for surgery.
 Methods:Between 2000 and 2020, 2,054 patients with metastatic testicular cancer underwent a PC-RPLND; of those men, 39 also underwent an aortic, external iliac, and/or IVC resection. For the men with a PC-RPLND and vascular resection, demographic, clinical, pathologic, and operative information were reviewed. Next, a Kaplan-Meier curve was created to determine overall survival
 Results:In this retrospective cohort study of 39 patients, PC-RPLND and vascular resection occurred at a median age of 40. The median follow-up of the cohort was 9 months. The median pre-operative mass size was 9 cm and 19 cm in the RP and pelvis, respectively. At PC-RPLND, 54%, 13%, 18%, and 15% of patients demonstrated cancer, teratoma, teratoma and cancer, and necrosis, respectively. Following PC-RPLND and vascular resection, 22 (56%) patients recurred. The median (IQR) time to relapse was 4.2 (2.5 – 8.2) months. Recurrence to the lung was most common, followed by the RP and liver. In total, 17 (44%) patients died of disease with a median overall survival of 14.8 months.
 Conclusion:With an overall survival rate of 45% at two years in this heavily pretreated patient population, PC-RPLND with resection of the aorta, external iliac, and/or IVC is reasonable in very select cases.

Need for organ preservation in postchemotherapy retroperitoneal lymph node dissection (PC-RPLND).

5031 Background: The aim ofPC-RPLND for advanced nonseminomatous germ cell tumors is to resect all remaining metastatic tissue. So far, the resection of adjacent visceral or vascular organs is also commonly performed to achieve complete resection of the residual mass. To determine the possibility of more organ preservation, we aimed to analyze the pathohistology of patients with adjunctive surgery as the frequency of metastatic involvement in those organs with teratoma or vital cancer is currently unknown. Methods: We reviewed a cohort of 1204 patients who underwent PC-RPLND between 2008 and 2021 as a 2-center study and identified 242 (20.1%) cases of adjunctive surgery during PC-RPLND. We analysed the pathohistological presence of germ cell tumor elements in the resected organs: viable tumor (V), teratoma (T) or necrosis / fibrosis (N). Surgery associated complications were reported according to the Clavien-Dindo classification. Outcomes of subgroups were compared by using log-rank test. Results: V, T and N were present in 54 (22%), 94 (39%) and 94 (39%) of all patients with adjunct resected organs. In 242 patients, 325 adjunct organs were resected with 66 (27.3%) of these patients receiving a resection of multiple organs. The kidney was the most often resected organ (n = 77; V: 29% T: 39% N: 32%), followed by V. Cava (n = 67; V: 25% T: 36%, N: 39%) and partial liver resections (n = 50; V: 16%, T: 30%, N: 54%). Postoperative complications occurred in 30% of which 22% were Clavien grade III-V, showing no significant differences between V, T and N; p = 0.093. 27% of all patients suffered from a relapse during a median follow-up of 22 months [0-180]. Patients with T or V in the resected specimens had a significantly reduced 5-year RFS compared to patients with only N (39%, 81%, p < 0.001). Conclusions: This study shows tremendous need for more organ preservation as 40% of all resections of adjunct organs are oncologically unnecessary due to the presence of N only in the pathological specimens. Therefore, in case of doubt, we should increase intraoperative frozen section to avoid oncologically unnecessary adjunctive surgeries, especially nephrectomies and vascular resections. Additionally, serological or image-based means for a more accurate presurgical workup are required to spare patients with N from PC-RPLND in general.

MP59-20 THE EFFECT OF AGGRESSIVE HISTOLOGIC VARIANTS ON NEPHRECTOMY AND IVC THROMBECTOMY FOR RENAL CELL CARCINOMA

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy V (MP59)1 Sep 2021MP59-20 THE EFFECT OF AGGRESSIVE HISTOLOGIC VARIANTS ON NEPHRECTOMY AND IVC THROMBECTOMY FOR RENAL CELL CARCINOMA Molly DeWitt-Foy, Mohamed Eltemamy, Scott Lundy, and Venkatesh Krishnamurthi Molly DeWitt-FoyMolly DeWitt-Foy More articles by this author , Mohamed EltemamyMohamed Eltemamy More articles by this author , Scott LundyScott Lundy More articles by this author , and Venkatesh KrishnamurthiVenkatesh Krishnamurthi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002094.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Though the presence of rhabdoid and/or sarcomatoid differentiation on final pathology has been identified as a poor prognostic indicator for patients with renal cell carcinoma (RCC), the impact of these features on RCC with inferior vena cava (IVC) thrombus has not yet been described. These aggressive histologic variants (AHV) are thought to cause a desmoplastic reaction which may complicate resection and carry worse longterm prognosis. We aim to describe the effect of AHV on the operative management and overall outcome of patients with RCC and IVC thrombus. METHODS: Retrospective chart review was performed for 383 patients with RCC who underwent nephrectomy and IVC thrombectomy at a single institution between 1990 and 2018. Baseline demographics, pre-, intra-, and postoperative details, radiology and pathology reports were reviewed. Data analysis was conducted using Fisher's exact and chi-square tests, Kaplan-Meier curves, and Wilcoxon tests as appropriate. RESULTS: AHV was demonstrated on final pathology in 78(20.37%) patients. There was no statistically significant difference between thrombus level, tumor size, operative time, or blood loss between those with and without AHV. As compared to RCC without sarcomatoid or rhabdoid differentiation, patients with AHV were more likely to require partial or total caval resection at the time of IVC thrombectomy (25.32% v 14.48%, P=0.0196) and to have pathologic node positive disease (41.07% v 23.35%, p=0.0061), metastatic disease (31.82% v 16.80%, P=0.0068), and sinus fat invasion (91.89% v 78.23%, p=0.0074). Rates of perioperative death and postoperative complications did not differ between groups. Though the difference in median survival time was not statistically significant between AHV+RCC group and RCC group (16.8 v 26.9 months, p=0.0648), subgroup analysis for RCC with sarcomatoid differentiation alone conveyed worse prognosis than RCC without AHV (12.25 v 25.7 months, p=0.0142). CONCLUSIONS: In this large single center series of RCCs with associated IVC thrombi, tumors with rhabdoid and/or sarcomatoid differentiation were more likely to metastasize and invade locally on the kidney and IVC level. The presence of AHV appears to result in a more adherent tumor thrombus, as evidenced by the higher rate of partial or total IVC resection in this group. In our experience these aggressive tumors do not necessarily portend worse operative risk, as demonstrated by equivalent operative time, blood loss, and intraoperative complications. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1038-e1039 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Molly DeWitt-Foy More articles by this author Mohamed Eltemamy More articles by this author Scott Lundy More articles by this author Venkatesh Krishnamurthi More articles by this author Expand All Advertisement Loading ...

Predicting Intraoperative Difficulty of Open Liver Resections: The DIFF-scOR Study, An Analysis of 1393 Consecutive Hepatectomies From a French Multicenter Cohort.

The aim of this study was to build a predictive model of operative difficulty in open liver resections (LRs). Recent attempts at classifying open-LR have been focused on postoperative outcomes and were based on predefined anatomical schemes without taking into account other anatomical/technical factors. Four intraoperative variables were perceived by the authors as to reflect operative difficulty: operation and transection times, blood loss, and number of Pringle maneuvers. A hierarchical ascendant classification (HAC) was used to identify homogeneous groups of operative difficulty, based on these variables. Predefined technical/anatomical factors were then selected to build a multivariable logistic regression model (DIFF-scOR), to predict the probability of pertaining to the highest difficulty group. Its discrimination/calibration was assessed. Missing data were handled using multiple imputation. HAC identified 2 clusters of operative difficulty. In the "Difficult LR" group (20.8% of the procedures), operation time (401 min vs 243 min), transection time (150 vs.63 minute), blood loss (900 vs 400 mL), and number of Pringle maneuvers (3 vs 1) were higher than in the "Standard LR" group. Determinants of operative difficulty were body weight, number and size of nodules, biliary drainage, anatomical or combined LR, transection planes between segments 2 and 4, 4, and 8 or 7 and 8, nonanatomical resections in segments 2, 7, or 8, caval resection, bilioentric anastomosis and number of specimens. The c-statistic of the DIFF-scOR was 0.822. By contrast, the discrimination of the DIFF-scOR to predict 90-day mortality and severe morbidity was poor (c-statistic: 0.616 and 0.634, respectively). The DIFF-scOR accurately predicts open-LR difficulty and may be used for various purposes in clinical practice and research.

Complete Resection of the Inferior Vena Cava Using a Robot

Isolated intrainferior vena cava (IVC) recurrence of renal cell carcinoma (RCC) is a rare presentation. In this investigator-initiated intervention, we present our novel experience, with first of kind—a robotic suprarenal cavectomy without reconstruction for an isolated RCC recurrence, occurring 3 years postright radical nephrectomy. The patient's procedure was undertaken with a Da Vinci Xi Surgical System®. As step 1, the patient was positioned right lateral side up and routine right nephrectomy port placement was undertaken, followed by side docking. As step 2, the right colon and duodenum were medialized. During step 3, the IVC was identified and en bloc retroperitoneal dissection was performed to fully expose all aspects of the IVC. A significant pericaval fibrotic rind was excised to allow exposure of the true IVC surface. Step 4 involved identification of the left renal vein, with preservation. For step 5, the suprarenal IVC was dissected circumferentially with lumbar veins clipped as necessary. The position and superior margin of the tumor thrombus were constantly confirmed with both transesophageal and robotic intraoperative sonography. Step 6 consisted of further intrahepatic caval dissection, performed to completely expose the suprarenal IVC. For step 7, a rummel-style tourniquet was placed below the level of the thrombus, and the superior margin of the IVC was secured using a Vicryl tie. Step 8 involved caval dissection, with adequate margin of IVC taken proximal to the superior border of the tumor (~2 cm). Once the mass was isolated, step 9 utilized a robotic 60 mm vascular stapler to divide the intrahepatic IVC above the mass and similarly below the mass. This wedge of IVC was collected with thrombus in situ and sent for histopathology. Hemostasis was achieved and port sites were closed in the usual manner. Tumor was confirmed as clear cell RCC (ISUP nucleolar grade 2), in keeping with the man's prior diagnosis. The tumor mass was clear of margins, and a lymph node isolated as part of the specimen demonstrated no evidence of malignancy. Patient progress since discharge has been unremarkable, with no evidence of lower limb edema, clinical or radiologic recurrence of malignancy 3 months since operation. A robot-assisted caval resection for isolated renal carcinoma recurrence within the IVC is a minimally invasive option that can facilitate complete resection with negative surgical margins and minimization of morbidity. Patient Consent Statement: Informed consent was obtained from the patient for publication of this case and accompanying images and video. The authors have received and archived patient consent for video recording/publication in advance of video recording of the procedure in accordance with the ethical standards of the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. No competing financial interests exist. Runtime of video: 5 mins 59 mins

Resection of retrohepatic inferior vena cava without reconstruction in ex vivo liver resection and autotransplantation: a retrospective study

BackgroundRetrohepatic inferior vena cava (RIVC) resection without reconstruction in ex vivo liver resection and autotransplantation (ERAT) for advanced alveolar echinococcosis (HAE) is unclear.MethodsThis is a retrospective study of consecutive patients referred to our hospital from 2014 to 2018. Depending on the presence of a rich collateral circulation and stable blood volume in ERAT, patients did not rebuild the RIVC. Then, patients were selected some appropriate revascularization techniques for the hepatic and renal veins. Finally, all ERAT procedures were completed, and short- and long-term outcomes were observed.ResultsFive advanced HAE patients underwent ERAT without RIVC reconstruction. One patient died of circulatory failure 1 day after surgery. Another four patients, with a median follow-up duration of 18 months (range, 10–25 months), demonstrated normal liver and kidney function, no thrombosis and no HAE recurrence.ConclusionsThrough the long-term results of ERAT, the pros and cons of not reconstructing the RIVC need to be re-examined. In cases with a rich collateral circulation, the RIVC cannot be reconstructed. However, in cases requiring the resection of multiple organs, RIVC without reconstruction was prudential.

Resection of vena cava inferior infiltrating by liver tumors

Introduction: Despite all new promising agents of oncotherapy, it is still liver resection that gives potential curative solution for primary and secondary liver tumors. The size of tumorous liver section for resection means no question any more but major vessel infiltration of tumor proposes challenge in liver surgery. Patients and method: Retrospective analysis was carried out covering 33 patients who underwent liver resection in St. Janos Hospital Surgery Department between 1st May 2017 and 1st May 2019. Demographic, surgical, histological data and postoperative course were taken into consideration and comparison with two of our patients who needed vena cava excision simultaneously with liver resection. Results: Patients with liver resection only (LR) had a mean operation time of 91.7 minutes, while operation time for patients with cava resection (CR) was 250 minutes. The average amount of blood transfusion was 1.2 units (200 ml) in group LR and 5 units in group CR. Among LR patients, resection was rated R0 in 23 and R1 in 8 cases, R2 resection could be performed in 2 cases, in group CR in both cases R1 resection was registered. 5 patients with colorectal liver metastasis were operated after previous chemotherapy. Two patients underwent laparoscopic liver resection and two had synchronous colorectal and liver resection, one of these was treated via laparoscopic approach. Conclusion: Liver resections in case of large vessel (vena cava, hepatic vein) infiltrating by liver tumors are indicated the most challenging procedures of liver surgery. The relating literature refers to oncological liver resections with vena cava excision and reconstruction to be safe and applicable. Orv Hetil. 2019; 160(33): 1304-1310.

PC214. Techniques and Outcomes of Concomitant Aortic and Caval Resection and Reconstruction for Cancer

PC214. Techniques and Outcomes of Concomitant Aortic and Caval Resection and Reconstruction for Cancer

Inferior vena cava resection and reconstruction for abdominal malignancies: Outcomes of limited resection versus IVC replacement

Background: Curative (R0) resection of abdominal malignancies with inferior vena cava (IVC) invasion or tumor thrombus often requires partial or circumferential caval resection. Reconstructive options frequently require multidisciplinary surgical support and are affected by location/extent of invasion, physiologic tolerance of vascular cross-clamping, and chronic occlusion of the distal IVC. Recent application of transplant techniques to accomplish ex-vivo liver resections have expanded the potential for curative resections in patients with previously unresectable malignant invasion of the retrohepatic IVC. This study aims to review the indications, techniques, and outcomes for IVC resection and reconstruction at a single institution. Methods: A retrospective review was conducted on patients with IVC resections for treatment of abdominal malignancies between 2008-2018 at a single institution. Demographics and cancer diagnoses were recorded, as well as operative approaches and reconstructive methods. Postoperative morbidity followed to 90 days after surgery and survival was tracked until death or loss to follow-up. Results: Of the 52 patients who underwent IVC repair for tumor invasion, 32 required a type of IVC wall resection. Of those that underwent wall resection, the most common malignancies were renal cell carcinoma (n = 17), intrahepatic cholangiocarcinoma (n = 4), leiomyosarcoma (n = 4), colorectal liver metastases (n = 2). One case occurred due to hepatocellular carcinoma, retroperitoneal liposarcoma, and metastatic disease from a pancreatic adenocarcinoma, gastrointestinal stromal tumor, and small bowel neuroendocrine tumor each. IVC reconstruction was performed through primary closure in 34% (11/32) or bovine pericardial patch in 25% (8/32) for partial wall resections, and synthetic graft in 25% (8/32) for circumferential resections. Five patients (16%) underwent ligation of the infrarenal IVC without reconstruction. Resection was performed on veno-venous cardiopulmonary bypass in 25% (8/32). Three patients underwent an ex-vivo partial hepatectomy with back-table IVC resection and reconstruction followed by liver auto-transplantation, including one case as stage II of an associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) procedure. R0 resection was accomplished in 60% (3/5) for IVC ligation without reconstruction, 73% (8/11) for primary repair, and 63% (5/8) for bovine pericardial patch. Circumferential resection with synthetic graft reconstruction achieved R0 in 100% (8/8) including all three ex-vivo resections. Ninety-day major morbidity (Clavien grade 3 or greater) for IVC resections was 41% (13/32), with no increase for synthetic grafts compared to primary or patch repair (25% vs 37%, p = 0.55). Overall survival for IVC resections at 90 days, 1-year, and 2-years was 79%, 68%, and 64%, respectively. Conclusion: IVC resection with or without various techniques for reconstruction has an acceptable morbidity and provides the only opportunity for R0 resection in some locally-advanced abdominal malignancies. Circumferential resection with graft reconstruction (including ex-vivo for select patients) can achieve an excellent rate of R0 resection without increased morbidity. These complex reconstructions frequently require the technical acumen of hepatobiliary and transplant disciplines and should be performed in highly specialized centers with a multidisciplinary approach.

Inferior vena cava resection with prosthesis replacement for recurrent leiomyosarcoma (with video)

Inferior vena cava (IVC) leiomyosarcoma (LY) is a rare tumor with poor prognosis and recurring in one third of patients, radical surgery represents the only chance of cure. Whether caval flow has to be re-established with IVC reconstruction is a matter of debate as well as neoadjuvant therapy. We herein present a case of recurrent IVC LY managed with caval resection and reconstruction with polyethylene terephthalate (PET) prosthesis and left lateral liver resection for suspected metastases. Although the patient experienced a prosthesis occlusion and transient renal failure, at 24 months’ follow-up is recurrence free with a normal renal function and no sign of lower limbs edema.

V06-04 ROBOT ASSISTED INFERIOR VENA CAVOSCOPY

You have accessJournal of UrologyAdrenal, Testis, UTUC Oncology & More1 Apr 2018V06-04 ROBOT ASSISTED INFERIOR VENA CAVOSCOPY Haidar Abdul-Muhsin, Anthony Chau, Richard Fowl, and Erik Castle Haidar Abdul-MuhsinHaidar Abdul-Muhsin More articles by this author , Anthony ChauAnthony Chau More articles by this author , Richard FowlRichard Fowl More articles by this author , and Erik CastleErik Castle More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1583AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Conventional therapy of inferior vena cava tumor invasion (IVC) retroperitoneal malignancies involves caval resection with or without vascular grafting. Assessment of the extent of tumor invasion relies on preoperative (CT and MRI) and intraoperative (US) imaging. However, these imaging modalities cannot differentiate between bland and tumor thrombi. In this video we are presenting a technique for direct visualization of the IVC lumen to assess for tumor invasion during a robot assisted retroperitoneal lymph node dissection for testicular cancer. METHODS A 29 year old male patient with metastatic non-seminomatous mixed germ cell tumor was found to have a persistent metastatic retroperitoneal lymph node mass following four cycles of BEP chemotherapy. Preoperative imaging demonstrated a 6 cm interaortocaval mass with adjacent filling defect in the IVC. Preoperative imaging could not differentiate between tumor invasion vs bland thrombus. RESULTS After induction of general anesthesia, the patient was placed in a modified lithotomy position. Following port placement and robot docking, the small bowel was retracted cephalad and to the left upper quadrant. The retroperitoneal space was developed. Retroperitoneal lymph node dissection was started in a regular manner. The large mass was encountered in the interaortocaval region and was adherent to the IVC wall. It was dissected free from all attachments except the IVC wall. Proximal and distal control was obtained with vessel loops. A small venotomy was made on the IVC anterior wall just distal to the mass. A flexible cystoscope was introduced through one of the assistant ports and into the IVC lumen. Examination of the IVC showed multiple synechiae and vascular webs consistent with organized and recanalized bland thrombus with no evidence of tumor invasion. Given these findings no caval resection was needed. These webs were excised and the remaining part of the wall reconstructed, preserving more than 50% of the IVC circumference. The remaining part of the dissection was completed in the conventional manner. Operative time was 383 min, EBL was 150 ml, and LOS was one day. Postoperatively patient had smooth recovery with no postoperative complication. Postoperative pathology was consistent with a bland thrombus. Follow up imaging showed preserved IVC circumference and no filling defects. CONCLUSIONS Direct visualization of the IVC lumen is feasible using conventional endoscopic instruments and robotic approach. This helps avoid a large venotomy or graft placement and completion of the retroperitoneal lymph node dissection in a minimally invasive manner. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e662 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Haidar Abdul-Muhsin More articles by this author Anthony Chau More articles by this author Richard Fowl More articles by this author Erik Castle More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Surgical treatment of renal cell carcinoma with advanced tumor invasion of the inferior vena cava

Objective. To evaluate short-term and long-term results of nephrectomy, thrombectomy, circular inferior vena cava (IVC) resection in patients with renal cell carcinoma (RCC) and advanced IVC tumor invasion. Materials and methods . Medical data of 49 patients with RCC and level II–IV tumor venous thrombus with advanced IVC wall tumor invasion were analyzed. All the patients underwent nephrectomy, thrombectomy, circular IVC resection (radical – 35 (71.0 %), cytoreductive, in M+ cases – 14 (28.6 %)). Circular resection of the infrarenal IVC segment was performed in 25 (51.0 %) patients; resection of the infrarenal, perirenal and retrohepatic IVC segments with a ligation of the left renal vein (RV) – in 24 (49.0 %) patients. Perirenal IVC prosthesis was used in 2 (4.1 %) patients with initially preserved IVC blood flow, in other cases replacement of the removed IVC segment wasn’t performed due to presence of a network of venous collaterals duplicating the IVC. Patients with metastases received systemic antitumor treatment after nephrectomy, thrombectomy. Results . Median operative time was 260 (135–580) minutes, median blood loss was 8750 (3000–27 000) ml. Severe intraoperative complications were observed in 2 (4.0 %) patients, 1 (2.0 %) patient died on the operating table due to hypovolemic shock. Postoperative complications were observed in 26 (53.2 %) cases (grade III–V in 22 (45.8 %) patients). Five-year overall and cancer-specific survival of all patients was 54.6 and 67.8 %, respectively, relapse-free survival of 35 patients with M0 category was 49.4 %. Both IVC prostheses were patent 12 months after the surgery. Function of the left kidney after ligation of the left RV was preserved at the preoperative level in all 24 patients in a median of 12 (2–120) months. Conclusion. Nephrectomy, segmental/subtotal cavectomy with preservation of the main renal venous entries is an effective treatment method in RCC patients with advanced tumor IVC invasion. The method allows to achieve satisfactory long-term survival rates and functional results.

Leiomyosarcoma of the Inferior Vena Cava: A Diagnostic Challenge

A 76 year old female with a history of CAD presented to the ER with a chief complaint of two months of progressively worsening sharp lower quadrant abdominal pain radiating to her right upper quadrant. A 10 point review of systems was unremarkable, including no prior history of malignancy, weight loss, melena or hematochezia. She was hemodynamically stable in the ER, and labs revealed a creatinine of 1.2 mg/dl, CEA of 1.3 ng/ml and Ca 19-9 of 30 U/ml. MRI of the abdomen showed a 2.6 cm x 2.6 cm x 2.7 cm solid mass along the posterior head of the pancreas, anterior to the inferior vena cava (IVC) at the origin of renal veins, which seemed to compress the IVC; however no thrombus or invasion was found. A diagnostic endoscopic ultrasound (EUS) showed the peri-duodenal retroperitoneal mass to be hypoechoic, heterogeneous with mixed solid and cystic features and an inconclusive EUS-FNA. A PET scan showed activity in proximal duodenum and pancreatic head, without evidence of regional lymphadenopathy and/or distant spread. Due to the non-diagnostic EUS, an exploratory laparotomy was performed which confirmed that the mass originated from the IVC requiring an en bloc caval resection. Pathology revealed spindle cell proliferation with atypical features positive for vimentin, desmin, actin and myosin, but negative for CD117, S-100 and a Ki67 proliferative index of 40-60% consistent with high grade poorly differentiated Leiomyosarcoma (LMS). Due to the lack of spread, the tumor was staged as Stage 2a (T1bN0M0) and a Grade 3 tumor histologically, for which patient underwent an adjuvant radiotherapy with good outcome. A 36 month follow up scan did not show any evidence of tumor recurrence. LMS of the IVC is a rare tumor that presents a diagnostic challenge. EUS can be helpful to differentiate pancreatic v/s non pancreatic origin. We would like to emphasize that the LMS should always be considered in the differential of retro-peritoneal sarcomas, as survival can improve with early detection. LMS arising from the IVC tend to respond better to surgical resection and neo adjuvant radiotherapy for patients with high grade tumor or positive margins following resection. Studies have not shown any role for adjuvant chemotherapy. Our patient had a unique presentation, and highlights some of the diagnostic challenges associated with retroperitoneal sarcomas. To our knowledge, this is one of the first case of LMS of IVC presenting in this age group with good outcome.Figure 1Figure 2Figure 3

Vena cava resection without venous bypass for liver transplant (LT) does not increase morbidity but does decrease operative time

Introduction: Vena cava reconstruction options in LT are controversial. Original Cava reconstruction included venous bypass and Cava resection (CR). Currently, Cava sparing (CS) techniques (Piggy-Back and cavocavostomy) have developed and demonstrated some potential benefits. Our aim is to compare CR without venous bypass and CS techniques. Methods: An historical cohort from Mar/1994 until May/2015 was analyzed. Variables as: age, gender, MELD, cause of liver failure (LF), complications, surgical outcomes and mortality were included. These variables were compared between Cava reconstruction technique groups. Results: 240 transplants were performed in our institution. 194 procedures (80,8%) were included at this study. Rest of cases were excluded due to missing data. CR: 41 (21,1%) and CS: 153 (78,9%) cases. There was no difference in MELD, cause of LF, age, gender, kidney failure, vascular, biliary nor cardiovascular complications between CR and CS groups. 30 -day survival was similar between groups CR: 97,6%, CP: 89,8% (p = 0,345). Operative time (CR: 271,5±67,6 min vs CS: 436,3±138,0 min ) and warm ischemia time (CR : 29,9±7,0 min vs CS: 44,9±24,4 min) were significantly higher in CS group. Conclusion: Clinical results of CR without bypass are comparable to CS techniques. CR is a safe and faster technique, associated to better operative and ischemic times. Our findings suggest that this technique is a valid option to be considered for vena cava reconstruction in LT.

Retrospective analysis of management for primary leiomyosarcoma of inferior vena cava

To study the treatment strategy and survival of patients with primary leiomyosarcoma of inferior vena cava (PIVCLMS). Clinical data of 12 cases with PIVCLMS admitted in Peking University People's Hospital from January 2006 to September 2014 were reviewed retrospectively. All cases were confirmed by pathology examination. Among them, there were 4 male and 8 female patients with a mean age of (54 ± 9) years old. Tumors arose from the inferior vena cava (IVC) upper segment in 5 patients, from the middle in other 7 patients. Cardiac extension was observed in 4 cases. Tumor resection was undertaken in 8 patients, the other 4 patients were inoperable. The series was analyzed to identify clinical outcome of surgical strategy and protective factors for patient survival. In tumor resection group, 6 patients had radical resection and 2 underwent palliative resection. As for IVC reconstruction, caval wall resection with a direct suture was carried out in 6 patients or with prosthetic patch in 1 patient. The other 1 patient underwent a segment caval resection and prosthetic graft replacement in situ. In 4 cases of suprahepatic PIVCLMS cardiopulmonary bypass or perfusion by right atrial intubation was performed to assist bleeding control and maintain circulation stabilization, among them 1 patient survived for more than 101 months with no tumor recurrence or metastasis. Among the patients submitted to tumor resection 2 early postoperative deaths occurred, and another 2 patients had complications. All 4 patients submitted to non-resective operation (only neoplasm biopsy) died of PIVCLMS within 8 months. Except for 2 cases of early death, mean survival after tumor resection was (54 ± 40) months. Two patients presented local recurrence and hepatic metastasis at follow-up of 16 months and 68 months. Tumor resection is the only therapy for PIVCLMS with an expectation for long-term survival. The applicant of cardiopulmonary bypass makes some inoperable indicated to tumor resection.

MP79-05 RESECTION OF THE INFERIOR VENA CAVA WITHOUT GRAFTING IN ADVANCED UROLOGIC MALIGNANCY

INTRODUCTION AND OBJECTIVES: Several advanced urologic malignancies can present with focal invasion of the inferior vena cava (IVC). When segmental resection of the IVC is oncologically necessary the need for caval reconstruction remains controversial. We reviewed our institution’s contemporary experience with the management of caval resection in patients presenting with advanced urologic malignancy to evaluate perioperative outcomes and whether pre-operative predictors of extensive caval involvement exist. METHODS: We queried our IRB approved genitourinary cancer databases for any case that included resection of the vena cava. Indications for resection included encasement or invasion of the cava, thrombus in which cavotomy and thrombectomy could not be performed, and postchemotherapy desmoplastic compression. Pre-operative predictors of caval involvement and the long-term morbidity of IVC resection were assessed. RESULTS: Between September 2010 and October 2014, 22 patients (median age of 47) underwent successful surgical extirpation of urologic cancers with resection of the inferior vena cava due to invasion. Pathology revealed renal cell carcinoma (9), upper tract urothelial cancer (6), testis cancer (6), and malignancy of adrenal origin (2). These included 13 infrarenal and 9 suprarenal resection of the IVC; one patient with suprarenal IVC resection underwent reconstruction with a PTFE graft. 21 of 22 patients were alive with mean post-operative follow-up of 9.1 months (1-45 m). Pre-operatively 6 patients (27%) had radiologic evidence of IVC involvement and 3 (14%) patients presented with lower extremity edema. Mean operative time was 491 minutes (302 e 754 min). Mean estimated blood loss was 3.84L (0.3-18L) and transfusion requirement was mean of 12.6 units (0-49 units). Mean length of hospital stay was 8.8 days (4-29 days). Six patients (27%) had pathologically confirmed IVC wall invasion. Postoperatively 5 patients (23%) developed deep venous thrombosis and 8 patients (36%) had lower extremity edema at time of discharge. At the time of the most recent follow-up this edema had resolved in all but 1 patient. All patients were successfully treated for DVT with no long-term sequelae. CONCLUSIONS: IVC resection without reconstruction is a welltolerated procedure with minimal sequelae following complete caval resection. Caval resection without reconstruction obviates the need for grafts and potential thrombosis. A significant number of patients did have identifiable evidence of caval involvement on pre-operative imaging which may serve as a predictor for caval resection.

Complex liver resections for colorectal metastases: are they safe in the low-volume, resource-poor Caribbean setting?

Introduction. Although many authorities suggest that major liver resections should only be carried out in high-volume specialized centres, many patients in the Caribbean do not have access to these health care systems. Presentation of a Case. A 50-year-old woman with a solitary colorectal metastasis invading the inferior vena cava underwent an extended left hepatectomy with caval resection and reconstruction. Several technical maneuvers were utilized that were suited to the resource-poor environment. Conclusion. We suggest that good outcomes can still be attained in the resource-poor, low-volume centres once dedicated and appropriately trained teams are available.