- Email: [email protected]
Venous Resection in Urological Surgery
Venous Resection in Urological Surgery Brian Duty and Siamak Daneshmand* From the Section of Urologic Oncology, Division of Urology and Renal Transplantation, Oregon Health & Science University, Portland, Oregon
Purpose: Complete removal of retroperitoneal and pelvic tumors may require resection or ligation of major retroperitoneal, pelvic and mesenteric venous structures. We provide an overview of venous anatomy and collateral drainage, and review the veins that can be safely resected. Materials and Methods: We reviewed major anatomical texts, and performed a directed MEDLINE® literature search of retroperitoneal, pelvic and mesenteric venous anatomy. Resection and reconstruction of these vessels were also reviewed with an emphasis on collateral blood flow and post-resection sequelae. Results: The infrarenal inferior vena cava, iliac veins, left renal vein, lumbar veins, inferior mesenteric vein and splenic vein may be resected or ligated without reconstruction. Resection of the right renal vein results in renal demise in the majority of instances. The portal vein may not be resected without reconstruction. Venous reconstruction may be performed with autologous or synthetic graft material. Conclusions: Most major veins in the body can be safely resected or ligated with minimal sequelae. However, it is imperative to understand venous anatomy and collateral blood flow to minimize intraoperative and postoperative complications. Key Words: vena cava, inferior; iliac vein; retroperitoneal space; reconstructive surgical procedures
rologists are confronted by a variety of malignancies within the pelvis and retroperitoneum. Complete surgical excision of these tumors affords patients the best chance at long-term disease-free survival. However, aggressive excision may require resection or ligation of major retroperitoneal and pelvic venous structures. An understanding of venous anatomy and collateral drainage is of paramount importance to safe venous resection, and it minimizes postoperative sequelae. There are only a few reports in the literature pertaining to resection of major pelvic or retroperitoneal veins and there is no consensus on when to use synthetic grafts. Therefore, decisions are largely based on experience and anecdotal reports. We provide an overview of retroperitoneal and pelvic venous anatomy with an emphasis on collateral blood flow. We consulted anatomy textbooks and reviewed the literature highlighting the clinical consequence of ligation or resection of the principal veins within the retroperitoneum and pelvis.
U
adrenal tributaries, gonadal veins, capsular veins and, if present, lumbar vein. A lumbar vein is associated with the left renal vein in approximately 40% of patients.1 Entering posteriorly along the entire length of the IVC are lumbar veins which travel anterior to the spinal transverse processes. The lumbar veins connect to the azygous and hemiazygous venous systems, ultimately draining into the superior vena cava (fig. 1).2 Blood from the abdominal viscera reaches the liver via the portal vein which arises from the SMV and splenic veins. The SMV drains the small intestines, cecum, ascending and transverse colon, stomach and pancreas. The splenic vein receives tributaries from the short gastric veins and IMV, which drain the greater curvature of the stomach and large intestines, respectively (fig. 1, inset).2 PELVIC VENOUS ANATOMY
The IVC arises from the confluence of the common iliac veins at the level of the 5th lumbar vertebrae. Tributaries of the IVC are the inferior phrenic veins, major and minor hepatic veins, right adrenal vein, renal veins, right gonadal vein and lumbar veins. The right renal vein usually lacks tributaries. Left renal vein collaterals include the inferior phrenic and
The pelvis is primarily drained by the internal iliac veins. However, some drainage occurs via the median sacral, superior rectal and ovarian veins. A small amount of blood from the pelvis also communicates with the internal vertebral venous plexuses. The internal iliac vein receives blood from outside the pelvis, the sacrum and the pelvic viscera. The superior and inferior gluteal veins drain the upper thigh and buttocks, the internal pudendal vein drains the perineum, and the obturator vein drains the adductor portion of the upper thigh. The anterolateral portion of the sacrum
Submitted for publication March 22, 2008. Nothing to disclose. * Correspondence: Division of Urology & Renal Transplantation, 3303 SW Bond Ave., CH10U, Portland, Oregon 97239 (telephone: 503-494-1342; e-mail: [email protected]).
Editor’s Note: This article is the second of 5 published in this issue for which category 1 CME credits can be earned. Instructions for obtaining credits are given with the questions on pages 2724 and 2725.
RETROPERITONEAL AND ABDOMINAL VENOUS ANATOMY
0022-5347/08/1806-2338/0 THE JOURNAL OF UROLOGY® Copyright © 2008 by AMERICAN UROLOGICAL ASSOCIATION
2338
Vol. 180, 2338-2342, December 2008 Printed in U.S.A. DOI:10.1016/j.juro.2008.08.028
VENOUS RESECTION IN UROLOGICAL SURGERY
2339
Azygous v.
R. inferior phrenic v. Short gastric v.
L. inferior phrenic v.
Hepatic vs.
L. Gastric v. Inferior vena cava Hemiazygous v.
R. Gastric v.
R. adrenal v.
Portal v. R. renal v.
L. adrenal v. L. renal v.
Middle colic v.
Inferior mesenteric v.
Superior mesenteric v.
L. gonadal v.
R. gonadal v.
Lumbar vs. Ascending lumbar vs.
R. iliolumbar v.
L. iliolumbar v.
Splenic v. Gastroepiploic v. Common iliac vs.
Internal iliac vs.
Median sacral v. Deep circumflex iliac v. Accessory obturator v. Obturator v.
Superior gluteal vs. External iliac vs. Inferior gluteal v. Internal pudendal v.
Inferior epigastric v. Superficial circumflex iliac v. Middle rectal v. Uterine v.
Pelvic venous plexus
Superior vesical v.
© 2008 LARAMIE STUDIO
Femoral v. Great saphenous v.
FIG. 1. Veins of retroperitoneum, pelvis and portal system
drains into the proximal internal iliac vein via the lateral sacral vein (fig. 1).2 The viscera of the pelvis drain into the internal iliac vein via an intercommunicating network of venous plexuses which include the rectal, prostatic, vesical and uterovaginal veins. The rectal plexus is drained by the superior, middle and inferior rectal veins which empty into the IMV, internal iliac and internal pudendal veins, respectively. The dorsal vein of the penis gives rise to the dorsal venous complex of the prostate which is composed of a superficial and 2 lateral plexuses which communicate with the vesical plexus. The vesical plexus drains the bladder by way of 3 to 5 inferior vesical veins and the superior vesical vein which each empty into the internal iliac vein. The vagina and uterus empty into the uterovaginal plexus, which in turn drains into the internal iliac vein via the uterine vein (fig. 1).2 RESECTION OF THE ILIAC VEINS The internal iliac vein has an extensive network of collaterals including the contralateral pelvic venous plexus, gonadal vein, median sacral vein, inferior mesenteric vein by way of the superior rectal vein, accessory obturator vein, if present, and the iliolumbar and lateral sacral veins depending on the
resection location. The external iliac vein has fewer collaterals. They include the deep and circumflex iliac veins, inferior epigastric vein and accessory obturator vein, if present. Collaterals of the internal and external iliac veins may bypass the common iliac vein. Internal iliac vein resection is commonly performed in renal transplantation and other urological procedures without consequence. However, there are case reports but no urological series to our knowledge regarding resection of the common and external iliac veins for malignancy. Mullins et al reported the Detroit General Hospital experience with traumatic injury and resultant operative ligation to the external iliac vein in 5 patients and common iliac vein in 3.3 None of the patients had lower extremity edema at discharge home, but of those who had outpatient followup moderate edema requiring support hose developed in half. Surgical reconstruction of the iliac veins is rarely performed. Data regarding long-term patency rates and clinical outcomes are scant. The risk of long-term graft failure is higher than for IVC reconstruction because of the smaller vessel diameter. Caldarelli et al reported their experience with iliofemoral vein bypass with reinforced PTFE grafts for urologically related malignancies in 5 patients.4 Two pa-
2340
VENOUS RESECTION IN UROLOGICAL SURGERY
tients had patent grafts at the time of death from disease progression at 24 and 30 months, respectively. The remaining patients had graft occlusion at 6 to 12 months postoperatively. The authors concluded that reconstruction with autologous vein grafts or prosthetic material should only be entertained in the setting of severe preoperative venous symptoms or dissections that will disrupt the few aforementioned collaterals.
It should be noted that these studies were not in the context of preexisting renal vein occlusion from malignancy. Renal vein resection is likely better tolerated in this setting because of preoperative collateral development. Nonetheless, data on this topic are scant and reconstruction should be considered in patients with a solitary left kidney, preoperative renal insufficiency or for resections that will endanger existing collaterals.
RESECTION OF THE RENAL VEINS
RESECTION OF THE LUMBAR AND MESENTERIC VEINS
There are no series addressing resection of the renal veins for urological malignancies. Potential complications include renal infarction, severe venous congestion with renal rupture and hemorrhage, chronic renal insufficiency, renal venous hypertension and varicocele. Unlike the left renal vein, which has multiple collaterals, resection of the right renal vein is almost invariably associated with renal demise except for extraordinary circumstances in which there has been marked collateralization of capsule perforators, or neovascularization to the IVC or gonadal vein (fig. 2). Therefore, renal vein reconstruction must be attempted when nephrectomy is not acceptable. The literature is conflicting regarding the need for left renal vein reconstruction with multiple studies arguing for or against it. Suzuki et al reviewed their experience in 14 patients undergoing vascular reconstruction with the use of a left renal vein graft in hepatobiliary-pancreatic surgery.5 Neither significant perioperative renal failure nor chronic renal insufficiency was encountered at a mean followup of 18 months. In contrast, Komori et al reported an increase in serum creatinine perioperatively and 1 month after surgery in 28 patients undergoing left renal vein division without reconstruction during abdominal aortic aneurysm repair.6 Marrocco-Trischitta et al reconstructed the renal vein by direct reanastomosis or PTFE grafting in 14 patients and found no difference in complication rate or glomerular filtration rate 6 months postoperatively compared to a matched cohort not undergoing renal vein ligation during abdominal aortic aneurysm repair.7
All of the lumbar veins may be resected without clinical consequence because of their connections with the ascending lumbar vein and vertebral venous plexus. The IMV receives blood from the rectum, sigmoid and descending colon before flowing into the splenic vein. The IMV is routinely taken without any adverse effects in RPLNDs and other operations in which adequate exposure to the retroperitoneum is required. This is made possible by the IMV connection to the SMV via the marginal vein and internal iliac vein via the middle and inferior rectal veins. The SMV and portal veins cannot be resected without reconstruction. Resection of these vessels with reconstruction was proposed by Fortner in 1974 as a means of obtaining negative margins in patients with locally advanced pancreatic cancer.8 Reconstruction may be accomplished by primary reanastomosis, autologous vein grafting (eg internal jugular vein, left renal vein, saphenous vein or superficial femoral vein) or synthetic vein grafting, most commonly with PTFE. In addition to the inferior mesenteric vein, the right and left gastric veins and the gastroepiploic vein receive collateral blood flow from the short gastric vessels in the setting of splenic vein obstruction or resection. Resection of the splenic vein does not mandate reconstruction but is associated with increased risk of splenomegaly, gastric varices from stomach congestion and hepatic steatosis. Splenic vein reconstruction may be performed by anastomosing the splenic vein to the SMV, IMV or portal vein. In a series by Misuta et al the decision to reconstruct the splenic vein was determined by the direction of splenic venous flow at surgery.9 RESECTION OF THE INFERIOR VENA CAVA
FIG. 2. Computerized tomography of abdomen in patient undergoing left renal vein resection demonstrating extensive perirenal collateral development.
Involvement of the IVC by retroperitoneal tumors or postchemotherapy scar tissue may necessitate IVC resection with or without graft replacement. In general, masses involving less than half of the IVC may be managed by primary closure or venous patch closure. For lesions involving more than half the circumference of the IVC, resection is indicated.4 Resection of the IVC is made possible by various abdominopelvic collaterals (fig. 3). A number of hemodynamic changes may occur after IVC resection. Caval resection impairs venous return resulting in decreased cardiac output and increased peripheral venous pressures. These may result in lymphatic third spacing, deep venous thrombosis and the sequelae of lower extremity venous disease.10,11 Suprarenal IVC resection is also associated with an increased risk of renal failure and venous congestion. Acute caval resection without preexisting obstruction is poorly tolerated because there has been no opportunity to
VENOUS RESECTION IN UROLOGICAL SURGERY
FIG. 3. Magnetic resonance of abdomen in patient undergoing IVC resection demonstrating collateral development.
form collaterals before surgery. Donaldson et al reported a 36% incidence of early postoperative leg swelling and a 50% incidence of late venous sequelae following IVC interruption to prevent pulmonary embolism in patients with lower extremity deep venous thrombosis.12 In contrast, IVC resection for malignancy often occurs in the setting of partial or complete IVC obstruction allowing collaterals to form preoperatively. The site of resection also influences outcome. Suprarenal IVC resection is an uncommon procedure with only a few case series in the literature. Huguet et al published a retrospective review of 6 patients undergoing resection or ligation of the suprarenal IVC with reconstruction in 4 cases.13 Major postoperative complications occurred in 67% of patients including 1 death and 1 patient with acute renal failure. Illuminati et al reviewed 11 patients undergoing infrahepatic IVC resection with reconstruction for primary leiomyoscarcoma.14 Perioperative complications were seen in 27% of patients including 1 with acute renal failure. Of the grafts 67% were patent at 60 months and no patients had chronic lower extremity edema. Urological malignancies involving the suprarenal IVC are exceedingly rare. However, urologists may encounter patients with tumors involving the infrarenal IVC. Spitz et al published an update in 1997 of the University of Southern California experience with post-chemotherapy IVC resection in 19 patients with metastatic testicular cancer.15 Of the patients 52% had early complications including prolonged ileus, small bowel obstruction, fascial dehiscence and pneumonia. Six patients died of disease recurrence. Of the remaining patients 3 had chronic lower extremity edema. A similar study was published by Beck and Lalka involving 24 patients who had long-term survival after undergoing RPLND with IVC resection.16 Immediate complications were seen in 50% of patients, and included 4 with renal failure, 3 with chylous ascites and 4 with lower extremity edema. Long-term venous disease included 4 patients with edema, 15 with stasis dermatitis and 1 with an active venous ulcer. Blute et al reported that 70% of their 40 patients undergoing IVC resection, ligation or interruption for renal cell carcinoma with caval thrombus did not require the use of support stockings 6 months postoperatively.17 None of the
2341
patients in these 3 studies underwent IVC grafting. In our experience of 5 patients undergoing IVC resection without reconstruction for metastatic germ cell cancer and renal cell carcinoma, lower extremity edema was transient and resolved by the time of discharge home in each patient (unpublished data). No evidence of chronic venous disease was noted at a mean followup of 11.2 months. Several studies demonstrate that infrarenal reconstruction may be performed with limited morbidity.18,19 These studies recommend considering IVC reconstruction with ringed PTFE grafts in patients with preoperative lower extremity venous symptoms (indicating partial IVC obstruction without collateral development or complete obstruction with inadequate collaterals) or in patients whose retroperitoneal dissection is likely to disrupt preexisting collaterals. Preoperative venograms were used in some series to evaluate the potential need for IVC reconstruction based on the extent of preexisting collaterals. However, at present there is no consensus in the literature regarding the usefulness of preoperative imaging studies. Review of the literature supports the feasibility of suprarenal and infrarenal IVC resection with or without IVC reconstruction in select patient populations. However, the risk of major postoperative complications such as death and renal failure is significant for suprarenal resections. Approximately 50% of patients undergoing infrarenal IVC resection will have perioperative complications but many have long-term survival with minimal sequelae in the setting of metastatic germ cell tumors. CONCLUSIONS The body has an array of collaterals allowing blood to return to the heart when major venous structures become occluded. Knowledge of these structures is of great clinical usefulness to urologists treating patients with advanced malignancies. Nearly all venous structures within the retroperitoneum, pelvis and mesentery may be resected or ligated without reconstruction except for the portal vein and superior mesenteric vein. Most patients have minimal long-term sequelae because venous occlusion with secondary collateralization precedes surgery in the majority of instances. However, venous reconstruction should be considered in patients with significant preoperative lower extremity symptoms or in those who will require extensive surgery that is likely to disrupt existing collaterals.
Abbreviations and Acronyms IMV IVC PTFE RPLND SMV
⫽ ⫽ ⫽ ⫽ ⫽
inferior mesenteric vein inferior vena cava polytetrafluoroethylene retroperitoneal lymph node dissection superior mesenteric vein
REFERENCES 1.
2.
Baniel J, Foster RS and Donohue JP: Surgical anatomy of the lumbar vessels: implications for retroperitoneal surgery. J Urol 1995; 153: 1422. Moore KL and Dalley AF: Clinically Oriented Anatomy, 4th ed. Philadelphia: Lippincott Williams & Wilkins 1999; chapt 2, p 175.
2342 3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
VENOUS RESECTION IN UROLOGICAL SURGERY
Mullins RJ, Lucas CE and Ledgerwood AM: The natural history following venous ligation for civilian injuries. J Trauma 1980; 20: 737. Caldarelli G, Minervini A, Guerra M, Bonari G, Caldarelli C and Minervini R: Prosthetic replacement of the inferior vena cava and the iliofemoral vein for urologically related malignancies. BJU Int 2002; 90: 368. Suzuki T, Yoshidome H, Kimura F, Shimizu H, Ohtsuka M, Kato A et al: Renal function is well maintained after use of left renal vein graft for vascular reconstruction in hepatobiliary-pancreatic surgery. J Am Coll Surg 2006; 202: 87. Komori K, Furuyama T and Maehara Y: Renal artery clamping and left renal vein division during abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg 2004; 27: 80. Marrocco-Trischitta MM, Melissano G, Kahlberg A, Setacci F, Segreti S, Spelta S et al: Glomerular filtration rate after left renal vein division and reconstruction during infrarenal aortic aneurysm repair. J Vasc Surg 2007; 45: 481. Buchler P, Friess H, Muller M, AlKhatib J and Buchler MW: Survival benefit of extended resection in pancreatic cancer. Am J Surg 2007; 194: S120. Misuta K, Shimada H, Miura Y, Kunihiro O, Kubota T, Endo I et al: The role of splenomesenteric vein anastomosis after division of the splenic vein in pancreatoduodenectomy. J Gastrointest Surg 2005; 9: 245. Gazzaniga AB, Cahill JL, Replogle RL and Tilney NL: Changes in blood volume and renal function following ligation of the inferior vena cava. Surgery 1967; 62: 417. Wysocki AP, Hetherington R, Nicol D and Gibbs HH: Haemodynamic assessment following inferior vena cava resection without replacement. ANZ J Surg 2004; 74: 667. Donaldson MC, Wirthlin LS and Donaldson GA: Thirty-year experience with surgical interruption of the inferior vena cava for prevention of pulmonary embolism. Ann Surg 1980; 191: 367. Huguet C, Ferri M and Gavelli A: Resection of the suprarenal inferior vena cava. The role of prosthetic replacement. Arch Surg 1995; 130: 793. Illuminati G, Calio’ FG, D’Urso A, Giacobbi D, Papaspyropoulos V and Ceccanei G: Prosthetic replacement of the infrahepatic
15.
16.
17.
18.
19.
inferior vena cava for leiomyoscarcoma. Arch Surg 2006; 141: 919. Spitz A, Wilson TG, Kawachi MH, Ahlering TE and Skinner DG: Vena caval resection for bulky metastatic germ cell tumors: an 18-year experience. J Urol 1997; 158: 1813. Beck SD and Lalka SG: Long-term results after inferior vena caval resection during retroperitoneal lymphadenectomy for metastatic germ cell cancer. J Vasc Surg 1998; 28: 808. Blute ML, Boorjian SA, Leibovich BC, Lohse CM, Frank I and Karnes RJ: Results of inferior vena caval interruption by Greenfield filter, ligation or resection during radical nephrectomy and tumor thrombectomy. J Urol 2007; 178: 440. Sarkar R, Eilber FR, Gelabert HA and Quinones-Baldrich WJ: Prosthetic replacement of the inferior vena cava for malignancy. J Vasc Surg 1998; 28: 75. Bower TC, Nagorney DM, Cherry KJ Jr, Toomey BJ, Hallett JW, Panneton JM et al: Replacement of the inferior vena cava for malignancy: an update. J Vasc Surg 2000; 31: 270.
EDITORIAL COMMENT This article nicely reviews venous anatomy and consequences of resection of various veins in the retroperitoneum. Such a review is appropriate since many urologists deal with these issues infrequently. Our experience with retroperitoneal lymphadenectomy at Indiana University has been that the arterial anatomy of the retroperitoneum, although subject to variability (such as lower pole renal arteries), is much more consistent from patient to patient compared to the venous anatomy of the retroperitoneum. Thus, it makes sense to dissect the aorta and its tributaries first during RPLND. This is a well executed and well written review, and a pertinent addition to the literature. Richard S. Foster Department of Urology Indiana Cancer Pavilion Indiana University Indianapolis, Indiana
Purpose: Complete removal of retroperitoneal and pelvic tumors may require resection or ligation of major retroperitoneal, pelvic and mesenteric venous structures. We provide an overview of venous anatomy and collateral drainage, and review the veins that can be safely resected. Materials and Methods: We reviewed major anatomical texts, and performed a directed MEDLINE® literature search of retroperitoneal, pelvic and mesenteric venous anatomy. Resection and reconstruction of these vessels were also reviewed with an emphasis on collateral blood flow and post-resection sequelae. Results: The infrarenal inferior vena cava, iliac veins, left renal vein, lumbar veins, inferior mesenteric vein and splenic vein may be resected or ligated without reconstruction. Resection of the right renal vein results in renal demise in the majority of instances. The portal vein may not be resected without reconstruction. Venous reconstruction may be performed with autologous or synthetic graft material. Conclusions: Most major veins in the body can be safely resected or ligated with minimal sequelae. However, it is imperative to understand venous anatomy and collateral blood flow to minimize intraoperative and postoperative complications. Key Words: vena cava, inferior; iliac vein; retroperitoneal space; reconstructive surgical procedures
rologists are confronted by a variety of malignancies within the pelvis and retroperitoneum. Complete surgical excision of these tumors affords patients the best chance at long-term disease-free survival. However, aggressive excision may require resection or ligation of major retroperitoneal and pelvic venous structures. An understanding of venous anatomy and collateral drainage is of paramount importance to safe venous resection, and it minimizes postoperative sequelae. There are only a few reports in the literature pertaining to resection of major pelvic or retroperitoneal veins and there is no consensus on when to use synthetic grafts. Therefore, decisions are largely based on experience and anecdotal reports. We provide an overview of retroperitoneal and pelvic venous anatomy with an emphasis on collateral blood flow. We consulted anatomy textbooks and reviewed the literature highlighting the clinical consequence of ligation or resection of the principal veins within the retroperitoneum and pelvis.
U
adrenal tributaries, gonadal veins, capsular veins and, if present, lumbar vein. A lumbar vein is associated with the left renal vein in approximately 40% of patients.1 Entering posteriorly along the entire length of the IVC are lumbar veins which travel anterior to the spinal transverse processes. The lumbar veins connect to the azygous and hemiazygous venous systems, ultimately draining into the superior vena cava (fig. 1).2 Blood from the abdominal viscera reaches the liver via the portal vein which arises from the SMV and splenic veins. The SMV drains the small intestines, cecum, ascending and transverse colon, stomach and pancreas. The splenic vein receives tributaries from the short gastric veins and IMV, which drain the greater curvature of the stomach and large intestines, respectively (fig. 1, inset).2 PELVIC VENOUS ANATOMY
The IVC arises from the confluence of the common iliac veins at the level of the 5th lumbar vertebrae. Tributaries of the IVC are the inferior phrenic veins, major and minor hepatic veins, right adrenal vein, renal veins, right gonadal vein and lumbar veins. The right renal vein usually lacks tributaries. Left renal vein collaterals include the inferior phrenic and
The pelvis is primarily drained by the internal iliac veins. However, some drainage occurs via the median sacral, superior rectal and ovarian veins. A small amount of blood from the pelvis also communicates with the internal vertebral venous plexuses. The internal iliac vein receives blood from outside the pelvis, the sacrum and the pelvic viscera. The superior and inferior gluteal veins drain the upper thigh and buttocks, the internal pudendal vein drains the perineum, and the obturator vein drains the adductor portion of the upper thigh. The anterolateral portion of the sacrum
Submitted for publication March 22, 2008. Nothing to disclose. * Correspondence: Division of Urology & Renal Transplantation, 3303 SW Bond Ave., CH10U, Portland, Oregon 97239 (telephone: 503-494-1342; e-mail: [email protected]).
Editor’s Note: This article is the second of 5 published in this issue for which category 1 CME credits can be earned. Instructions for obtaining credits are given with the questions on pages 2724 and 2725.
RETROPERITONEAL AND ABDOMINAL VENOUS ANATOMY
0022-5347/08/1806-2338/0 THE JOURNAL OF UROLOGY® Copyright © 2008 by AMERICAN UROLOGICAL ASSOCIATION
2338
Vol. 180, 2338-2342, December 2008 Printed in U.S.A. DOI:10.1016/j.juro.2008.08.028
VENOUS RESECTION IN UROLOGICAL SURGERY
2339
Azygous v.
R. inferior phrenic v. Short gastric v.
L. inferior phrenic v.
Hepatic vs.
L. Gastric v. Inferior vena cava Hemiazygous v.
R. Gastric v.
R. adrenal v.
Portal v. R. renal v.
L. adrenal v. L. renal v.
Middle colic v.
Inferior mesenteric v.
Superior mesenteric v.
L. gonadal v.
R. gonadal v.
Lumbar vs. Ascending lumbar vs.
R. iliolumbar v.
L. iliolumbar v.
Splenic v. Gastroepiploic v. Common iliac vs.
Internal iliac vs.
Median sacral v. Deep circumflex iliac v. Accessory obturator v. Obturator v.
Superior gluteal vs. External iliac vs. Inferior gluteal v. Internal pudendal v.
Inferior epigastric v. Superficial circumflex iliac v. Middle rectal v. Uterine v.
Pelvic venous plexus
Superior vesical v.
© 2008 LARAMIE STUDIO
Femoral v. Great saphenous v.
FIG. 1. Veins of retroperitoneum, pelvis and portal system
drains into the proximal internal iliac vein via the lateral sacral vein (fig. 1).2 The viscera of the pelvis drain into the internal iliac vein via an intercommunicating network of venous plexuses which include the rectal, prostatic, vesical and uterovaginal veins. The rectal plexus is drained by the superior, middle and inferior rectal veins which empty into the IMV, internal iliac and internal pudendal veins, respectively. The dorsal vein of the penis gives rise to the dorsal venous complex of the prostate which is composed of a superficial and 2 lateral plexuses which communicate with the vesical plexus. The vesical plexus drains the bladder by way of 3 to 5 inferior vesical veins and the superior vesical vein which each empty into the internal iliac vein. The vagina and uterus empty into the uterovaginal plexus, which in turn drains into the internal iliac vein via the uterine vein (fig. 1).2 RESECTION OF THE ILIAC VEINS The internal iliac vein has an extensive network of collaterals including the contralateral pelvic venous plexus, gonadal vein, median sacral vein, inferior mesenteric vein by way of the superior rectal vein, accessory obturator vein, if present, and the iliolumbar and lateral sacral veins depending on the
resection location. The external iliac vein has fewer collaterals. They include the deep and circumflex iliac veins, inferior epigastric vein and accessory obturator vein, if present. Collaterals of the internal and external iliac veins may bypass the common iliac vein. Internal iliac vein resection is commonly performed in renal transplantation and other urological procedures without consequence. However, there are case reports but no urological series to our knowledge regarding resection of the common and external iliac veins for malignancy. Mullins et al reported the Detroit General Hospital experience with traumatic injury and resultant operative ligation to the external iliac vein in 5 patients and common iliac vein in 3.3 None of the patients had lower extremity edema at discharge home, but of those who had outpatient followup moderate edema requiring support hose developed in half. Surgical reconstruction of the iliac veins is rarely performed. Data regarding long-term patency rates and clinical outcomes are scant. The risk of long-term graft failure is higher than for IVC reconstruction because of the smaller vessel diameter. Caldarelli et al reported their experience with iliofemoral vein bypass with reinforced PTFE grafts for urologically related malignancies in 5 patients.4 Two pa-
2340
VENOUS RESECTION IN UROLOGICAL SURGERY
tients had patent grafts at the time of death from disease progression at 24 and 30 months, respectively. The remaining patients had graft occlusion at 6 to 12 months postoperatively. The authors concluded that reconstruction with autologous vein grafts or prosthetic material should only be entertained in the setting of severe preoperative venous symptoms or dissections that will disrupt the few aforementioned collaterals.
It should be noted that these studies were not in the context of preexisting renal vein occlusion from malignancy. Renal vein resection is likely better tolerated in this setting because of preoperative collateral development. Nonetheless, data on this topic are scant and reconstruction should be considered in patients with a solitary left kidney, preoperative renal insufficiency or for resections that will endanger existing collaterals.
RESECTION OF THE RENAL VEINS
RESECTION OF THE LUMBAR AND MESENTERIC VEINS
There are no series addressing resection of the renal veins for urological malignancies. Potential complications include renal infarction, severe venous congestion with renal rupture and hemorrhage, chronic renal insufficiency, renal venous hypertension and varicocele. Unlike the left renal vein, which has multiple collaterals, resection of the right renal vein is almost invariably associated with renal demise except for extraordinary circumstances in which there has been marked collateralization of capsule perforators, or neovascularization to the IVC or gonadal vein (fig. 2). Therefore, renal vein reconstruction must be attempted when nephrectomy is not acceptable. The literature is conflicting regarding the need for left renal vein reconstruction with multiple studies arguing for or against it. Suzuki et al reviewed their experience in 14 patients undergoing vascular reconstruction with the use of a left renal vein graft in hepatobiliary-pancreatic surgery.5 Neither significant perioperative renal failure nor chronic renal insufficiency was encountered at a mean followup of 18 months. In contrast, Komori et al reported an increase in serum creatinine perioperatively and 1 month after surgery in 28 patients undergoing left renal vein division without reconstruction during abdominal aortic aneurysm repair.6 Marrocco-Trischitta et al reconstructed the renal vein by direct reanastomosis or PTFE grafting in 14 patients and found no difference in complication rate or glomerular filtration rate 6 months postoperatively compared to a matched cohort not undergoing renal vein ligation during abdominal aortic aneurysm repair.7
All of the lumbar veins may be resected without clinical consequence because of their connections with the ascending lumbar vein and vertebral venous plexus. The IMV receives blood from the rectum, sigmoid and descending colon before flowing into the splenic vein. The IMV is routinely taken without any adverse effects in RPLNDs and other operations in which adequate exposure to the retroperitoneum is required. This is made possible by the IMV connection to the SMV via the marginal vein and internal iliac vein via the middle and inferior rectal veins. The SMV and portal veins cannot be resected without reconstruction. Resection of these vessels with reconstruction was proposed by Fortner in 1974 as a means of obtaining negative margins in patients with locally advanced pancreatic cancer.8 Reconstruction may be accomplished by primary reanastomosis, autologous vein grafting (eg internal jugular vein, left renal vein, saphenous vein or superficial femoral vein) or synthetic vein grafting, most commonly with PTFE. In addition to the inferior mesenteric vein, the right and left gastric veins and the gastroepiploic vein receive collateral blood flow from the short gastric vessels in the setting of splenic vein obstruction or resection. Resection of the splenic vein does not mandate reconstruction but is associated with increased risk of splenomegaly, gastric varices from stomach congestion and hepatic steatosis. Splenic vein reconstruction may be performed by anastomosing the splenic vein to the SMV, IMV or portal vein. In a series by Misuta et al the decision to reconstruct the splenic vein was determined by the direction of splenic venous flow at surgery.9 RESECTION OF THE INFERIOR VENA CAVA
FIG. 2. Computerized tomography of abdomen in patient undergoing left renal vein resection demonstrating extensive perirenal collateral development.
Involvement of the IVC by retroperitoneal tumors or postchemotherapy scar tissue may necessitate IVC resection with or without graft replacement. In general, masses involving less than half of the IVC may be managed by primary closure or venous patch closure. For lesions involving more than half the circumference of the IVC, resection is indicated.4 Resection of the IVC is made possible by various abdominopelvic collaterals (fig. 3). A number of hemodynamic changes may occur after IVC resection. Caval resection impairs venous return resulting in decreased cardiac output and increased peripheral venous pressures. These may result in lymphatic third spacing, deep venous thrombosis and the sequelae of lower extremity venous disease.10,11 Suprarenal IVC resection is also associated with an increased risk of renal failure and venous congestion. Acute caval resection without preexisting obstruction is poorly tolerated because there has been no opportunity to
VENOUS RESECTION IN UROLOGICAL SURGERY
FIG. 3. Magnetic resonance of abdomen in patient undergoing IVC resection demonstrating collateral development.
form collaterals before surgery. Donaldson et al reported a 36% incidence of early postoperative leg swelling and a 50% incidence of late venous sequelae following IVC interruption to prevent pulmonary embolism in patients with lower extremity deep venous thrombosis.12 In contrast, IVC resection for malignancy often occurs in the setting of partial or complete IVC obstruction allowing collaterals to form preoperatively. The site of resection also influences outcome. Suprarenal IVC resection is an uncommon procedure with only a few case series in the literature. Huguet et al published a retrospective review of 6 patients undergoing resection or ligation of the suprarenal IVC with reconstruction in 4 cases.13 Major postoperative complications occurred in 67% of patients including 1 death and 1 patient with acute renal failure. Illuminati et al reviewed 11 patients undergoing infrahepatic IVC resection with reconstruction for primary leiomyoscarcoma.14 Perioperative complications were seen in 27% of patients including 1 with acute renal failure. Of the grafts 67% were patent at 60 months and no patients had chronic lower extremity edema. Urological malignancies involving the suprarenal IVC are exceedingly rare. However, urologists may encounter patients with tumors involving the infrarenal IVC. Spitz et al published an update in 1997 of the University of Southern California experience with post-chemotherapy IVC resection in 19 patients with metastatic testicular cancer.15 Of the patients 52% had early complications including prolonged ileus, small bowel obstruction, fascial dehiscence and pneumonia. Six patients died of disease recurrence. Of the remaining patients 3 had chronic lower extremity edema. A similar study was published by Beck and Lalka involving 24 patients who had long-term survival after undergoing RPLND with IVC resection.16 Immediate complications were seen in 50% of patients, and included 4 with renal failure, 3 with chylous ascites and 4 with lower extremity edema. Long-term venous disease included 4 patients with edema, 15 with stasis dermatitis and 1 with an active venous ulcer. Blute et al reported that 70% of their 40 patients undergoing IVC resection, ligation or interruption for renal cell carcinoma with caval thrombus did not require the use of support stockings 6 months postoperatively.17 None of the
2341
patients in these 3 studies underwent IVC grafting. In our experience of 5 patients undergoing IVC resection without reconstruction for metastatic germ cell cancer and renal cell carcinoma, lower extremity edema was transient and resolved by the time of discharge home in each patient (unpublished data). No evidence of chronic venous disease was noted at a mean followup of 11.2 months. Several studies demonstrate that infrarenal reconstruction may be performed with limited morbidity.18,19 These studies recommend considering IVC reconstruction with ringed PTFE grafts in patients with preoperative lower extremity venous symptoms (indicating partial IVC obstruction without collateral development or complete obstruction with inadequate collaterals) or in patients whose retroperitoneal dissection is likely to disrupt preexisting collaterals. Preoperative venograms were used in some series to evaluate the potential need for IVC reconstruction based on the extent of preexisting collaterals. However, at present there is no consensus in the literature regarding the usefulness of preoperative imaging studies. Review of the literature supports the feasibility of suprarenal and infrarenal IVC resection with or without IVC reconstruction in select patient populations. However, the risk of major postoperative complications such as death and renal failure is significant for suprarenal resections. Approximately 50% of patients undergoing infrarenal IVC resection will have perioperative complications but many have long-term survival with minimal sequelae in the setting of metastatic germ cell tumors. CONCLUSIONS The body has an array of collaterals allowing blood to return to the heart when major venous structures become occluded. Knowledge of these structures is of great clinical usefulness to urologists treating patients with advanced malignancies. Nearly all venous structures within the retroperitoneum, pelvis and mesentery may be resected or ligated without reconstruction except for the portal vein and superior mesenteric vein. Most patients have minimal long-term sequelae because venous occlusion with secondary collateralization precedes surgery in the majority of instances. However, venous reconstruction should be considered in patients with significant preoperative lower extremity symptoms or in those who will require extensive surgery that is likely to disrupt existing collaterals.
Abbreviations and Acronyms IMV IVC PTFE RPLND SMV
⫽ ⫽ ⫽ ⫽ ⫽
inferior mesenteric vein inferior vena cava polytetrafluoroethylene retroperitoneal lymph node dissection superior mesenteric vein
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Baniel J, Foster RS and Donohue JP: Surgical anatomy of the lumbar vessels: implications for retroperitoneal surgery. J Urol 1995; 153: 1422. Moore KL and Dalley AF: Clinically Oriented Anatomy, 4th ed. Philadelphia: Lippincott Williams & Wilkins 1999; chapt 2, p 175.
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Mullins RJ, Lucas CE and Ledgerwood AM: The natural history following venous ligation for civilian injuries. J Trauma 1980; 20: 737. Caldarelli G, Minervini A, Guerra M, Bonari G, Caldarelli C and Minervini R: Prosthetic replacement of the inferior vena cava and the iliofemoral vein for urologically related malignancies. BJU Int 2002; 90: 368. Suzuki T, Yoshidome H, Kimura F, Shimizu H, Ohtsuka M, Kato A et al: Renal function is well maintained after use of left renal vein graft for vascular reconstruction in hepatobiliary-pancreatic surgery. J Am Coll Surg 2006; 202: 87. Komori K, Furuyama T and Maehara Y: Renal artery clamping and left renal vein division during abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg 2004; 27: 80. Marrocco-Trischitta MM, Melissano G, Kahlberg A, Setacci F, Segreti S, Spelta S et al: Glomerular filtration rate after left renal vein division and reconstruction during infrarenal aortic aneurysm repair. J Vasc Surg 2007; 45: 481. Buchler P, Friess H, Muller M, AlKhatib J and Buchler MW: Survival benefit of extended resection in pancreatic cancer. Am J Surg 2007; 194: S120. Misuta K, Shimada H, Miura Y, Kunihiro O, Kubota T, Endo I et al: The role of splenomesenteric vein anastomosis after division of the splenic vein in pancreatoduodenectomy. J Gastrointest Surg 2005; 9: 245. Gazzaniga AB, Cahill JL, Replogle RL and Tilney NL: Changes in blood volume and renal function following ligation of the inferior vena cava. Surgery 1967; 62: 417. Wysocki AP, Hetherington R, Nicol D and Gibbs HH: Haemodynamic assessment following inferior vena cava resection without replacement. ANZ J Surg 2004; 74: 667. Donaldson MC, Wirthlin LS and Donaldson GA: Thirty-year experience with surgical interruption of the inferior vena cava for prevention of pulmonary embolism. Ann Surg 1980; 191: 367. Huguet C, Ferri M and Gavelli A: Resection of the suprarenal inferior vena cava. The role of prosthetic replacement. Arch Surg 1995; 130: 793. Illuminati G, Calio’ FG, D’Urso A, Giacobbi D, Papaspyropoulos V and Ceccanei G: Prosthetic replacement of the infrahepatic
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inferior vena cava for leiomyoscarcoma. Arch Surg 2006; 141: 919. Spitz A, Wilson TG, Kawachi MH, Ahlering TE and Skinner DG: Vena caval resection for bulky metastatic germ cell tumors: an 18-year experience. J Urol 1997; 158: 1813. Beck SD and Lalka SG: Long-term results after inferior vena caval resection during retroperitoneal lymphadenectomy for metastatic germ cell cancer. J Vasc Surg 1998; 28: 808. Blute ML, Boorjian SA, Leibovich BC, Lohse CM, Frank I and Karnes RJ: Results of inferior vena caval interruption by Greenfield filter, ligation or resection during radical nephrectomy and tumor thrombectomy. J Urol 2007; 178: 440. Sarkar R, Eilber FR, Gelabert HA and Quinones-Baldrich WJ: Prosthetic replacement of the inferior vena cava for malignancy. J Vasc Surg 1998; 28: 75. Bower TC, Nagorney DM, Cherry KJ Jr, Toomey BJ, Hallett JW, Panneton JM et al: Replacement of the inferior vena cava for malignancy: an update. J Vasc Surg 2000; 31: 270.
EDITORIAL COMMENT This article nicely reviews venous anatomy and consequences of resection of various veins in the retroperitoneum. Such a review is appropriate since many urologists deal with these issues infrequently. Our experience with retroperitoneal lymphadenectomy at Indiana University has been that the arterial anatomy of the retroperitoneum, although subject to variability (such as lower pole renal arteries), is much more consistent from patient to patient compared to the venous anatomy of the retroperitoneum. Thus, it makes sense to dissect the aorta and its tributaries first during RPLND. This is a well executed and well written review, and a pertinent addition to the literature. Richard S. Foster Department of Urology Indiana Cancer Pavilion Indiana University Indianapolis, Indiana