Inferior Vena Cava Extension Research Articles

Oncologic Outcomes Following Surgical Resection of Renal Cell Carcinoma with Inferior Vena Caval Thrombus Extending Above the Hepatic Veins: A Contemporary Multicenter Cohort

Suprahepatic inferior vena caval tumor thrombus in renal cell carcinoma cases has historically portended a poor prognosis. With advances in perioperative treatment of patients with high level thrombus contemporary outcomes are hypothesized to be improved. We evaluated long-term oncologic outcomes of contemporary surgical treatment of patients with renal cell carcinoma in whom level III-IV inferior vena caval thrombus was managed at high volume centers. We examined clinical and pathological data on patients with renal cell carcinoma and level III-IV thrombus treated with surgery from January 2000 to June 2013 at 4 tertiary referral centers. Survival outcomes and associated prognostic variables were assessed by Kaplan-Meier and multivariate Cox regression analyses. We identified 166 patients, including 69 with level III and 97 with level IV thrombus. Median postoperative followup was 27.8 months. Patients with no evidence of nodal or distant metastasis (pN0/X, M0) had 5-year 49.0% cancer specific survival and 42.2% overall survival. There was no difference in survival based on tumor thrombus level or pathological tumor stage. Variables associated with an increased risk of death from kidney cancer on multivariate analysis were regional nodal metastases (HR 3.94, p <0.0001), systemic metastases (HR 2.39, p= 0.01), tumor grade 4 (HR 2.25, p = 0.02), histological tissue necrosis (HR 3.11, p = 0.004) and increased preoperative serum alkaline phosphatase (HR 2.30, p = 0.006). Contemporary surgical management achieves almost 50% 5-year survival in patients without metastasis who have renal cell carcinoma thrombus above the hepatic veins. Factors associated with increased mortality included nodal/distant metastases, advanced grade, histological necrosis and increased preoperative serum alkaline phosphatase. These findings support anaggressive surgical approach to the treatment of patients with renal cell carcinoma who have advanced tumor thrombus.

Renal arteriovenous malformation with inferior vena caval extension mimicking renal cell carcinoma

A young lady presented with complaints of right flank pain and a palpable mass. On contrast-enhanced tomography (CECT), a renal mass with extension into the inferior vena cava (IVC) - suggestive of renal cell carcinoma - was diagnosed and she underwent radical nephrectomy with en bloc excision of the IVC thrombus. Histopathology revealed a benign arteriovenous malformation that had extended into the IVC. Arteriovenous malformation should therefore be kept in the list of differentials for a renal mass with IVC extension.

Invited Commentary

Fabiani and colleagues [1Fabiani J.-N. Raux M. Alsac J.-M. et al.Deep hypothermia and low flow for surgery for abdominal or extraperitoneal tumors with cavoatrial extension.Ann Thorac Surgery. 2013; 95: 2036-2041Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar] report the removal of tumor thrombus into the inferior vena cava (IVC) by use of deep hypothermic low-flow cardiopulmonary bypass (CPB). There was no mortality at the 1-year follow-up of these patients. The authors conclude that this technique allows for safe and complete removal of tumor thrombus into the IVC while providing organ protection. It is not clear whether the authors placed an IVC filter when the IVC was partially obstructed at the end of the operation to avoid pulmonary emboli. Perhaps the only limitation of this report is the limited number of patients, making it difficult to standardize the surgical approach for removal of these tumors. The prevalence of patients with extensive IVC tumor thrombus is very low. However, the surgical procedure is associated with high morbidity and mortality (over 8%) when deep hypothermic circulatory arrest is used [2Shuch B. Crispen P.L. Leibovich B.C. et al.Cardiopulmonary bypass and renal cell carcinoma with level IV tumor thrombus: can deep hypothermic circulatory arrest limit perioperative mortality?.BJU Int. 2010; 107: 724-728Crossref Scopus (42) Google Scholar]. This underscores the importance of the experience of the surgical team performing the operation. Some centers, such as ours, have gone to great lengths to avoid CPB altogether, using innovative technical maneuvers [3Ciancio G. Gonzalez J. Shirodkar S.P. Angulo J.C. Soloway M.S. Liver transplantation techniques for the surgical management of renal cell carcinoma with tumor thrombus in the inferior vena cava: step-by-step description.Eur Urol. 2010; 59: 401-406Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar, 4Ciancio G. Shirodkar S.P. Soloway M.S. Livingstone A.S. Barron M. Salerno T.A. Renal carcinoma with supradiaphragmatic tumor thrombus: avoiding sternotomy and cardiopulmonary bypass.Ann Thorac Surg. 2010; 89: 505-510Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar]. The best approach for such patients would be to refer them to centers with extensive experience with these complex operations, where the operation can be tailored to the specific location of the tumor, with use of a multidisciplinary surgical team that includes a urologic oncologist, a cardiothoracic surgeon, and an anesthesiologist with expertise in transesophageal echocardiography. It is important to determine the exact extension of the tumor thrombus and involvement of the IVC wall with imaging technology. This helps the surgeons to individualize the approach, the extent of expected surgical procedure, and the need for CPB. These tumors with vascular invasion into the IVC continue to be a challenge to the surgical team. It is clear that complete excision of the tumor, including removal of involved IVC, with negative margins, as described by the authors, allows the best chance for patient survival. Deep Hypothermia and Low Flow for Surgery for Abdominal or Extraperitoneal Tumors With Cavoatrial ExtensionThe Annals of Thoracic SurgeryVol. 95Issue 6PreviewSurgical treatment of retroperitoneal tumors with cavoatrial involvement can be challenging. Completeness of resection of the cava tumor extension is crucial for the patient's survival. We report a monocentric experience with the use of cardiopulmonary bypass and deep hypothermic low flow for the surgical resection of caval and atrial involvement of retroperitoneal tumors. Full-Text PDF

455 Liver mobilisation reduces the need for cardiopulmonary bypass in renal tumours with inferior vena cava extension

455 Liver mobilisation reduces the need for cardiopulmonary bypass in renal tumours with inferior vena cava extension

In cholestatic hepatic dysfunction, also consider the kidneys and the heart: A probable case of Stauffer syndrome in renal leiomyosarcoma with cava-atrial extension

Introduction: Abnormal liver function tests (LFts) are a common reason for referral to hospital although in some cases, no obvious hepatic pathology is found. Yet, they can indicate other disease processes not immediately obvious. A rare cause of cholestatic hepatic dysfunction is the paraneoplastic manifestation of malignancy. case report: Herein, we report a case referred with anicteric cholestatic hepatic dysfunction that was found to have a renal leiomyosarcoma with inferior vena cava (IVc) and right atrium extension. conclusion: the abnormal LFts were thought to be a paraneoplastic manifestation of the tumor as these were improving following surgical treatment.

Advanced Hepatocellular Carcinoma with Subtotal Occlusion of the Inferior Vena Cava and a Right Atrial Mass

Hepatocellular carcinoma usually metastasizes to regional lymph nodes, lung, and bones but can rarely invade the inferior vena cava with intravascular extension to the right atrium. We present the case of a 75-year-old man who was admitted for generalized oedema and was found to have advanced HCC with invasion of the inferior vena cava and endovascular extension to the right atrium. In contrast to the great majority of hepatocellular carcinoma, which usually develops on the basis of liver cirrhosis due to identifiable risk factors, none of those factors were present in our patient.

Inferior vena cava resection and reconstruction for retroperitoneal tumor excision

This study reviews the results of en bloc resection of the inferior vena cava (IVC) for malignant tumor excision and reconstruction. A prospective database was reviewed. IVC resection was categorized as suprarenal, perirenal, infrarenal, or extensive (>one segment resected). Repairs were divided into primary, patch, or circumferential. Tumor type, perioperative morbidity, mortality, and graft patency were recorded. Between 1990 and 2011, 47 patients (21 women; mean age, 56; range, 35-89 years) underwent IVC resection for en bloc tumor excision. Sarcomas were most common (36 [77%]: 30 primary IVC). Eleven patients had primary IVC repair, nine patch repair (two autogenous), and 27 had circumferential replacement with a polytetrafluoroethylene ringed graft. Extensive IVC reconstruction in 18 patients included the entire IVC, with renal (RV) and hepatic vein reimplantation in eight; suprarenal and perirenal in six (seven RVs reimplanted); and infrarenal and perirenal in four (four RVs reimplanted). Nine single-segment IVC replacements were infrarenal. Morbidity was 10.6%: one each with bowel obstruction, chyle leak, renal failure with complete recovery (left RV reimplant, right nephrectomy), reoperation for bleeding, and IVC graft thrombosis. Morbidity did not differ by type of reconstruction. There was no mortality. Follow-up ranged from 1.5 to 216 months (18 years) with a mean of 3.5 years. Computed tomography or duplex scans were available in 28 of 47 patients and in 15 of 27 patients in group 3 at a mean follow-up of 36 and 20 months, respectively. One IVC graft thrombosis was documented at 10 months after chemotherapy/sepsis. Tumor recurrence caused three graft stenoses. Cumulative 5-year patency in group 3 was 80% (imaging) and 92% (clinical). Lower extremity edema was universally avoided. Cumulative 5-year survival for the series was 45% ± 8.5%. Mean long-term survival was 5.8 ± 0.56 years (range, 4 months-17 years), with a significant difference between primary or patch (mean, 6.5 years) and circumferential or extensive repair (mean, 4.2 years; P < .005). Cumulative (47% vs 52%) and mean (3.1 vs 3.6 years; P > .12) survival was similar between patients with single-segment and extensive IVC resection and replacement. IVC resection and reconstruction for en bloc tumor excision is safe, even when extensive repairs are necessary. Replacement of the IVC with prosthetic graft avoids extremity venous complications and likely contributes to quality of survival. Survival depends on tumor behavior and degree of IVC involvement, where primary and patch repair has a better prognosis than circumferential resection.

Reconstruction of inferior right hepatic veins in living donor liver transplantation using right liver grafts

Because revascularization of the inferior right hepatic vein (IRHV) is a major component of right liver graft (RLG) reconstruction, we assessed the surgical techniques and clinical outcomes of IRHV reconstruction so that we could formulate practical guidelines for standardized procedures. From July 2004 to February 2010, we performed separate IRHV reconstructions in 487 of 1142 adult RLG recipients (42.7%). These recipients included 364 patients with a natural single IRHV and 123 patients with multiple IRHVs; in the latter group, the IRHVs were unified by venoplasty, which enabled a single anastomosis. The 1-year stenosis rates for the single-vein and venoplasty groups were 23% and 18.9%, respectively, and the early stent insertion rates were 7.1% and 9.8%, respectively (P = 0.09). Late IRHV occlusion did not lead to graft dysfunction, and all large major IRHVs were patent. A morphometric analysis showed that IRHV stenosis was associated with IRHV stretching and an anastomotic level discrepancy. This led to refinements of the surgical techniques: IRHV orifices were shaped into funnels, and the IRHV anastomosis was accurately placed at the recipient inferior vena cava (IVC). In an ongoing prospective study of 35 patients, our funneling unification venoplasty resulted in only 1 episode (2.9%) of early IRHV stenosis requiring stenting at a median follow-up of 8 months. The final configurations of the reconstructed IRHVs after funneling unification venoplasty and extensive IVC dissection were very similar to those of the native donor liver. In conclusion, we suggest that in combination with extensive recipient IVC dissection, funneling and unification venoplasty techniques are useful for securely reconstructing single or multiple IRHVs during the implantation of RLGs.

Strategy for management of retroperitoneal tumors with caval tumor thrombus

The surgical management of retroperitoneal tumors extending into the inferior vena cava (IVC) can be challenging. Although Wilms' tumor is the most common retroperitoneal tumor extending into the IVC, one must approach these tumors systematically as other diagnoses are possible. We present 4 consecutive cases of retroperitoneal tumors with IVC extension as a basis for a management strategy in approaching these patients. Despite similar presentations, these cases illustrate the nuances in surgical management and need for multidisciplinary care with the pediatric oncologists, pediatric surgeons, and pediatric cardiac surgeons.

Graft Reconstruction of Inferior Vena Cava for Renal Cell Carcinoma Stage pT3b or Greater

To review the methods and outcomes for simultaneous radical nephrectomy and inferior vena cava (IVC) graft reconstruction at our institution. Renal cell carcinoma has the potential to propagate and invade the IVC, requiring resection and/or reconstruction of the IVC concurrently with radical nephrectomy. A prospective database of patients undergoing simultaneous radical nephrectomy with IVC reconstruction for renal cell carcinoma was queried. The data were collected and analyzed for patients who had undergone IVC graft reconstruction. A total of 17 patients were identified from 1999 to 2010, with a median age of 61 years (range 36-77). The tumor was right sided in 14 patients. The median tumor size was 12 cm (range 7.5-23), 15 tumors had clear cell histologic findings, and 16 were high grade. Seven patients had clinical metastasis found on imaging preoperatively, with another 4 having lymph node metastasis on pathologic examination. Of the 17 patients, 11 underwent patch grafting (3 expanded polytetrafluoroethylene and 8 bovine pericardium) and 6 underwent IVC interposition (3 Dacron and 3 expanded polytetrafluoroethylene). Also, 5 and 3 patients underwent cardiopulmonary and venovenous bypass, respectively. The mean estimated blood loss was 4 L, and the mean hospitalization was 7 days (range 5-16). Six patients experienced perioperative complications, with 1 perioperative mortality. Two patients overall developed graft thrombosis. Of the 6 patients initially without metastasis, the recurrence-free and overall survival rate was 50% and 83%, respectively, at a mean of 55 months. Of the 11 patients initially with metastasis, the recurrence-free and overall survival rate was 18% and 45%, respectively, at a mean of 13 months. For selected patients with advanced renal cell carcinoma and extensive IVC thrombus, resection with patch or interposition grafting of the IVC yields acceptable patency rates, minimal complications related to the graft, and reasonable oncologic results in a high-risk patient population.

Inferior Vena Cava Resection and Reconstruction for Retroperitoneal Tumor Excision

The purpose of this study was to review the results of resection and reconstruction of the inferior vena cava (IVC) for en bloc malignant tumor excision. We conducted a retrospective review of all patients having IVC resection for en bloc malignant tumor excision. IVC resection was categorized as suprarenal, perirenal, infrarenal, or extensive (>1 segment resected). Repairs were divided into primary, patch, or circumferential. Tumor type, perioperative morbidity, mortality, clinical graft patency, and survival (social security death index) were recorded. Between 1992 and 2010, 48 patients (24 female) had IVC resection for tumor en bloc excision. Sarcomas were most common (33; 69%: 5 [10%] primary IVC). Thirteen patients had primary IVC repair, nine patch repairs (one autogenous), and 26 had circumferential replacement with polytetrafluoroethylene (PTFE) ringed graft (12-16 mm). Extensive IVC reconstructions were performed in 17 cases of which seven involved the entire IVC with renal vein (RV) and hepatic vein reimplantation, six were suprarenal and perirenal (seven RV reimplanted), and four were infrarenal and perirenal (four RV reimplanted). All single segment (9) repairs were infrarenal. Overall morbidity was 6% (one bowel obstruction requiring surgery, one chyle leak resolved with medical therapy, and one renal failure with complete recovery [L RV reimplant, R nephrectomy]). There was no difference in morbidity between primary, patch, circumferential, and extensive reconstruction. There was no mortality. One IVC graft thrombosis was documented on follow-up (after chemotherapy/sepsis). There were two graft stenosis associated with tumor recurrence. Lower extremity edema was universally avoided. Mean long-term survival was 3.34 years (4 months to 11 years) with a significant difference between primary or patch (mean 66.7 months) and circumferential or extensive repair (mean 39.7 months; P < .005). There was no survival difference between single segment and extensive IVC repair (36.7 vs 42.8 months; P > .12). IVC resection and reconstruction for en bloc tumor excision is safe even when extensive repairs are necessary. Replacement of the IVC with a prosthetic graft avoids extremity venous complications and likely contributes to quality of survival. Survival is dependent on tumor behavior and degree of IVC involvement where primary and patch repair has a better prognosis than circumferential resection.

Large cell non-Hodgkin's lymphoma masquerading as renal carcinoma with inferior vena cava thrombosis: a case report

IntroductionMany cancers are associated with inferior vena cava (IVC) obstruction, but very few cancers have the ability to propagate within the lumen of the renal vein or the IVC. Renal cell carcinoma is the most common of these cancers. Renal cancer with IVC extension has a high rate of recurrence and a low five year survival rate.Case presentationA 62-year-old Caucasian woman previously in good health developed the sudden onset of severe reflux symptoms and right-sided abdominal pain that radiated around the right flank. A subsequent ultrasound and CT scan revealed a right upper pole renal mass with invasion of the right adrenal gland, liver, left renal vein and IVC. This appeared to be consistent with stage III renal cancer with IVC extension. Metastatic nodules were believed to be present in the right pericardial region; the superficial anterior abdominal wall; the left perirenal, abdominal and pelvic regions; and the left adrenal gland. The pattern of these metastases, as well as the invasion of the liver by the tumor, was thought to be atypical of renal cancer. A needle biopsy of a superficial abdominal wall mass revealed a surprising finding: The malignant cells were diagnostic of large-cell, B-cell non-Hodgkin's lymphoma. The lymphoma responded dramatically to systemic chemotherapy, which avoided the need for nephrectomy.ConclusionLymphomas only rarely progress via intraluminal vascular extension. We have been able to identify only one other case report of renal lymphoma with renal vein and IVC extension. While renal cancer would have been treated with radical nephrectomy and tumor embolectomy, large-cell B-cell lymphomas are treated primarily with chemotherapy, and nephrectomy would have been detrimental. It is important to remember that, rarely, other types of cancer arise from the kidney which are not derived from the renal tubular epithelium. These may be suspected if an atypical pattern of metastases or unusual invasion of surrounding organs is present. A preoperative or intraoperative biopsy may be helpful in these cases.

Morphology Identification Using Transesophageal Echocardiography in Migratory Renal Cell Carcinoma Surgery

RENAL CELL CARCINOMA WITH INFERIOR VENA CAVAL (IVC) extension presents many difficulties for intraoperative management. Transesophageal echocardiography (TEE) has been recognized as a valuable intraoperative tool to monitor the tumor during surgical resection. 1 Chan F. Ngan Kee W.D. Low J.M. Anesthetic management of renal cell carcinoma with inferior vena caval extension. J Clin Anesth. 2001; 13: 585-587 Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar , 2 Koide Y. Mizoguchi T. Ishii K. et al. Intraoperative management for removal of tumor thrombus in the inferior vena cava or the right atrium with multiplane transesophageal echocardiography. J Cardiovasc Surg. 1998; 39: 641-647 PubMed Google Scholar Real-time monitoring of the tumor during surgery allows rapid diagnosis of tumor embolization. This is a relatively rare complication, occurring in less than 0.4% of all renal cell carcinomas and less than 5% of renal cell carcinomas involving the IVC, 3 Chen H. Ng V. Kane C.J. et al. The role of transesophageal echocardiography in rapid diagnosis and treatment of migratory tumor embolus. Anesth Analg. 2004; 99: 357-359 Crossref PubMed Scopus (27) Google Scholar but is feared because of its disastrous complications.

Bilateral Intratesticular and Extratesticular Varicoceles Secondary to Extensive Inferior Vena Cava Thrombosis

Intratesticular varicoceles are relatively rare findings with unknown clinical implications. 1 Gray scale and color Doppler sonography can confirm the diagnosis, showing findings similar to those of the more commonly identified extratesticular varicoceles. We present a case of bilateral intratesticular and extratesticular varicoceles secondary to congenital interruption of the inferior vena cava (IVC) with azygos/hemiazygos continuation. To our knowledge, there is no other reported case in the literature.

Renal cell carcinoma with caval involvement: Contemporary strategies of surgical treatment

Objectives We retrospectively evaluated the outcome of the surgical treatment of patients with renal cell carcinoma (RCC) and extensive inferior vena cava (IVC) involvement. Our aim was to investigate if a particular surgical technique could reduce morbidity and complications associated with this condition. Materials and methods From 1996 to 2007, 22 patients with RCC and extensive IVC involvement underwent radical surgical treatment with the intention to avoid, whenever possible, sternotomy and cardiopulmonary bypass. The level of the tumor thrombus was I (<2 cm above the renal vein) in 2 patients, II (below the intrahepatic vena cava) in 9 patients, III (intrahepatic vena cava below the diaphragm) in 7 patients, and IV (atrial) in 4 patients. Extracorporeal vascular bypass was used for 4 patients with level IV and for 2 patients with level III tumor thrombi, with hypothermic circulatory arrest in 2 patients. Extensive liver mobilization techniques were adopted in 16 patients. Overall and cancer-specific survival (CSS) were analyzed based on tumor extent (N0M0, N+M+), pathologic stage (pT3b, pT3c, pT4), thrombus level, and caval wall infiltration. Results Two patients died within 1 month of surgery and the remaining 20 patients have a mean follow-up of 32.2 months (range 6–90): 8 are alive (overall survival 40%), but 2 with disease (CSS 30%). A total of 10 severe complications developed in 8 patients (36%). Both overall and CSS were significantly associated with tumor stage (Log-rank P = 0.0237 and 0.0465), presence of nodal or systemic metastases (Log-rank P = 0.0835 and 0.0669; Wilcoxon's test P = 0.0407 and 0.0411), and caval wall infiltration (Log-rank P = 0.0200 and 0.0418). Conclusions Despite the low overall survival, related to the high percentage of nodal and systemic metastases, aggressive surgical management with resection of synchronous metastatic disease for symptom palliation and cytoreduction, followed by immunotherapy is justified in this setting. A transabdominal approach to RCC and IVC involvement, even in patients with level III thrombus, can provide the surgeon with an exposure similar to thoracoabdominal incisions without the complications associated with thoracotomy.

Acute Bilateral Renal Vein Thrombosis

Acute Bilateral Renal Vein Thrombosis

Gonadal Vein Tumor Thrombus in Metastatic Renal Cell Carcinoma

Although renal vein invasion and/or inferior vena cava extension occurs in 4%-10% of patients with renal cell carcinoma, involvement of the gonadal vein is uncommon. We present a case of a patient with unresectable metastatic renal cell carcinoma invading the gonadal vein, who was initially treated with targeted molecular therapy.

Sacral preservation in cauda equina syndrome from inferior vena cava thrombosis

Acute cauda equina syndrome can occur due to a variety of causes. Inferior vena cava (IVC) thrombosis has been reported as the causal source of this phenomenon twice in the relevant literature, both cases of which presented in a form complete with a component of bowel and/or bladder dysfunction. The authors report an atypical case of cauda equina syndrome in a patient in a hypercoagulable state with an extensive IVC thrombosis, resulting in acute paraparesis in the absence of incontinence or perineal anesthesia. An increasing number of prophylactic and/or therapeutic IVC filters placed in the perioperative period should engender an increased clinical suspicion for IVC thrombosis in patients presenting with acute paraparesis.

Hepatocellular carcinoma with extension to the diaphragm, falciform ligament, rectus abdominis and paraumbilical vein

Hepatocellular carcinoma is the most common primary tumour of the liver. The most common extrahepatic metastatic sites are the lung, lymph nodes, bones and adrenal glands. All forms of HCC demonstrate a tendency for vascular invasion, producing extensive intrahepatic metastases and, occasionally, portal vein or inferior vena cava extension with spread into the right atrium in extreme cases. Tumour spread of abdominal diseases via hepatic ligaments has also been previously reported. We report a rare case of hepatocellular carcinoma with extension into the falciform ligament, overlying rectus sheath and adjacent diaphragm with concomitant infiltration into the recanalised paraumbilical vein.

Outcomes of Laparoscopic Radical Nephrectomy in the Setting of Vena Caval and Renal Vein Thrombus: Seven-Year Experience

We present our experience with laparoscopic radical nephrectomy for T(3b) disease focusing on thrombus within the vena cava. A total of 14 patients with T(3b) disease were identified from a retrospective laparoscopic renal cancer database from 2000 to 2007. Patient demographics, clinical stage, preoperative imaging, intraoperative parameters, final pathology, and postoperative course were analyzed. In patients with a large tumor thrombus, the infraumbilical extraction excision was performed early and a gel port was placed. This was used when laparoscopic milking or determination of the distal extent of the tumor thrombus was difficult. Preoperative imaging identified T(3b) disease in all but four patients. Four patients had caval involvement seen on imaging, with one extending well above 2 to 3 cm above the renal vein. Of the 14 patients, procedures in 13 were completed laparoscopically. There was one conversion early in the experience because of a positive frozen section of the renal vein; however, additional vein and caval margins were negative. There was one complication-a pulmonary embolism 5 days postoperatively, managed with anticoagulation, with no disease recurrence 4 years later. In patients with T(3b) disease, laparoscopy is feasible and safe. Using advanced laparoscopic techniques to milk the tumor thrombus into the proximal renal vein with laparoscopic vascular instruments is critical to success in a purely laparoscopic thrombectomy. Placement of a gel port in the extraction incision early in the procedure may aid in hand-milking of the tumor thrombus into the renal vein in cases of extensive inferior vena cava involvement.