Preoperative Renal Artery Embolization Research Articles

A systematic review and meta-analysis on the efficacy of preoperative renal artery embolization prior to radical nephrectomy for renal cell carcinoma: Is it necessary?

Radical nephrectomy for Renal Cell Carcinoma (RCC) is still the treatment of choice for all stages except for stage I and IV, which need patient selectivity. The purpose of Renal Artery Embolization (RAE) pre-operative before radical nephrectomy is to facilitate resection, reduce bleeding, and reduce the time to surgery, but the necessity of this procedure is still debatable. This study investigates the efficacy of pre-operative Renal Artery Embolization (PRAE) before radical nephrectomy for RCC patients. The systematic searches based on PRISMA guidelines were conducted in Pubmed, Scopus, Web of Science, Medrxiv, and ScienceDirect databases with pre-defined keywords. Both analyses, quantitative and qualitative, were performed to assess blood loss, transfusion rate, surgical time, Intensive Care Unit (ICU) stay, and hospital stay. A total of 921 patients from 8 eligible studies were included. The blood loss was significantly lower in the PRAE group compared to the control group (p = < 0.00001; SMD -20 mL; 95%CI -0.29, -0.12). There is no statistically significant difference between RAE and without RAE in the transfusion rate nephrectomy (p = 0.53, OR 0.65; 95% CI 0.16, 2.57), mean operative time (p = 0.69; SMD 5.91; 95% CI -23.25, 35.07), mean length of hospital stay (p = 0.05; SMD 0.56; 95% CI 0.00, 1.12), and mean length of stay in the ICU (p = 0.45; SMD 11.61; 95% CI -18.35, 41.57) Conclusions: PRAE before radical nephrectomy significantly reduces blood loss in RCC patients but is similar in the surgical time, transfusion rate, and length of hospital stay and ICU stay.

Preoperative Renal Artery Embolization Before Radical Nephrectomy for Nonmetastatic Renal Cell Carcinoma: A Propensity Score Matched Analysis

Purpose: This study investigated the effects of preoperative renal artery embolization (PRAE) before radical nephrectomy (RN) for advanced nonmetastatic renal cell carcinoma (RCC) on perioperative and oncologic outcomes.Materials and Methods: We analyzed 820 patients who had undergone RN for advanced nonmetastatic RCC (cT3-4/N0-1) between June 2003 and May 2022. Propensity score matching (PSM) at a 1:2 ratio was performed using the nearest-neighbor method, matching 121 PRAE patients to 242 controls. The primary endpoints included recurrence rate, overall survival, cancer-specific survival, and recurrence-free survival.Results: Before PSM, there were differences in sex (p=0.047), clinical stage (p=0.001), and the Fuhrman grade (p&lt;0.001) between the 2 groups. After PSM, the baseline characteristics were well balanced. The mean age at operation was 58.2±13.0 years, and the median follow-up was 42.0 months. The postoperative transfusion rate was higher in PRAE group (18.2% vs. 10.7%, p=0.049). No significant differences were found between the PRAE and control groups in operation time (166.6±95.3 minutes vs. 155.5±74.2 minutes, p=0.263), estimated blood loss (360.4±732.0 mL vs. 293.4±596.6 mL, p=0.384), or length of hospital stay (7.7±4.9 days vs. 7.7±3.7 days, p=0.961) between the 2 groups. Recurrence was significantly less common in the PRAE group than in the control group (20.7% vs. 34.3%, p=0.007). No significant differences were found in cancer-specific death (8.3% vs. 9.1%, p=0.793) or overall death (8.3% vs. 12.0%, p=0.281). In multivariate logistic regression analysis, clinical T stage ≥3 (odds ratio [OR], 4.365; p&lt;0.001), clinical N stage 1 (OR, 2.405; p=0.020) and no PRAE (OR, 2.293; p=0.004) were independent predictors of recurrence.Conclusions: Our results showed that PRAE was related to a lower recurrence rate. Thus, PRAE seems to be useful before RN for nonmetastatic RCC patients.

V05-07 ROBOTIC-ASSISTED LEFT RADICAL NEPHRECTOMY AND IVC THROMBECTOMY IN CROSS-FUSED RENAL ECTOPIA

You have accessJournal of UrologyCME1 Apr 2023V05-07 ROBOTIC-ASSISTED LEFT RADICAL NEPHRECTOMY AND IVC THROMBECTOMY IN CROSS-FUSED RENAL ECTOPIA Hannah Pham, Raj Satkunasivam, Brian Miles, Wesley Ekeruo, Mark Sultenfuss, Michael Brooks, and Monty Aghazadeh Hannah PhamHannah Pham More articles by this author , Raj SatkunasivamRaj Satkunasivam More articles by this author , Brian MilesBrian Miles More articles by this author , Wesley EkeruoWesley Ekeruo More articles by this author , Mark SultenfussMark Sultenfuss More articles by this author , Michael BrooksMichael Brooks More articles by this author , and Monty AghazadehMonty Aghazadeh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003263.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Crossed fused renal ectopia is a relatively rare entity with an estimated prevalence of 1 in 2000 births (Tsuboi et al). Renal cell carcinoma (RCC) in this setting is even more rare and there are no previous reports of associated inferior vena cava (IVC) tumor thrombi. Renal malignancy involving crossed fused ectopia presents a unique, complex surgical challenge and, therefore, there a few reports of minimally invasive surgical management. Herein, we describe a successful robotic resection of a large left renal mass with IVC thrombus involving a crossed fused ectopic right kidney. METHODS: We performed a transperitoneal robotic nephrectomy and caval thrombectomy on a 68-year-old male with an 11cm left renal mass and level 1 IVC thrombus, in the setting of a crossed fused ectopic right kidney. A two-position approach - modified left flank, followed by modified right flank - was employed to safely complete the procedure. Critical procedure steps included: 1) Pre-operative left renal artery embolization, 2) IVC control, cavotomy, and thrombectomy, 3) Left radical nephrectomy, and 4) Partial nephrectomy of the ectopic right kidney. The use of intraoperative ultrasound, Firefly technology, and indocyanine green were also fundamental adjuncts to the procedure. Perioperative outcomes are reported along with associated contemporary comparisons. RESULTS: The total operative time was five hours and thirty-one minutes, which included re-positioning and re-docking time. Estimated blood loss was 300cc without the need for perioperative transfusion. The postoperative course was uncomplicated, and the patient was discharged on postoperative day 4. There were no major perioperative complications. Pre- and postoperative estimated glomerular filtration rate was 86 and 52, respectively. Final pathology showed pT3b, N1, and clear cell RCC. Margins were negative. CONCLUSIONS: We demonstrate robotic resection of RCC with IVC thrombus in the setting of crossed fused renal ectopia, which is, to our knowledge, the first reported description of this entity and this approach. Success was predicated on strict adherence to standard oncologic and operative principles for minimally invasive IVC thrombectomy, radical nephrectomy, and partial nephrectomy. Source of Funding: None. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e426 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hannah Pham More articles by this author Raj Satkunasivam More articles by this author Brian Miles More articles by this author Wesley Ekeruo More articles by this author Mark Sultenfuss More articles by this author Michael Brooks More articles by this author Monty Aghazadeh More articles by this author Expand All Advertisement PDF downloadLoading ...

P088 - Renal tumors with left renal vein tumoral thrombosis. Is Preoperative Renal Artery Embolization (PRAE) helpful?

P088 - Renal tumors with left renal vein tumoral thrombosis. Is Preoperative Renal Artery Embolization (PRAE) helpful?

Management of Renal Cell Carcinoma With Extensive Caval Thrombosis Utilizing a Temporary Atrial Caval Filter Through a Combined Endovascular and Open Surgical Technique

The most common cause of neoplastic thrombotic infiltration of the inferior vena cava is renal cell carcinoma (RCC). In the present report we described a case of a patient with massive RCC and extensive neoplastic thrombosis reaching the retrohepatic tract of the inferior vena cava. After a discussion in a multidisciplinary team meeting we decided to perform a radical nephrectomy with vena cava thrombectomy along with the support of a novel removable vena cava filter in order to avoid thromboembolism during the surgical procedure. Furthermore, a preoperative renal artery embolization with a non-adhesive liquid embolic agent was performed ahead of the surgical procedure in order to reduce the risk of intraoperative bleeding. The surgical procedure performed the day after was based on a hybrid endovascular-surgical approach consisting in nephrectomy, liver derotation, cavotomy with the additional use of a novel temporary caval filter, thus reducing the risk of intraoperative thromboembolic dissemination.

SC174 - Immediate preoperative renal artery embolization in the resection of complex renal tumors

SC174 - Immediate preoperative renal artery embolization in the resection of complex renal tumors

Adjuvant instant preoperative renal artery embolization facilitates the radical nephrectomy and thrombectomy in locally advanced renal cancer with venous thrombus: a retrospective study of 54 cases

BackgroundThe role of renal artery embolization (RAE) in the therapeutic armamentarium is always controversial. The present study aimed to assess the safety and the surgical outcomes of the instant renal artery embolization (I-RAE) prior to nephrectomy and thrombectomy in patients with locally advanced renal cell carcinoma (RCC) with venous thrombus.MethodsWe performed a retrospective analysis of 54 patients treated with nephrectomy and thrombectomy between January 2012 and January 2019. Twenty-four patients were treated with I-RAE before surgery. Thirty patients received surgery alone (non-RAE group). The patient demographics, operation time, blood loss, transfusion requirements, complications, and other surgical parameters were analyzed between the two groups.ResultsThe mean tumor size in the I-RAE group was significantly larger than that in the non-RAE group (11.1 cm versus 7.9 cm; p = .001). The mean estimated blood loss was significantly lower in the I-RAE group compared to that in the non-RAE group (596 ml versus 827 ml; p = .015), and the patients in the non-RAE group were more likely to receive blood transfusion (red blood cell, RBC units, 4 U versus 6 U, p = .025; plasma volume, 200 ml versus 400 ml, p = .01). No differences were found in operative duration, ICU stay, perioperative complications, and length of postoperative hospitalization.ConclusionsInstant preoperative adjuvant renal artery embolization (I-RAE) is a safe technique. It facilitates nephrectomy and thrombectomy by reducing blood loss, transfusion requirements, and complications of delayed operations, providing urologists with a reliable option for treatment of locally advanced RCC with tumor thrombus.

Renal Artery Embolization Before Radical Nephrectomy for Complex Renal Tumour: Which are the True Advantages?

IntroductionRenal artery embolization is performed before radical nephrectomy (RN) for renal mass in order to induce preoperative infarction and to facilitate surgical intervention through decrease of intraoperative bleeding. Moreover, in metastatic renal cancer it seems to stimulate tumour-specific antibodies, even if no established benefits in clinical response or survival have been reported. The role of preoperative renal artery embolization (PRAE) in management of renal masses has been often debated and its real benefits are still unclear. Nevertheless, in huge and complex renal masses, which are often characterized by a high and anarchic blood supply and rapid local invasion, radical nephrectomy can be challenging even for skilled surgeons. The aim of this prospective randomized study was to evaluate the effectiveness and safety of PRAE in complex masses by comparing perioperative outcomes of RN with and without PRAE.Materials and methodsFrom December 2015 to May 2018 we enrolled prospectively 64 patients who underwent RN for localized (T2a-b) or locally advanced (T3 and T4) or advanced (N+, M+) renal cancers. Patients were divided in two groups. The first group included 30 patients who underwent PRAE; in the second group we enrolled 34 patients who did not undergo RN without PRAE. Perioperative outcomes in terms of operative time, blood loss, transfusion rate and length of hospitalization were evaluated. Statistical analysis was performed using GraphPad Prism 6.0 software.ResultsMedian blood loss was 250 ml (50-500) and 400 ml (50-1000) in the first and second group, respectively, with a statistically significant difference (p=0.0066). Median surgical time was 200 min (90-390) and 240 min (130-390) in PRAE and No-PRAE group (p=0.06), respectively. No major complications occurred after embolization. Overall complication rate in Group 1 and 2 was 46.7% (14/30) and 50% (17/34), respectively (p=0.34). No major complications occurred in both groups. The mean follow up was 21,5 months.ConclusionsOur results prove PRAE to be a safe procedure with low complications rate. To our experience, PRAE seems to be a useful tool in surgical management of a large mass and advanced disease.

Robotic Left-sided Level II Caval Thrombectomy and Nephrectomy Using a Novel Supine, Single-dock Approach: Primary Description

To demonstrate a novel supine, single-dock approach for robotic nephrectomy and inferior vena cava (IVC) thrombectomy for a left-sided renal cell carcinoma with level II IVC thrombus. We perform robotic nephrectomy and IVC thrombectomy in a 79-year-old man with a 6-cm left renal mass and level II IVC thrombus. For this approach, the patient is placed in steep Trendelenburg, and a 6-port transperitoneal technique is used, with the robot docked such that the arms are oriented in a cephalad direction. We describe key steps, including (1) exposure of the retroperitoneum, (2) IVC exposure and control, (3) left renal hilar control, (4) cavotomy, thrombectomy, and reconstruction, (5) nephrectomy and lymph node dissection. Perioperative outcomes are reported. Robotic left nephrectomy and level II IVC thrombectomy were successfully completed using this novel, single-dock approach. Total operative time was 7 hours with IVC clamp time of 27 minutes. Estimated blood loss was 500 cc without perioperative transfusion. There were no intraoperative or major perioperative complications. The patient was discharged on postoperative day 5. This approach allows rapid caval control, bilateral renal hilar access, and obviates the need for preoperative renal artery embolization or intraoperative redocking or repositioning steps, as has been previously described for other approaches. We demonstrate the first description of robotic left-sided level II IVC thrombectomy and radical nephrectomy using a supine, single-dock approach. This novel, versatile approach adds to the armamentarium for minimally invasive surgical management of renal cell carcinoma with IVC thrombus.

The impact to operation safety of preoperative renal artery embolization for management of diameter≥10 cm renal cell carcinoma

Objective: To study the impact to operation safety of preoperative renal artery embolization for management of ≥10 cm renal cell carcinoma. Methods: The clinical data of 239 cases with ≥10 cm renal cell carcinoma which all had underwent operation in Department of Urology, Peking University First Hospital from January 2002 to December 2014 were retrospectively analyzed. Fifty-three patients underwent preoperative renal artery embolization (therapeutic group) and 186 patients did not (control group). The effect of embolization on operative time, transfusion requirements, hospitalization, ICU stay and perioperative complications were analyzed by comparing the two groups using rank sum test and χ(2) test or Fisher exact test. Results: Comparing the therapeutic group and control group, there was significant difference in tumor location (on the left or right). The mean age, sex, mean primary tumor size, and TNM stage were similar in both groups. Comparing the therapeutic group and control group, there were more open surgeries in therapeutic group (96.2% vs. 82.3%, χ(2)=6.438, P=0.013). There were no significant differences in mean operative time (238 (525) minutes vs. 208 (583) minutes, Z=-2.182, P=0.062). The mean blood transfusion (700 (1 900) ml vs. 925 (8 800) ml, Z=-1.064, P=0.006) had significant difference. The therapeutic group had a longer mean hospitalization (21 (50) days vs. 15 (79) days, Z=-4.322, P=0.000) and higher rate of intensive care unit stay (54.7% vs. 34.4%, χ(2)=6.103, P=0.027). There was no significant difference in perioperative complications between two groups (0 vs.3.2%, P=0.408). Conclusion: Preoperative renal artery embolization in ≥10 cm renal cell carcinoma patients undergoing operation provides benefit in increasing operation safety and reducing perioperative death.

V3-03 ROBOTIC LEFT-SIDED LEVEL II CAVAL THROMBECTOMY AND NEPHRECTOMY: PRIMARY DESCRIPTION OF NOVEL SUPINE, SINGLE-DOCK APPROACH

You have accessJournal of UrologyRenal Oncology1 Apr 2017V3-03 ROBOTIC LEFT-SIDED LEVEL II CAVAL THROMBECTOMY AND NEPHRECTOMY: PRIMARY DESCRIPTION OF NOVEL SUPINE, SINGLE-DOCK APPROACH Monty Aghazadeh, Spencer Craven, and Alvin Goh Monty AghazadehMonty Aghazadeh More articles by this author , Spencer CravenSpencer Craven More articles by this author , and Alvin GohAlvin Goh More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.718AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Initial descriptions of robotic management of renal cell carcinoma with Inferior Vena Cava (IVC) thrombus employ a lateral approach predicated on early IVC exposure and control. However, for left-sided renal masses and associated tumor thrombi, this approach requires re-positioning and re-docking steps, as well as pre-operative left renal artery embolization. Herein, we describe a novel supine, single dock technique for robotic left nephrectomy and caval thrombectomy. METHODS We perform robotic nephrectomy and caval thrombectomy on a 79 y.o. male with a 6cm left renal mass and level II IVC thrombus. The patient is placed supine, in steep trendelenburg. We employ a 6-port trans-peritoneal technique and dock the robot such that arms are directed cephalad. Key steps critical to the procedure include: 1) Exposure of the retroperitoneum 2) IVC exposure and control 3) Left Renal Hilar Control 4) Cavotomy, thrombectomy, and reconstruction 5) Nephrectomy and lymph node dissection (LND). Peri-operative outcomes are reported and compared to previously published case series. RESULTS Robotic left nephrectomy and level II caval thrombectomy was performed successfully via a single-dock, supine approach. This method yielded excellent and early access to the IVC and left renal hilum, and allowed for concomitant nephrectomy/LND without re-positioning. Total operative time was 420 minutes with 330 minutes robotic console time (174 minutes for exposure, 27 minutes IVC clamp time, 84 minutes for nephrectomy/LND). EBL was 500cc without need for peri-operative transfusions and no intraoperative complications. Length of stay was 5 days and no major perioperative complications were noted. Outcomes compare favorably to previously reported robotic caval thrombectomy procedures employing the lateral approach. CONCLUSIONS We demonstrate successful robotic left nephrectomy with Level II caval thrombectomy using a supine, single-dock approach. To our knowledge, this is the first description of this approach for robotic caval thrombectomy. In appropriately selected patients, this versatile approach allows for rapid caval control, bilateral renal hilar access, and obviates the need for patient re-positioning. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e288-e289 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Monty Aghazadeh More articles by this author Spencer Craven More articles by this author Alvin Goh More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The benefit of preoperative renal artery embolization in patients with renal cell carcinoma and venous tumor thrombus

Objective To evaluate the impact of preoperative renal artery embolization in renal cell carcinoma patients with venous tumor thrombus. Methods A total of 249 RCC patients with venous tumor thrombus underwent radical nephrectomy and thrombectormy in our hospital. Seventy-four patients received preoperative renal artery embolization while other 175 patients did not. The related items were analyzed. The tumor thrombus level was divided into 5 groups with American Mayo clinic classification system. Considering the significant difference in tumor situation and treatment strategies, we took the hepatic vein as a cut-off line, dividing patients into two subgroups, the early and advanced tumor thrombus groups. There were 208 patients in the early tumor thrombus group and 41 patients in the advanced group. The related items were analyzed respectively. Results Patients in the embolization group tended to have larger tumors and higher percentage of advanced tumor thrombus. For all patients, the embolization group had longer operation time [(4.8±2.1)h vs. (4.1±2.2)h , P 0.05). Conclusion Preoperative RAE may be more appropriate for patients with advanced tumor thrombus because of its benefits in reducing operation time, intraoperative blood loss and elevating the operative security. Key words: Renal artery embolization; Renal cell carcinoma; venous tumor thrombus

524 Preoperative renal artery embolization in renal carcinoma with venous thrombus: Preliminary results of a multicenter study

524 Preoperative renal artery embolization in renal carcinoma with venous thrombus: Preliminary results of a multicenter study

813 Cancer specific and overall survival of patients undergoing preoperative renal artery embolization prior to radical nephrectomy for renal cell carcinoma

813 Cancer specific and overall survival of patients undergoing preoperative renal artery embolization prior to radical nephrectomy for renal cell carcinoma

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.

938 Application of preoperative renal artery embolization in patients with renal cell carcinoma and venous tumor thrombus: An effective preoperative adjuvant therapy for patients with advanced tumor thrombus

938 Application of preoperative renal artery embolization in patients with renal cell carcinoma and venous tumor thrombus: An effective preoperative adjuvant therapy for patients with advanced tumor thrombus

Renal artery embolization for managing uncontrolled hypertension in a kidney transplant candidate

We report a case of pre-operative bilateral renal artery embolization to control the resistant and malignant hypertension in a patient prepared for kidney transplantation. A 34-year-old man with end-stage renal disease as a result of the focal segmental glomerulosclerosis and uncontrolled hypertension that precluded the transplantation surgery and the patient's post-transplant blood pressure and the renal function remained within normal limits following the transplant for 6 months of follow-up.

Renal Embolization and Nephrectomy in a Single Surgical Act in High-Risk Renal Tumor Pathology

Renal artery embolization is a procedure that has been shown to be useful as a concomitant treatment for the resection of large renal tumors. Over the years, preoperative renal artery embolization concomitant with nephrectomy as a treatment option has proved to be useful in reducing morbi-mortality rates; however this procedure is not exempt from significant iatrogenia. Performing this technique in conjunction with nephrectomy in a single surgical act helps to maintain the advantages of this treatment, which in turn considerably reduces the associated morbi-mortality rates. This study presents seven patients selected by the Urology Service in a nonconsecutive manner who underwent renal artery embolization concomitant with nephrectomy in a single surgical procedure for large renal tumors, thus presenting a variation to the usual techniques to improve and simplify the procedure. General data were obtained from all patients including age, gender, characteristics of the tumor, and symptomatology at the time of diagnosis. For all the cases, use of resources was analyzed in terms of duration of surgery, the amount of iodinated contrast medium used during the embolization procedure, and the mean duration of hospital and intensive care unit stay. Complications were evaluated with respect to general morbi-mortality associated with the complete procedure, hematic losses during the procedure, transfusion requirements, and renal function (calculated by measuring preoperative and 48-hour postoperative serum creatinine levels). All patients reported having symptoms at the time of diagnosis, all of them had tumors measuring >13cm in diameter (major). In all the cases, 100% technical success was obtained with the embolization and nephrectomy. The mean duration of surgery in the case of embolization with coils was 45 minutes, and 25 minutes in the case of embolization with Amplatzer. Amean volume of 115 mL of contrast medium was used in the case of embolization with coils, whereas for the other cases, a mean volume of 71 mL of iodinated contrast was used. Among all the patients, only two of them required to be cared at the intensive care unit during 24 hours. On an average, reported blood loss was 380 mL. During the procedure, two patients (28.6%) required a transfusion of two units of red cells. No cases of perioperative or postoperative mortality were reported. With respect to morbidity, only one patient (14.3%) experienced a complication in the form of a superficial infection of the surgical wound, which was later resolved by antibiotic therapy. One patient (14.3%) presented a slightly higher preintervention level of creatinine (1.42). Two patients (28.6%), both of whom underwent embolization by using coils, experienced deterioration of postoperative renal function. Preoperative embolization of the renal artery as a coadjuvant treatment option in high-risk renal neoplasia has clear technical benefits for the subsequent nephrectomy and also medical benefits for the patients. Performing both the procedures concomitantly as a single surgical act seems to retain the advantages of the embolization procedure, by reducing mortality rates and producing little associated morbidity. Technically, embolization with Amplatzer plugs seems to be faster and easier as compared with embolization with coils.

Reply

We agree that most bleeding during radical nephrectomy with inferior vena cava (IVC) thrombectomy is venous in origin and does not appear to be decreased by renal (arterial) angioinfarction. We also agree that radical nephrectomy with IVC thrombectomy is primarily a vena caval operation, and thus the initial steps of the operation should be directed toward obtaining control of the vena cava (both above and below the level of the tumor thrombus and of any significant tributaries). We do not advocate occluding the vena cava at this time but simply obtaining circumferential control for subsequent clamping. We also proceed with renal artery ligation after IVC control. From this point, however, we do not always favor the approach described by the reviewer for several reasons. The radiographic and intraoperative findings enable the surgeon to determine the extent to which the tumor thrombus adheres to the vena caval wall and thus dictates the operative sequence. In our experience, a large proportion of vena caval thrombi (particularly those that fill the entire IVC lumen) are quite adherent to the IVC intima. These thrombi are unlikely to become dislodged during kidney tumor manipulation. In this setting, we generally proceed with radical nephrectomy before IVC thrombectomy. We believe this is an important step in the operative sequence, because removing the kidney enables the surgeon to perform additional dissection on the posterior vena cava, which is necessary to allow for mobility in the posterior caval wall after tumor thrombectomy. We find that with the kidney in place, the posterior IVC is less exposed and less mobile for reapproximation during closure of the vena cavotomy. In some cases, the tumor thrombus may appear to be “loosely attached” or incompletely filling the IVC lumen, and mobilization and removal of the kidney tumor might promote distal embolization. In such situations, we would proceed with IVC thrombectomy before radical nephrectomy or remove the kidney tumor and IVC thrombus in an en bloc manner. Utility of Preoperative Renal Artery Embolization for Management of Renal Tumors With Inferior Vena Caval ThrombiUrologyVol. 74Issue 1PreviewTo review our experience with radical nephrectomy and inferior vena cava thrombectomy (RNIVCT) to determine the utility of preoperative embolization. Preoperative embolization has been used as an adjunctive procedure to facilitate surgical resection of complex renal tumors. Full-Text PDF Editorial CommentUrologyVol. 74Issue 1PreviewThese authors from a large kidney surgery center report their experience with preoperative renal artery embolization before radical nephrectomy and inferior vena cava (IVC) tumor thrombectomy during a 17-year period. Although not done using a prospective protocol, it appears these surgeons systematically used preoperative arterial embolization for advanced level 3-4 kidney cancers in 58% (135/231) of patients with IVC tumor thrombus, making this a large and unique data set. In brief, this retrospective analysis found patients with preoperative embolization did worse or no better than those with upfront radical nephrectomy in perioperative mortality, transfusion, and morbidity, and the authors have recommended abandoning its use. Full-Text PDF

Utility of Preoperative Renal Artery Embolization for Management of Renal Tumors With Inferior Vena Caval Thrombi

To review our experience with radical nephrectomy and inferior vena cava thrombectomy (RNIVCT) to determine the utility of preoperative embolization. Preoperative embolization has been used as an adjunctive procedure to facilitate surgical resection of complex renal tumors. From 1990 to 2007, 225 patients with renal tumors and inferior vena cava thrombus underwent RNIVCT, including 135 patients who had undergone preoperative renal artery embolization and 90 patients who had not. The effect of embolization on perioperative morbidity and mortality, transfusion requirements, blood loss, and operative time was analyzed by comparing the 2 groups. The mean primary tumor size was similar in both groups; however, 67% of the RNIVCT embolization group vs 48% of the nonembolization group had retrohepatic (level III) or supradiaphragmatic (level IV) thrombus extension (P = .032). The RNIVCT embolization patients had a greater median number of perioperative units transfused (8 vs 4; P = .001), a longer operative time (390 vs 313 minutes; P < .001), more postoperative complications (43% vs 29%; P < .001), a longer intensive care unit stay (2 vs 0.5 days), and increased perioperative mortality (13% vs 3%; P = .017). No differences were found in intraoperative complications or length of hospitalization. Multivariate analysis showed a fivefold greater risk of perioperative death (adjusted odds ratio 5.5; P = .029) and a trend toward increased blood transfusion (regression coefficient 3.9; P = .08) with preoperative embolization. The results of our study have shown that routine preoperative renal artery embolization in patients undergoing RNIVCT does not provide any measurable benefit in reducing blood loss or complications and was associated with increased major perioperative complications and mortality.