Management Of Retroperitoneal Tumors Research Articles

Anaesthesia for nephrectomy

### Key points This paper will summarize the perioperative anaesthetic considerations for patients undergoing nephrectomy for both non-neoplastic and neoplastic disease of the kidney. It does not include the management of patients undergoing living donor nephrectomy. Nephrectomy for patients with renal cell carcinoma (RCC) was first described in 1969.1 Surgical treatment varies with the pathology. Simple nephrectomy is the preferred option for those with non-neoplastic disease (e.g. trauma, non-functioning kidney with chronic infection) with radical nephrectomy being preferred in those with neoplastic disease. Radical nephrectomy implies resection of the whole of Gerota's fascia, including the perinephric fat, lymphatics, and the ipsilateral adrenal gland. The vast majority (∼90%) of solid renal masses are RCC; the remainder comprising mainly of transitional cell carcinoma or Wilm's tumour (in children). RCC accounts for between 1% and 3% of all visceral malignancies. It is twice as common in men when compared with women and most commonly presents in the seventh decade of life. The main environmental risk factor is cigarette smoking, contributing to one-third of all cases. Other important risk factors include obesity, hypertension, asbestos exposure, and acquired polycystic kidney disease. If symptomatic, presentation is usually with haematuria, loin pain, and a palpable mass. Non-specific symptoms such as malaise, …

Retroperitoneal tumors in the pelvis: a diagnostic challenge in gynecology.

Retroperitoneal tumors can pose a diagnostic and therapeutic challenge to gynecologists because of their rarity, late presentation, and complex anatomical location in the retroperitoneum. This article reviews the diagnosis and management of retroperitoneal tumors in the pelvis, and highlights the potential pitfalls that may be faced by gynecologists.

Benefits of Liver Transplantation Surgical Techniques in the Management of Extensive Retroperitoneal Tumors

The potential for massive hemorrhage imposes additional challenge in the management of retroperitoneal tumors. This report details technical considerations for the management of upper retroperitoneal tumors using principles of liver transplantation. A retrospective chart review of patients who underwent surgery for extensive retroperitoneal tumors using techniques for liver transplantation from December 2002 to November 2007 was done. Twenty-four patients (14 males and 10 females with a mean age 57 years) underwent major retroperitoneal surgery. Renal cell carcinoma was the most common tumor seen in 17 patients. Mean tumor dimension was 12.4 cm. Abdominal exposure was achieved via bilateral subcostal incision with upper midline extension. Right hepatic lobe mobilization and isolation from the inferior vena cava (IVC) was performed in 23 cases. Fourteen patients had IVC involvement by tumor thrombus, which was infrahepatic in six, retrohepatic in five, and intra-atrial in three patients. Tumor thrombus was removed by cavotomy in seven cases, resection and plasty in four cases, IVC graft reconstruction in two cases, and one patient required IVC and atrial graft reconstruction. Liver resection was needed in seven patients to achieve R0 resection. The Pringle maneuver was used in three patients; total liver vascular isolation with venovenous bypass was required in two cases, transdiaphragmatic intrapericardial IVC control in one case, and cardiopulmonary bypass in one patient. There was no intraoperative or postoperative mortality and mean length of stay was 13 days. Liver transplantation surgical principles help achieve exposure and vascular control of major vascular structures that enable safe resection of these extensive retroperitoneal tumors.

COMPLETE RADICAL NEPHRECTOMY AND VENA CAVAL THROMBECTOMY DURING CIRCULATORY ARREST

A modification of radical nephrectomy for renal carcinoma and vena caval tumor thrombectomy for supradiaphragmatic tumor extension under hypothermic circulatory arrest is presented. Nephrectomy was performed during the circulatory arrest time in 16 consecutive patients during the last 4 years. Average hypothermic circulatory arrest time increased by 6 minutes. By elimination of manipulation of tumor and thrombus before circulatory arrest potential thrombus fragmentation and embolization were minimized. There were no significant differences in blood loss or complications compared to a prior series of 10 patients undergoing the procedure using conventional techniques. Performance of complete radical nephrectomy along with venal caval embolectomy during circulatory arrest increases the safety of the procedure without significant morbidity.

Experience with Cardiopulmonary Bypass and Deep Hypothermic Circulatory Arrest in the Management of Retroperitoneal Tumors with Large Vena Caval Thrombi

From June 1984 to September 1989, 43 patients with large vena caval tumor thrombi from retroperitoneal malignancies underwent surgical treatment with cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA). The primary malignancies were renal cell carcinoma (RCC) (n = 39), renal pelvic transitional cell carcinoma (n = 1), adrenal pheochromocytoma (n = 1), and renal (n = 1) or retroperitoneal (n = 1) sarcoma. The level of the caval thrombus was either suprahepatic (n = 27), intrahepatic (n = 14), or subhepatic (n = 2). In all cases the primary tumor and caval thrombus were completely removed. Concomitant procedures included coronary artery bypass grafting (n = 5), pulmonary resection (n = 2), and hepatic lobectomy (n = 1). The time of circulatory arrest ranged from 10 to 44 minutes (mean, 23.5 minutes). There were two operative deaths (4.7%), neither of them due to to the use of DHCA. Major postoperative complications occurred in 13 patients (30.2%). There were no ischemic or neurologic complications and no cases of perioperative tumor embolization. The median postoperative hospital stay was 9 days. Twenty-two patients (51%) are alive and enjoying a good quality of life. The 3-year patient survival rates in patients with localized (n = 24) versus metastatic (n = 15) RCC are 63.9% and 10.9%, respectively (p = 0.02). We conclude that CPB with DHCA facilities excision of retroperitoneal malignancies with large caval thrombi and provides the potential for cure with low morbidity and mortality rates.

The role of second-look procedures in the management of retroperitoneal tumors in children.

Forty-two infants and children with retroperitoneal solid tumors underwent second operative procedures. Twenty-three children had stage III (4) or stage IV (19) neuroblastoma and 19 had Wilms' tumor. This report suggests that second-look procedures are quite beneficial in selected cases. In children with Wilms' tumor, second procedures are most useful in those patients inadequately staged with flank operations, in cases of bilateral tumors, and in children with initially unresectable tumors following cytoreduction. Patients with significant tumor spill at a previous procedure may also benefit from early reoperation. Late recurrence of tumor, especially in children with unfavorable histology and/or hematogenous liver metastases, carries an ominous prognosis. Ten of the 19 patients with Wilms' tumor are long-term survivors (52.6%). Patients with initially unresectable (stage III) neuroblastoma occurring in the pelvis respond well to second-look resection. Children with primary tumors surrounding the celiac axis eventually died despite subsequent resection. Although the efficacy of primary tumor resection in cases of metastatic neuroblastoma remains controversial, stage IV patients with tumor resection had a longer duration of survival. Our only long-term survivors had their primary tumors resected. Second-look or delayed abdominal operations in metastatic cases may be useful in assessing the effectiveness of treatment and for sampling of retroperitoneal lymph nodes as a prognostic indicator.