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Resection of the Suprarenal Inferior Vena Cava for Retroperitoneal Malignant Disease
0022-5347/79/1211-0112$02. 00/0 THE JOURNAL OF UROLOGY Copyright © 1979 by The Williams & Wilkins Co.
Vol. 121, January
Printed in U.S.A.
RESECTION OF THE SUPRARENAL INFERIOR VENA CAVA FOR RETROPERITONEAL MALIGNANT DISEASE A. DAVID BECK* From the Division of Urology, Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
ABSTRACT
Minimal renal dysfunction was noted in 4 of 5 patients undergoing right nephrectomy with resection of the inferior vena cava and ligation of the left renal vein. However, the results of this series confirm previous reports that patients with locally advanced right renal carcinoma requiring vena caval resection are cured rarely by an operation alone. In the absence of effective adjunctive therapy for renal cell carcinoma this procedure will most likely benefit patients with neoplasms responsive to either chemotherapy or radiation therapy. Retroperitoneal neoplasms, particularly those originating from the right kidney, occasionally will invade the inferior vena cava or surround it to such an extent that an adequate cancer operation requires concomitant vena caval resection. Ligation of the inferior vena cava below the level of the renal veins is done frequently for pulmonary embolic disease and presents no threat to renal function. In contrast, the consequences of ligation or resection of the suprarenal vena cava often are regarded as disastrous. However, resection of the vena cava, right nephrectomy and ligation of the left renal vein seem to have little deleterious effect on renal function; 10 such cases have been reported in the English literature. 1-6 The 5 patients who have been treated in similar fashion at this institution form the basis of this study.
vena cava in the vicinity of the right renal vein was densely adherent to the tumor and total removal required resection of the vena cava and ligation of the left renal vein. Two units of packed cells were given to replace estimated blood loss. Histologic examination showed renal cell carcinoma invading the wall of the inferior vena cava and protruding into the lumen. Tumor extended beyond the kidney into the perinephric fat but all nodes were negative. The patient had normal renal function and no evidence of metastatic disease 8 months postoperatively. Case 3. G. E.W., MMC 203-360, a 61-year-old white man, had a mass in a functioning right kidney on IVP 2 weeks after an episode of hematuria. Arteriograms revealed neovascularity within the mass and the vena caval lumen contained a bulky tumor deposit causing significant obstruction (fig. 3). CASE REPORTS These findings were confirmed at exploration; tumor extendCase 1. M. A. L., MMC 189-510, a 36-year-old white man, ing within the vena cava approximately 2 cm. above the was evaluated because of a large abdominal mass on the right hepatic veins. The main mass of intracaval tumor was exside and edema of the right thigh. The right kidney was non- tracted without difficulty but since it was noted to be adherent functional on excretory urography (IVP); the left kidney and to the posterior caval wall the infrahepatic vena cava was ureter were displaced laterally but were normal otherwise. excised along with 5 cm. of vena cava below the renal veins. Markedly increased uptake of contrast medium in the periph- The left renal vein was ligated 1 cm. from its junction with ery of the mass was apparent on a gallium citrate scan. The the inferior vena cava and routine radical nephrectomy was inferior vena cava was obstructed completely with numerous done. The patient received 3 units of blood to replace intracollateral channels demonstrated on venacavography (fig. 1, operative loss. · Histologic examination revealed renal cell carcinoma invadA). Laparotomy revealed a huge mass occupying most of the ing the inferior vena cava and perinephric fat. Most of the right retroperitoneal space and crossing the midline. Biopsy excised lymph nodes also contained tumor. The patient was discharged from the hospital 9 days postand frozen section showed a poorly differentiated malignant tumor of uncertain origin. Subtotal excision was accomplished operatively, after an uneventful convalescence. Multiple pulbut necessitated removal of the right kidney and resection of monary metastases were seen 9 months later and the patient the inferior vena cava from its origin to a point just below the died 11 months after nephrectomy. Although no autopsy was obtained death was presumed to be owing to widespread hepatic veins. The left renal vein was ligated (fig. 1, B). Permanent sections revealed a poorly differentiated diffuse metastatic renal cell carcinoma. Case 4. W. C. C., MMC 223-428, an 82-year-old man, had a lymphosarcoma. The patient was treated w1th cyclical chemotherapy and has normal renal function and is, seemingly, free non-functioning kidney on an IVP done during the evaluation of prostatic obstructive disease. The neoplastic nature of this of disease 3 years postoperatively. Case 2. J. L. W., S. J. 204-651, a 63-year-old white woman lesion was confirmed by arteriography. A large intraluminal with gross hematuria, had slight delay in function and a mass filling defect was seen in the inferior vena cava, which was in the upper pole of the right kidney on IVP. Arteriographic not obstructed totally (fig. 4). At operation the right renal vein was packed solid with studies confirmed the malignant nature of this lesion, which tumor, which protruded into the inferior vena cava. The was seen to invade the inferior vena cava (fig. 2). Right radical nephrectomy was accomplished through a neoplasm was invading almost the entire circumference of the thoracoabdominal incision. The lateral wall of the inferior vena cava and radical nephrectomy was combined with resection of the vena cava and ligation of the left renal vein. The Accepted for publication March 29, 1978. patient was given 4 units of packed cells during the operation Read at annual meeting of American Urological Association, to replace estimated blood loss. Washington, D. C., May 21-25, 1978. Histologic examination revealed renal cell carcinoma invad* Requests for reprints: Division of Urology, Southern Illinois ing the inferior vena cava and perinephric fat. Lymph nodes University School of Medicine, 200 West Dodge, Springfield, Illinois 62708. were free of tumor. 112
RESECTION OF SUPRARENAL INFERIOR VENA CAVA
113
Fm. 1. Case 1. A, complete obstruction ofleft common iliac vein (arrow 1). Ascending lumbar vein (arrow 2) and segmental lumbar veins (arrow 3) are dilated. B, operative findings excluding arterial system. C, solid area indicates limits of surgical resection of inferior vena cava.
Fm. 3. Case 3. Large filling defect in obstructed inferior vena cava. Lumbar veins are dilated and tortuous.
Fm. 2. Case 2. Inferior venacavogram shows irregular filling defect. Arrows indicate patent left renal vein.
Acute cardiorespiratory failure developed 2 days postoperatively and the patient died 6 days later. No evidence of residual tumor was found at autopsy. Histologic abnormalities in the solitary left kidney were confined to the tubules, which showed change consistent with acute tubular necrosis. The
glomeruli were normal and the kidney showed no evidence of venous congestion (fig. 5). Case 5. L. W. S., MMC 217-487, a 63-year-old white man, had a non-functioning right kidney demonstrated on IVP in July 1976. Because of associated pulmonary emboli and a normal right retrograde pyelogram, loss of function was attributed to renal artery embolus. Further retrograde studies in July 1977, after repeated episodes of hematuria, revealed caliceal distortion. At this time the patient had ascites and
114
BECK
numerous dilat.ed veins on the anterior abdominal wall. Exploration revealed a large neoplastic kidney invading the inferior vena cava, which was considered inoperable. Three weeks lat.er the patient was referred to this institution for further evaluation. Arteriography confirmed the neoplastic nature of the right renal mass, the venous phase demonstrating large tortuous collat.eral veins draining the kidney. Trans-
femoral venacavograms showed complet.e obstruction of the inferior vena cava. Radiographic studies done via the brachial vein and right atrium revealed vena caval obstruction just below the hepatic veins (fig. 6, A). The suprahepatic inferior vena cava was better demonstrated by comput.erized axial tomography, which showed an excessively dilated vessel up to its junction with the right atrium. No distant metastases were demonstrat.ed. Transfemoral embolization of the right renal artery was accomplished and the patient was re-explored 18 hours lat.er. The operative findings are shown in figure 6, B. Tumor extending into the right atrium was isolat.ed by digital compression and extracted with a Foley cathet.er passed upward through an incision in the suprarenal vena cava. Because of obvious invasion of the infrahepatic vena cava this vessel was divided just below the hepatic veins. The left renal vein was ligated and the abdominal inferior vena cava was removed en bloc with the right kidney. The patient was given 10 units of blood during the operation. Histologic examination revealed renal cell carcinoma invading the perinephric fat. No metastases were discovered in the excised lymph nodes. Convalescence was uneventful and the patient was discharged from the hospital 11 days postoperatively. The patient is free of disease 15 months postoperatively. RESULTS
Fm. 4. Case 4. Filling defect in inferior vena cava at level of right renal vein.
Renal function. A transient increase in serum creatinine was observed in 2 patients (cases 1 and 2), both of whom had grossly normal function within 10 days of the operation (fig. 7). Two patients maintained normal creatinine levels throughout the immediate postoperative period, 1 dying 11 months lat.er with normal renal function. The sustained elevation of serum creatinine seen in case 4 was consist.ent with acute tubular necrosis secondary to hypotension. No glomerular damage was evident at autopsy. IVPs 6 to 9 days postoperatively revealed a normal left kidney in the 4 surviving patients. Urinary output. All patients exhibited a postoperative decrease in urine output lasting 2 to 3 days (fig. 8). Excluding the patient who had acut.e tubular necrosis, urine output increased to and maintained normal levels thereafter. Urinary protein. Of the 4 patients monitored only 1 (case 1) had a 24-hour urinary protein excretion of >0.5 gm. (fig. 9),
Fm. 5. Case 4. Photomicrograph of left kidney shows normal glomerulus and histologic features of acute tubular necrosis. No vascular congestion is apparent.
115
RESECTION OF SUPRARENAL INFERIOR VENA CAVA
Fm. 6. Case 5. A, retrograde inferior venacavogram shows filling of right hepatic veins and total obstruction of inferior vena cava. B, diagram of operative findings. RENAL FUNCTION FOLLOWING RENAL VEIN LIGATION OF SOLITARY LEFT KIDNEY CASE I CASE II CASE Ill
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which decreased to normal (<0.15 gm./24 hours) within 4 weeks postoperatively. DISCUSSION
Most studies designed to determine the results of renal vein ligation have used the dog as an experimental model. Siderys and Kilman ligated the left renal vein at its junction with the inferior vena cava in 25 animals, 15 of which died of massive
retroperitoneal hemorrhage. In the surviving dogs there was a universal decrease in the size of the left kidney. 7 Similar results were reported by Harris and associates. 8 Bowles and Koehler ligated the left renal vein at the hilus of the kidney in 10 animals, 9 of which survived. Acute swelling followed by renal atrophy was noted in all cases. 9 These pessimistic results in animals must be interpreted cautiously if applied to man. Hollinshead and McFarlane, in a meticulous study of the renal venous system in dogs, showed that the only major tributary vf the left renal vein, apart from small ureteral vessels, was the left gonadal vein. There was
116
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URINARY PROTEIN EXCRETION FOLLOWING RENAL VEIN LIGATION OF SOLITARY LEFT KIDNEY
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no communication with the azygos, lumbar, adrenal or inferior phrenic veins. In contrast, the left renal veins in man regularly possess complex connections with the suprarenal, phrenic and gonadal veins, and with all deep veins from the azygos to iliac level through the ascending lumbar vein (fig. 10). 10 It is apparent, therefore, that the potential for development of an efficient collateral circulation is far greater in man after obstruction of the left renal vein. Evidence for the relative safety of left renal vein ligation in humans comes from a variety of sources. In 1964 Erlik and associates proposed anastomosing the left renal vein to the splenic vein as a decompressive procedure for portal hypertension. The renal vein was divided 5 cm. from the vena cava and the distal end was ligated. The left kidney was considered normal on IVP within 17 days of the operation in the 4 surviving patients. 11 Approximately 23 similar cases have been reported. 12• 13 No patient had irreversible damage to the left kidney and in all patients the renal vein was divided medial to the gonadal and adrenal tributaries. However, an essential prerequisite for this procedure is a normal right kidney and even transient renal dysfunction obviously will pose a far greater problem in patients whose right kidney has been removed. A note of caution also is sounded by Swanson and associates who used the left renal vein for portal decompression but divided the adrenal and gonadal vessels and transected the renal vein at the hilus of the kidney. One patient sustained rupture of the left kidney requiring nephrectomy and transient impairment of renal function was a not infrequent finding. 14 Similar results were reported by Warren and associates. 15 The latter 2 series illustrate the importance of preserving all tributaries of the left renal vein, which must be ligated as close to the vena cava as possible. Table 1 illustrates the effects on renal function after right nephrectomy and ligation of the left renal vein. Information available in 14 cases showed that 8 patients retained normal function and only 2 (including case 4 in this report) sustained a degree of renal damage that might require dialysis. Gradual vena caval obstruction presumably would allow time for a collateral circulation to develop but we could find no correlation between the status of the vena cava and postoperative renal function. Case 1 for instance, with total obstruction and numerous enlarged collateral veins, was the only patient who exhibited a significant degree ofproteinuria. Conversely, case 2 with a widely patent left renal vein and only partial obstruction of the vena cava, had minimal pro-
Fm. 10. Venous drainage of kidneys TABLE
1. Renal function after right nephrectomy and ligation of left
renal vein No. Pts. Nonna! Creatinine <3 mg.% >5 mg.%
8 4 2
teinuria and an insignificant, transient increase in serum creatinine. Significant proteinuria might be expected to be common after venous obstruction of a solitary kidney. Urinary protein excretion was not mentioned in 8 case reports. Only 2 patients had 24-hour protein excretion >0.5 gm. and in both cases this was normal within 4 weeks of the operation. Although none of our patients had hypertension 1 case reported by McCullough and Gittes had elevation of peripheral venous renin and blood pressure, both of which returned to normal within a few days. 4 Maintenance of a normal circulating blood volume is essential, particularly during the immediate postoperative period. This may pose problems since there is a tendency for fluid to pool in the interstitial space of the lower limbs and pelvis. We consider it mandatory to monitor central venous pressure in all patients. Should hypotension or oliguria fail to respond to a suitable fluid challenge we insert a catheter and measure mean wedge pulmonary pressures, the latter being a more reliable index of cardiac function. With adequate fluid and colloid replacement the decline in urinary output noted in all of our patients and observed by several other authors returned to normal within 2 or 3 days. The importance of preoperative evaluation of the vena cava cannot be over emphasized. The association of main renal vein invasion by neoplasm with a non-functioning kidney is well known. However, 2 of our 4 patients with renal cell carcinoma
117
RESECTION OF SUPRARENAL INFERIOR VENA CAVA
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had minimal functional impairment and the findings on IVP must be considered an unreliable sign of possible vena caval involvement. We continue to be impressed by the ability of high dose selective arteriography to demonstrate a normal renal vein. 16 Failure to opacify the major venous system, including the vena cava, with this technique is an absolute indication for inferior venacavography. Fortunately, most cases of vena caval involvement requiring resection originate from a neoplasm in the right kidney, allowing preservation of the left kidney with its rich anastomotic venous network. We have shown that a solitary right kidney will maintain normal function after transient venous occlusion.17 However, ligation of the right renal vein probably is incompatible with sustained useful function. 18 When presented with a patient requiring left nephrectomy and resection of the suprarenal vena cava the right renal vein could be anastomosed to the portal vein. We are not aware of this procedure being done in man, although Lome and Bush reported normal renal function in dogs after right renoportal venous anastomosis and left nephrectomy. 19 Exposure of the infrahepatic vena cava is best afforded by a thoracoabdominal approach, excising the 8th or 9th ribs, as used in our 4 patients with renal cell carcinoma. Mobilization of the entire right colon, including the hepatic flexure, and incision of the inferior leaf of the small bowel mesentery allow the intestines to be reflected beyond the midline, thus exposing the inferior vena cava from its origin to the hepatic veins. If possible, the right adrenal vein is ligated and a tape is placed around the vena cava immediately below the liver. The left renal vein is isolated and taped. The second lumbar veins entering the posterior surface of the vena cava at or below the level of the renal veins are ligated and divided, and a tape is placed around the infrarenal vena cava. Initial clamping of the renal artery, which is especially difficult when there is tumor invasion of the renal pedicle, is nonetheless highly desirable to prevent extreme venous engorgement and subsequent hemorrhage. We have found the right renal artery readily accessible medial to the vena cava, where it is ligated in continuity before cross-clamping the vena cava and left renal vein (fig. 11). This simple maneuver frequently obviates the necessity for pi eoperative embolic or balloon occlusion of the renal artery. 20 • 21 However, in 1 of our patients (case 5) pre-nephrectomy embolization was believed to have contributed significantly to the ease of the operation by decreasing the venous collateral drainage of the kidney.
TABLE
2. Indications for right nephrectomy and ligation of left renal vein No. Pts.
Renal cell Ca N ephroblastoma Transitional cell Ca Fibrosarcoma Lymphoma
10 2 1 1 1
Most previous case reports make no reference to operative hemorrhage. However, the case described by Solomon required 30 units of blood. 6 We attribute our relatively modest blood loss to initial ligation of the renal artery and early identification and control of all venous tributaries, particularly the upper lumbar vessels. The indications for vena caval resection and left renal vein ligation are listed in table 2. Followup is lacking in most cases and, when available, indicates a rather dismal prognosis, particularly for patients with renal cell carcinoma. Our 4 patients all had invasion of perinephric fat, 1 dying of disseminated carcinoma within 12 months and followup in the other 2 being less than 1 year. Of the remaining 6 reported cases 1 had a pulmonary metastasis at the time of the operation and another has tumor on the chest x-ray 8 months postoperatively.3,6 No patient has survived 5 years free of tumor. It obviously is difficult to draw definite conclusions fr?m sue~ a small series, although it would appear that most patie~ts with renal cell carcinoma invading the vena cava are, m fact, surgically incurable. This does little to alleviate the surgeon's problem of deciding how much risk and effort are justified in an attempt to increase the quality of life and length of survival. Since renal carcinoma is largely unresponsive to radiation and chemotherapy, it seems justifiable to offer these patients an admittedly slim chance of cure provided operative mortality and morbidity are kept at an acceptable level. However, it is quite evident that right nephrectomy can be extended to include resection of the suprarenal inferior vena cava with little immediate and apparently no delayed threat to renal function. The question is which patients are likely to benefit from this procedure? Cytoreductive or debulking operations have been shown to enharice tumor response to radiation and cytotoxic therapy. For this reason, the operation may be of most value in the management of locally advanced nephroblastoma, testicular tumors and lymphomas. Perhaps renal cell carcinoma could be more confidently added to this list when the results of immunotherapy are better defined. REFERENCES
Fm. 11. Technique of right renal artery ligation in continuity. Second lumbar veins have been divided.
1. Clark, C. D.: Survival after excision of a kidney, segmental resection of the vena cava, and division of the opposite renal vein. Lancet, 2: 1015, 1961. 2. Pathak, I. C.: Survival after right nephrectomy, excision of the infrahepatic vena cava and ligation of the left renal vein: a case report. J. Urol., 106: 599, 1971. 3. Skinner, D. G., Pfister, R. F. and Colvin, R.: Extension of renal cell carcinoma into the vena cava: the rationale for aggressive surgical management. J. Urol., 107: 711, 1972. 4. McCullough, D. L. and Gittes, R. F.: Ligation of the left renal vein in the solitary kidney: effects on renal function. J. Urol., 113: 295, 1975. 5. Duckett, J. W., Jr., Lifland, J. H. and Peters, P. C.: Resection of the inferior vena cava for adjacent malignant disease. Surg., Gynec. & Obst., 136: 711, 1973. 6. Solomon, H. D.: Renal tumor into the vena cava requires surgical management. Urol. Times, 3: 1, 1977. 7. Siderys, H. and Kilman, J. W.: The effects of acute occlusion of the renal vein in dogs. Surgery, 59: 282, 1966. 8. Harris, J. D., Ehrenfeld, W. K., Lee, J. C. and Wylie, E. J.: Experimental renal vein occlusion. Surg., Gynec. & Obst., 126: 555, 1968. 9. Bowles, W. T. and Koehler, P. R.: Acute renal vein ligation in dogs. Invest. Urol., 4: 341, 1967.
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10. Hollinshead, W. H. and McFarlane, J. A.: The collateral venous drainage from the kidney following occlusion of the renal vein in the dog. Surg., Gynec. & Obst., 97: 213, 1953. 11. Erlik, D., Barzilai, A. and Shramek, A.: Porto-renal shunt: a new technique for porto-systemic anastomosis in portal hypertension. Ann. Surg., 159: 72, 1964. 12. Simeone, F. A. and Hopkins, R. W.: Portorenal shunt for hepatic cirrhosis and portal hypertension. Surgery, 61: 153, 1967. 13. Baird, R. J., Tutassaura, H. and Miyagishima, R. T.: Use of the left renal vein for portal decompression. Ann. Surg., 173: 551, 1971. 14. Swanson, R. J., Carlson, R. E., Olcott, C., IV and Stoney, R. J.: Rupture of the left kidney following a renosplenic shunt. Surgery, 79: 710, 1976. 15. Warren, W. D., Salam, A. A., Faraldo, A., Hutson, D. and Smith, R. B.: End renal vein-to-splenic vein shunts for total or selective portal decompression. Surgery, 72: 995, 1972. 16. Beck, A. D.: Renal cell carcinoma involving the inferior vena cava: radiologic evaluation and surgical management. J. Urol., 118: 533, 1977. 17. Beck, A. D.: The results of aggressive surgery for renal cell carcinoma involving the vena cava. J. Urol., in preparation. 18. Paty, U. S., Abeyatunge, L. R., Karnath, M. L., Lindsay, G. K. and Wise, G. J.: Renal function after ligation of right renal vein. Urology, 5: 95, 1975. 19. Lome, L. C. and Bush, I. M.: Resection of the vena cava for renal cell carcinoma: an experimental study. J. Urol., 107: 717, 1972. 20. Bracken, R. B., Johnson, D. E., Goldstein, H. M., Wallace, S. and Ayala, A. G.: Percutaneous transfemoral renal artery occlusion in patients with renal carcinoma. Urology, 6: 6, 1975. 21. Marberger, M. and Georgi, M.: Balloon occlusion of the renal artery in tumor nephrectomy. J. Urol., 114: 360, 1975.
ence in 5 other cases indicate that nearly 50 per cent of patients undergoing vena caval resection with ligation of the left renal vein for extensive renal cell carcinoma of the right kidney will have temporary renal dysfunction sufficient to prolong hospitalization significantly (average of nearly 45 days in 5 of the 11 cases reviewed with postoperative renal dysfunction). The author has minimized this problem by emphasizing preoperative hydration and careful monitoring of central venous pressure but the possibility of this complication remains and it should be remembered that usually only the best results are reported in the literature. However, the main question remains unanswered-is vena caval resection today indicated for patients with renal cell carcinoma whose tumors directly invade the vena cava? We have demonstrated that long-term survival is possible when renal cell carcinoma is confined to venous channels, even with extensive propagation along the vena cava-in these cases venacavotomy with removal of the tumor thrombus but restoration ofleft renal vein drainage is all that is necessary, and there is no evidence that vena caval resection improves survival. The author states that there are no known 5-year survivors of vena caval resection for renal cell carcinoma if the primary tumor invades the vena cava directly. In 2 of the author's cases the primary tumor and tumor thrombus were removed before subsequent caval resection which, in my opinion, did not improve the chance for survival and increased the possible risk of postoperative morbidity. Therefore, until adjuvant therapy is available vena caval resection with ligation of the left renal vein would seldom seem indicated in patients with renal cell carcinoma and should be reserved for those tumors, such as testicular tumors or sarcomas, in which effective adjuvant therapy is available. Donald G. Skinner Department of Surgery (Urology) University of California School of Medicine Los Angeles, California
EDITORIAL COMMENT
The longest postoperative hospitalization in this series was 20 days. In cases 3 and 5 extraction of the main mass of tumor thrombus was accomplished before vena caval resection. Both patients, however, had direct invasion of the endothelium of the inferior vena cava and simple venacavotomy appeared doomed to failure. Renal dysfunction after this operation is almost always on a pre-renal basis and can be avoided only when meticulous attention is paid to intraoperative and postoperative fluid and colloid replacement. I agree with the reviewer that the operation described herein is likely to benefit only those patients whose neoplasms are responsive to adjuvant therapy.
REPLY BY AUTHOR The author reports on 5 patients, 4 with primary renal cell carcinoma and 1 with a lymphosarcoma, who underwent resection of the infrahepatic vena cava with ligation of the left renal vein. One patient died postoperatively (20 per cent operative mortality rate) and may have been selected poorly (age 82) and 1 patient had transient renal dysfunction. The postoperative hospitalization was 11 and 9 days, respectively, in 2 patients and not stated in the other 2 patients who survived the operation. The 1 long-term survivor had a lymphosarcoma, amenable to adjuvant therapy. A close review of the 6 cases reported by McCullough and Gittes and personal experi-
Vol. 121, January
Printed in U.S.A.
RESECTION OF THE SUPRARENAL INFERIOR VENA CAVA FOR RETROPERITONEAL MALIGNANT DISEASE A. DAVID BECK* From the Division of Urology, Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
ABSTRACT
Minimal renal dysfunction was noted in 4 of 5 patients undergoing right nephrectomy with resection of the inferior vena cava and ligation of the left renal vein. However, the results of this series confirm previous reports that patients with locally advanced right renal carcinoma requiring vena caval resection are cured rarely by an operation alone. In the absence of effective adjunctive therapy for renal cell carcinoma this procedure will most likely benefit patients with neoplasms responsive to either chemotherapy or radiation therapy. Retroperitoneal neoplasms, particularly those originating from the right kidney, occasionally will invade the inferior vena cava or surround it to such an extent that an adequate cancer operation requires concomitant vena caval resection. Ligation of the inferior vena cava below the level of the renal veins is done frequently for pulmonary embolic disease and presents no threat to renal function. In contrast, the consequences of ligation or resection of the suprarenal vena cava often are regarded as disastrous. However, resection of the vena cava, right nephrectomy and ligation of the left renal vein seem to have little deleterious effect on renal function; 10 such cases have been reported in the English literature. 1-6 The 5 patients who have been treated in similar fashion at this institution form the basis of this study.
vena cava in the vicinity of the right renal vein was densely adherent to the tumor and total removal required resection of the vena cava and ligation of the left renal vein. Two units of packed cells were given to replace estimated blood loss. Histologic examination showed renal cell carcinoma invading the wall of the inferior vena cava and protruding into the lumen. Tumor extended beyond the kidney into the perinephric fat but all nodes were negative. The patient had normal renal function and no evidence of metastatic disease 8 months postoperatively. Case 3. G. E.W., MMC 203-360, a 61-year-old white man, had a mass in a functioning right kidney on IVP 2 weeks after an episode of hematuria. Arteriograms revealed neovascularity within the mass and the vena caval lumen contained a bulky tumor deposit causing significant obstruction (fig. 3). CASE REPORTS These findings were confirmed at exploration; tumor extendCase 1. M. A. L., MMC 189-510, a 36-year-old white man, ing within the vena cava approximately 2 cm. above the was evaluated because of a large abdominal mass on the right hepatic veins. The main mass of intracaval tumor was exside and edema of the right thigh. The right kidney was non- tracted without difficulty but since it was noted to be adherent functional on excretory urography (IVP); the left kidney and to the posterior caval wall the infrahepatic vena cava was ureter were displaced laterally but were normal otherwise. excised along with 5 cm. of vena cava below the renal veins. Markedly increased uptake of contrast medium in the periph- The left renal vein was ligated 1 cm. from its junction with ery of the mass was apparent on a gallium citrate scan. The the inferior vena cava and routine radical nephrectomy was inferior vena cava was obstructed completely with numerous done. The patient received 3 units of blood to replace intracollateral channels demonstrated on venacavography (fig. 1, operative loss. · Histologic examination revealed renal cell carcinoma invadA). Laparotomy revealed a huge mass occupying most of the ing the inferior vena cava and perinephric fat. Most of the right retroperitoneal space and crossing the midline. Biopsy excised lymph nodes also contained tumor. The patient was discharged from the hospital 9 days postand frozen section showed a poorly differentiated malignant tumor of uncertain origin. Subtotal excision was accomplished operatively, after an uneventful convalescence. Multiple pulbut necessitated removal of the right kidney and resection of monary metastases were seen 9 months later and the patient the inferior vena cava from its origin to a point just below the died 11 months after nephrectomy. Although no autopsy was obtained death was presumed to be owing to widespread hepatic veins. The left renal vein was ligated (fig. 1, B). Permanent sections revealed a poorly differentiated diffuse metastatic renal cell carcinoma. Case 4. W. C. C., MMC 223-428, an 82-year-old man, had a lymphosarcoma. The patient was treated w1th cyclical chemotherapy and has normal renal function and is, seemingly, free non-functioning kidney on an IVP done during the evaluation of prostatic obstructive disease. The neoplastic nature of this of disease 3 years postoperatively. Case 2. J. L. W., S. J. 204-651, a 63-year-old white woman lesion was confirmed by arteriography. A large intraluminal with gross hematuria, had slight delay in function and a mass filling defect was seen in the inferior vena cava, which was in the upper pole of the right kidney on IVP. Arteriographic not obstructed totally (fig. 4). At operation the right renal vein was packed solid with studies confirmed the malignant nature of this lesion, which tumor, which protruded into the inferior vena cava. The was seen to invade the inferior vena cava (fig. 2). Right radical nephrectomy was accomplished through a neoplasm was invading almost the entire circumference of the thoracoabdominal incision. The lateral wall of the inferior vena cava and radical nephrectomy was combined with resection of the vena cava and ligation of the left renal vein. The Accepted for publication March 29, 1978. patient was given 4 units of packed cells during the operation Read at annual meeting of American Urological Association, to replace estimated blood loss. Washington, D. C., May 21-25, 1978. Histologic examination revealed renal cell carcinoma invad* Requests for reprints: Division of Urology, Southern Illinois ing the inferior vena cava and perinephric fat. Lymph nodes University School of Medicine, 200 West Dodge, Springfield, Illinois 62708. were free of tumor. 112
RESECTION OF SUPRARENAL INFERIOR VENA CAVA
113
Fm. 1. Case 1. A, complete obstruction ofleft common iliac vein (arrow 1). Ascending lumbar vein (arrow 2) and segmental lumbar veins (arrow 3) are dilated. B, operative findings excluding arterial system. C, solid area indicates limits of surgical resection of inferior vena cava.
Fm. 3. Case 3. Large filling defect in obstructed inferior vena cava. Lumbar veins are dilated and tortuous.
Fm. 2. Case 2. Inferior venacavogram shows irregular filling defect. Arrows indicate patent left renal vein.
Acute cardiorespiratory failure developed 2 days postoperatively and the patient died 6 days later. No evidence of residual tumor was found at autopsy. Histologic abnormalities in the solitary left kidney were confined to the tubules, which showed change consistent with acute tubular necrosis. The
glomeruli were normal and the kidney showed no evidence of venous congestion (fig. 5). Case 5. L. W. S., MMC 217-487, a 63-year-old white man, had a non-functioning right kidney demonstrated on IVP in July 1976. Because of associated pulmonary emboli and a normal right retrograde pyelogram, loss of function was attributed to renal artery embolus. Further retrograde studies in July 1977, after repeated episodes of hematuria, revealed caliceal distortion. At this time the patient had ascites and
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numerous dilat.ed veins on the anterior abdominal wall. Exploration revealed a large neoplastic kidney invading the inferior vena cava, which was considered inoperable. Three weeks lat.er the patient was referred to this institution for further evaluation. Arteriography confirmed the neoplastic nature of the right renal mass, the venous phase demonstrating large tortuous collat.eral veins draining the kidney. Trans-
femoral venacavograms showed complet.e obstruction of the inferior vena cava. Radiographic studies done via the brachial vein and right atrium revealed vena caval obstruction just below the hepatic veins (fig. 6, A). The suprahepatic inferior vena cava was better demonstrated by comput.erized axial tomography, which showed an excessively dilated vessel up to its junction with the right atrium. No distant metastases were demonstrat.ed. Transfemoral embolization of the right renal artery was accomplished and the patient was re-explored 18 hours lat.er. The operative findings are shown in figure 6, B. Tumor extending into the right atrium was isolat.ed by digital compression and extracted with a Foley cathet.er passed upward through an incision in the suprarenal vena cava. Because of obvious invasion of the infrahepatic vena cava this vessel was divided just below the hepatic veins. The left renal vein was ligated and the abdominal inferior vena cava was removed en bloc with the right kidney. The patient was given 10 units of blood during the operation. Histologic examination revealed renal cell carcinoma invading the perinephric fat. No metastases were discovered in the excised lymph nodes. Convalescence was uneventful and the patient was discharged from the hospital 11 days postoperatively. The patient is free of disease 15 months postoperatively. RESULTS
Fm. 4. Case 4. Filling defect in inferior vena cava at level of right renal vein.
Renal function. A transient increase in serum creatinine was observed in 2 patients (cases 1 and 2), both of whom had grossly normal function within 10 days of the operation (fig. 7). Two patients maintained normal creatinine levels throughout the immediate postoperative period, 1 dying 11 months lat.er with normal renal function. The sustained elevation of serum creatinine seen in case 4 was consist.ent with acute tubular necrosis secondary to hypotension. No glomerular damage was evident at autopsy. IVPs 6 to 9 days postoperatively revealed a normal left kidney in the 4 surviving patients. Urinary output. All patients exhibited a postoperative decrease in urine output lasting 2 to 3 days (fig. 8). Excluding the patient who had acut.e tubular necrosis, urine output increased to and maintained normal levels thereafter. Urinary protein. Of the 4 patients monitored only 1 (case 1) had a 24-hour urinary protein excretion of >0.5 gm. (fig. 9),
Fm. 5. Case 4. Photomicrograph of left kidney shows normal glomerulus and histologic features of acute tubular necrosis. No vascular congestion is apparent.
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RESECTION OF SUPRARENAL INFERIOR VENA CAVA
Fm. 6. Case 5. A, retrograde inferior venacavogram shows filling of right hepatic veins and total obstruction of inferior vena cava. B, diagram of operative findings. RENAL FUNCTION FOLLOWING RENAL VEIN LIGATION OF SOLITARY LEFT KIDNEY CASE I CASE II CASE Ill
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which decreased to normal (<0.15 gm./24 hours) within 4 weeks postoperatively. DISCUSSION
Most studies designed to determine the results of renal vein ligation have used the dog as an experimental model. Siderys and Kilman ligated the left renal vein at its junction with the inferior vena cava in 25 animals, 15 of which died of massive
retroperitoneal hemorrhage. In the surviving dogs there was a universal decrease in the size of the left kidney. 7 Similar results were reported by Harris and associates. 8 Bowles and Koehler ligated the left renal vein at the hilus of the kidney in 10 animals, 9 of which survived. Acute swelling followed by renal atrophy was noted in all cases. 9 These pessimistic results in animals must be interpreted cautiously if applied to man. Hollinshead and McFarlane, in a meticulous study of the renal venous system in dogs, showed that the only major tributary vf the left renal vein, apart from small ureteral vessels, was the left gonadal vein. There was
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URINARY PROTEIN EXCRETION FOLLOWING RENAL VEIN LIGATION OF SOLITARY LEFT KIDNEY
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no communication with the azygos, lumbar, adrenal or inferior phrenic veins. In contrast, the left renal veins in man regularly possess complex connections with the suprarenal, phrenic and gonadal veins, and with all deep veins from the azygos to iliac level through the ascending lumbar vein (fig. 10). 10 It is apparent, therefore, that the potential for development of an efficient collateral circulation is far greater in man after obstruction of the left renal vein. Evidence for the relative safety of left renal vein ligation in humans comes from a variety of sources. In 1964 Erlik and associates proposed anastomosing the left renal vein to the splenic vein as a decompressive procedure for portal hypertension. The renal vein was divided 5 cm. from the vena cava and the distal end was ligated. The left kidney was considered normal on IVP within 17 days of the operation in the 4 surviving patients. 11 Approximately 23 similar cases have been reported. 12• 13 No patient had irreversible damage to the left kidney and in all patients the renal vein was divided medial to the gonadal and adrenal tributaries. However, an essential prerequisite for this procedure is a normal right kidney and even transient renal dysfunction obviously will pose a far greater problem in patients whose right kidney has been removed. A note of caution also is sounded by Swanson and associates who used the left renal vein for portal decompression but divided the adrenal and gonadal vessels and transected the renal vein at the hilus of the kidney. One patient sustained rupture of the left kidney requiring nephrectomy and transient impairment of renal function was a not infrequent finding. 14 Similar results were reported by Warren and associates. 15 The latter 2 series illustrate the importance of preserving all tributaries of the left renal vein, which must be ligated as close to the vena cava as possible. Table 1 illustrates the effects on renal function after right nephrectomy and ligation of the left renal vein. Information available in 14 cases showed that 8 patients retained normal function and only 2 (including case 4 in this report) sustained a degree of renal damage that might require dialysis. Gradual vena caval obstruction presumably would allow time for a collateral circulation to develop but we could find no correlation between the status of the vena cava and postoperative renal function. Case 1 for instance, with total obstruction and numerous enlarged collateral veins, was the only patient who exhibited a significant degree ofproteinuria. Conversely, case 2 with a widely patent left renal vein and only partial obstruction of the vena cava, had minimal pro-
Fm. 10. Venous drainage of kidneys TABLE
1. Renal function after right nephrectomy and ligation of left
renal vein No. Pts. Nonna! Creatinine <3 mg.% >5 mg.%
8 4 2
teinuria and an insignificant, transient increase in serum creatinine. Significant proteinuria might be expected to be common after venous obstruction of a solitary kidney. Urinary protein excretion was not mentioned in 8 case reports. Only 2 patients had 24-hour protein excretion >0.5 gm. and in both cases this was normal within 4 weeks of the operation. Although none of our patients had hypertension 1 case reported by McCullough and Gittes had elevation of peripheral venous renin and blood pressure, both of which returned to normal within a few days. 4 Maintenance of a normal circulating blood volume is essential, particularly during the immediate postoperative period. This may pose problems since there is a tendency for fluid to pool in the interstitial space of the lower limbs and pelvis. We consider it mandatory to monitor central venous pressure in all patients. Should hypotension or oliguria fail to respond to a suitable fluid challenge we insert a catheter and measure mean wedge pulmonary pressures, the latter being a more reliable index of cardiac function. With adequate fluid and colloid replacement the decline in urinary output noted in all of our patients and observed by several other authors returned to normal within 2 or 3 days. The importance of preoperative evaluation of the vena cava cannot be over emphasized. The association of main renal vein invasion by neoplasm with a non-functioning kidney is well known. However, 2 of our 4 patients with renal cell carcinoma
117
RESECTION OF SUPRARENAL INFERIOR VENA CAVA
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had minimal functional impairment and the findings on IVP must be considered an unreliable sign of possible vena caval involvement. We continue to be impressed by the ability of high dose selective arteriography to demonstrate a normal renal vein. 16 Failure to opacify the major venous system, including the vena cava, with this technique is an absolute indication for inferior venacavography. Fortunately, most cases of vena caval involvement requiring resection originate from a neoplasm in the right kidney, allowing preservation of the left kidney with its rich anastomotic venous network. We have shown that a solitary right kidney will maintain normal function after transient venous occlusion.17 However, ligation of the right renal vein probably is incompatible with sustained useful function. 18 When presented with a patient requiring left nephrectomy and resection of the suprarenal vena cava the right renal vein could be anastomosed to the portal vein. We are not aware of this procedure being done in man, although Lome and Bush reported normal renal function in dogs after right renoportal venous anastomosis and left nephrectomy. 19 Exposure of the infrahepatic vena cava is best afforded by a thoracoabdominal approach, excising the 8th or 9th ribs, as used in our 4 patients with renal cell carcinoma. Mobilization of the entire right colon, including the hepatic flexure, and incision of the inferior leaf of the small bowel mesentery allow the intestines to be reflected beyond the midline, thus exposing the inferior vena cava from its origin to the hepatic veins. If possible, the right adrenal vein is ligated and a tape is placed around the vena cava immediately below the liver. The left renal vein is isolated and taped. The second lumbar veins entering the posterior surface of the vena cava at or below the level of the renal veins are ligated and divided, and a tape is placed around the infrarenal vena cava. Initial clamping of the renal artery, which is especially difficult when there is tumor invasion of the renal pedicle, is nonetheless highly desirable to prevent extreme venous engorgement and subsequent hemorrhage. We have found the right renal artery readily accessible medial to the vena cava, where it is ligated in continuity before cross-clamping the vena cava and left renal vein (fig. 11). This simple maneuver frequently obviates the necessity for pi eoperative embolic or balloon occlusion of the renal artery. 20 • 21 However, in 1 of our patients (case 5) pre-nephrectomy embolization was believed to have contributed significantly to the ease of the operation by decreasing the venous collateral drainage of the kidney.
TABLE
2. Indications for right nephrectomy and ligation of left renal vein No. Pts.
Renal cell Ca N ephroblastoma Transitional cell Ca Fibrosarcoma Lymphoma
10 2 1 1 1
Most previous case reports make no reference to operative hemorrhage. However, the case described by Solomon required 30 units of blood. 6 We attribute our relatively modest blood loss to initial ligation of the renal artery and early identification and control of all venous tributaries, particularly the upper lumbar vessels. The indications for vena caval resection and left renal vein ligation are listed in table 2. Followup is lacking in most cases and, when available, indicates a rather dismal prognosis, particularly for patients with renal cell carcinoma. Our 4 patients all had invasion of perinephric fat, 1 dying of disseminated carcinoma within 12 months and followup in the other 2 being less than 1 year. Of the remaining 6 reported cases 1 had a pulmonary metastasis at the time of the operation and another has tumor on the chest x-ray 8 months postoperatively.3,6 No patient has survived 5 years free of tumor. It obviously is difficult to draw definite conclusions fr?m sue~ a small series, although it would appear that most patie~ts with renal cell carcinoma invading the vena cava are, m fact, surgically incurable. This does little to alleviate the surgeon's problem of deciding how much risk and effort are justified in an attempt to increase the quality of life and length of survival. Since renal carcinoma is largely unresponsive to radiation and chemotherapy, it seems justifiable to offer these patients an admittedly slim chance of cure provided operative mortality and morbidity are kept at an acceptable level. However, it is quite evident that right nephrectomy can be extended to include resection of the suprarenal inferior vena cava with little immediate and apparently no delayed threat to renal function. The question is which patients are likely to benefit from this procedure? Cytoreductive or debulking operations have been shown to enharice tumor response to radiation and cytotoxic therapy. For this reason, the operation may be of most value in the management of locally advanced nephroblastoma, testicular tumors and lymphomas. Perhaps renal cell carcinoma could be more confidently added to this list when the results of immunotherapy are better defined. REFERENCES
Fm. 11. Technique of right renal artery ligation in continuity. Second lumbar veins have been divided.
1. Clark, C. D.: Survival after excision of a kidney, segmental resection of the vena cava, and division of the opposite renal vein. Lancet, 2: 1015, 1961. 2. Pathak, I. C.: Survival after right nephrectomy, excision of the infrahepatic vena cava and ligation of the left renal vein: a case report. J. Urol., 106: 599, 1971. 3. Skinner, D. G., Pfister, R. F. and Colvin, R.: Extension of renal cell carcinoma into the vena cava: the rationale for aggressive surgical management. J. Urol., 107: 711, 1972. 4. McCullough, D. L. and Gittes, R. F.: Ligation of the left renal vein in the solitary kidney: effects on renal function. J. Urol., 113: 295, 1975. 5. Duckett, J. W., Jr., Lifland, J. H. and Peters, P. C.: Resection of the inferior vena cava for adjacent malignant disease. Surg., Gynec. & Obst., 136: 711, 1973. 6. Solomon, H. D.: Renal tumor into the vena cava requires surgical management. Urol. Times, 3: 1, 1977. 7. Siderys, H. and Kilman, J. W.: The effects of acute occlusion of the renal vein in dogs. Surgery, 59: 282, 1966. 8. Harris, J. D., Ehrenfeld, W. K., Lee, J. C. and Wylie, E. J.: Experimental renal vein occlusion. Surg., Gynec. & Obst., 126: 555, 1968. 9. Bowles, W. T. and Koehler, P. R.: Acute renal vein ligation in dogs. Invest. Urol., 4: 341, 1967.
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10. Hollinshead, W. H. and McFarlane, J. A.: The collateral venous drainage from the kidney following occlusion of the renal vein in the dog. Surg., Gynec. & Obst., 97: 213, 1953. 11. Erlik, D., Barzilai, A. and Shramek, A.: Porto-renal shunt: a new technique for porto-systemic anastomosis in portal hypertension. Ann. Surg., 159: 72, 1964. 12. Simeone, F. A. and Hopkins, R. W.: Portorenal shunt for hepatic cirrhosis and portal hypertension. Surgery, 61: 153, 1967. 13. Baird, R. J., Tutassaura, H. and Miyagishima, R. T.: Use of the left renal vein for portal decompression. Ann. Surg., 173: 551, 1971. 14. Swanson, R. J., Carlson, R. E., Olcott, C., IV and Stoney, R. J.: Rupture of the left kidney following a renosplenic shunt. Surgery, 79: 710, 1976. 15. Warren, W. D., Salam, A. A., Faraldo, A., Hutson, D. and Smith, R. B.: End renal vein-to-splenic vein shunts for total or selective portal decompression. Surgery, 72: 995, 1972. 16. Beck, A. D.: Renal cell carcinoma involving the inferior vena cava: radiologic evaluation and surgical management. J. Urol., 118: 533, 1977. 17. Beck, A. D.: The results of aggressive surgery for renal cell carcinoma involving the vena cava. J. Urol., in preparation. 18. Paty, U. S., Abeyatunge, L. R., Karnath, M. L., Lindsay, G. K. and Wise, G. J.: Renal function after ligation of right renal vein. Urology, 5: 95, 1975. 19. Lome, L. C. and Bush, I. M.: Resection of the vena cava for renal cell carcinoma: an experimental study. J. Urol., 107: 717, 1972. 20. Bracken, R. B., Johnson, D. E., Goldstein, H. M., Wallace, S. and Ayala, A. G.: Percutaneous transfemoral renal artery occlusion in patients with renal carcinoma. Urology, 6: 6, 1975. 21. Marberger, M. and Georgi, M.: Balloon occlusion of the renal artery in tumor nephrectomy. J. Urol., 114: 360, 1975.
ence in 5 other cases indicate that nearly 50 per cent of patients undergoing vena caval resection with ligation of the left renal vein for extensive renal cell carcinoma of the right kidney will have temporary renal dysfunction sufficient to prolong hospitalization significantly (average of nearly 45 days in 5 of the 11 cases reviewed with postoperative renal dysfunction). The author has minimized this problem by emphasizing preoperative hydration and careful monitoring of central venous pressure but the possibility of this complication remains and it should be remembered that usually only the best results are reported in the literature. However, the main question remains unanswered-is vena caval resection today indicated for patients with renal cell carcinoma whose tumors directly invade the vena cava? We have demonstrated that long-term survival is possible when renal cell carcinoma is confined to venous channels, even with extensive propagation along the vena cava-in these cases venacavotomy with removal of the tumor thrombus but restoration ofleft renal vein drainage is all that is necessary, and there is no evidence that vena caval resection improves survival. The author states that there are no known 5-year survivors of vena caval resection for renal cell carcinoma if the primary tumor invades the vena cava directly. In 2 of the author's cases the primary tumor and tumor thrombus were removed before subsequent caval resection which, in my opinion, did not improve the chance for survival and increased the possible risk of postoperative morbidity. Therefore, until adjuvant therapy is available vena caval resection with ligation of the left renal vein would seldom seem indicated in patients with renal cell carcinoma and should be reserved for those tumors, such as testicular tumors or sarcomas, in which effective adjuvant therapy is available. Donald G. Skinner Department of Surgery (Urology) University of California School of Medicine Los Angeles, California
EDITORIAL COMMENT
The longest postoperative hospitalization in this series was 20 days. In cases 3 and 5 extraction of the main mass of tumor thrombus was accomplished before vena caval resection. Both patients, however, had direct invasion of the endothelium of the inferior vena cava and simple venacavotomy appeared doomed to failure. Renal dysfunction after this operation is almost always on a pre-renal basis and can be avoided only when meticulous attention is paid to intraoperative and postoperative fluid and colloid replacement. I agree with the reviewer that the operation described herein is likely to benefit only those patients whose neoplasms are responsive to adjuvant therapy.
REPLY BY AUTHOR The author reports on 5 patients, 4 with primary renal cell carcinoma and 1 with a lymphosarcoma, who underwent resection of the infrahepatic vena cava with ligation of the left renal vein. One patient died postoperatively (20 per cent operative mortality rate) and may have been selected poorly (age 82) and 1 patient had transient renal dysfunction. The postoperative hospitalization was 11 and 9 days, respectively, in 2 patients and not stated in the other 2 patients who survived the operation. The 1 long-term survivor had a lymphosarcoma, amenable to adjuvant therapy. A close review of the 6 cases reported by McCullough and Gittes and personal experi-