Radical nephrectomy with vena caval thrombectomy: a contemporary experience

OBJECTIVE To report on the contemporary Memorial Sloan-Kettering Cancer Center experience with radical nephrectomy and vena caval thrombectomy. PATIENTS AND METHODS Patients who underwent radical nephrectomy and vena caval thrombectomy without the use of bypass techniques were retrospectively identified. Data were collected on intraoperative and pathological findings as well as postoperative complications and oncological outcomes. RESULTS In all, 78 patients underwent radical nephrectomy with off-bypass resection of vena caval thrombus between 1989 and 2009. The median (interquartile range, IQR) operation duration was 293 (226–370) min, and median (IQR) blood loss was 1300 (750–2500) mL. In all, 10 patients (13%) were confirmed to have intra- or supra-hepatic tumour thrombus (level 3/4), eight of whom required supra-hepatic control of the inferior vena cava (IVC). Major (grade 3–5) postoperative complications occurred in 14 (18%), with five postoperative deaths. Disease recurred in 27/62 patients who were considered completely resected at surgery and had adequate follow-up. The overall 5-year survival (95% confidence interval) probability was 48% (35–60%). CONCLUSIONS Radical nephrectomy with vena caval thrombectomy is associated with acceptable postoperative morbidity and mortality, and long-term survival is possible in some patients. Many level 3/4 thrombi could be safely approached without the use of bypass techniques. Keywords: RCC, kidney, vena cava, nephrectomy INTRODUCTION Despite the recent stage migration in renal cell carcinoma (RCC) with an increased incidence of small, localized tumours, the detection rate of advanced-stage disease has not diminished [1]. Historically, extension of RCC into the inferior vena cava (IVC) has been reported in 5–10% of patients [2,3]. Slightly lower rates of IVC involvement (3–7%) are reported in contemporary series from the Memorial Sloan-Kettering Cancer Center (MSKCC) and the Mayo Clinic [4,5]. Surgical resection is required, and in some cases is sufficient, for the cure of such advanced disease. In one large series, the 5-year cancer-specific survival after radical nephrectomy and IVC thrombectomy was 32%; patients at lower risk (free of distant metastasis at surgery) enjoyed better outcomes (5-year cancer-specific survival of 59%) [5]. Initial descriptions of the thrombectomy technique describe reliance upon cardiopulmonary bypass and, in some cases, hypothermic circulatory arrest for the resection of thrombi involving the intra- and supra-hepatic IVC [2,3,6]. Subsequently, venovenous bypass techniques were described with the same goal: obtaining a bloodless operative field to facilitate complex IVC resection and reconstruction [7–9]. Earlier in this decade, investigators at the University of Miami began to describe the application of liver transplantation techniques to aid in the dissection of the intra- and supra-hepatic IVC, eliminating the need for circulatory bypass in their hands [10,11]. Despite advances in targeted systemic therapy, surgical resection remains the critical component in the care of patients with locally advanced RCC, including those with IVC thrombi. As described, the technique continues to evolve. In 1991 Burt [12] reported the initial experience with IVC thrombectomy without cardiovascular bypass at MSKCC in nine patients. In the present study, we report our updated single-institution experience with radical nephrectomy and off-bypass IVC thrombectomy, with attention to intraoperative findings, postoperative morbidity and mortality, and oncological outcomes.