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Left Hand-assisted Laparoscopic Nephrectomy With Renal Vein Thrombectomy for Stage T3b Renal Cell Carcinoma
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Images in Clinical Urology Left Hand-assisted Laparoscopic Nephrectomy With Renal Vein Thrombectomy for Stage T3b Renal Cell Carcinoma George M. Ghareeb, Dorian A. Kenleigh, and James A. Brown A 60-year-old male was found to have an 8.0 cm left renal mass and associated renal vein thrombus on computed tomography. The thrombus extended 3 mm beyond the right aortic border to within 1.6 cm of the left border of the inferior vena cava. The patient underwent left nephrectomy with renal vein thrombectomy using a hand-assisted laparoscopic approach. The tumor thrombus was “milked” proximally back into left renal vein, which was then divided with an endovascular stapler. Left renal vein thrombi extending to right margin of the aorta can be managed with handassisted laparoscopic approach. UROLOGY ■■: ■■–■■, 2016. © 2015 Elsevier Inc.
A
60-year-old male presented for evaluation of left flank pain. Computed tomography (CT) imaging demonstrated an 8.0 cm left renal mass and associated renal vein thrombus. Evaluation of the extent of the thrombus in relation to the inferior vena cava (IVC), left adrenal vein, left gonadal vein, and right border of the aorta was used to better elucidate the feasibility of a handassisted laparoscopic (HAL) approach of left renal vein thrombectomy. CT assessment of the thrombus demonstrated that it extended beyond the left gonadal vein and adrenal vein tributaries, and 3 mm beyond the right aortic border to within 1.6 cm of the left border of the IVC (Fig. 1). The patient then underwent left radical nephrectomy with renal vein thrombectomy using a hand-assisted laparoscopic approach. Intraoperatively, the tumor thrombus was “milked” proximally back into left renal vein using fingertip control (Fig. 2). The left renal vein was divided with an endovascular stapler (Fig. 2). Pathology demonstrated a Fuhrman grade IV, stage T3b clear cell renal carcinoma. This case illustrates that a left renal vein thrombus extending to the right margin of the aorta, even within 2 cm of the IVC, can be effectively managed with a handassisted laparoscopic approach.
Figure 1. CT abdomen and pelvis with intravenous and oral contrast demonstrating left renal mass and renal vein thrombus extending to within 1.6 cm of the left border of the inferior vena cava.
Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, IA Address correspondence to: George M. Ghareeb, M.D., Department of Urology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 3 RCP, Iowa City, IA 522421089. E-mail: [email protected] Submitted: November 7, 2015, accepted (with revisions): December 28, 2015
© 2015 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.urology.2015.12.045 0090-4295
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ARTICLE IN PRESS
Figure 2. Intraoperative images demonstrating proximal “milking” of left renal vein thrombus (above) and division of left renal vein with endovascular staple (below). (Color version available online.)
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UROLOGY ■■ (■■), 2016
Images in Clinical Urology Left Hand-assisted Laparoscopic Nephrectomy With Renal Vein Thrombectomy for Stage T3b Renal Cell Carcinoma George M. Ghareeb, Dorian A. Kenleigh, and James A. Brown A 60-year-old male was found to have an 8.0 cm left renal mass and associated renal vein thrombus on computed tomography. The thrombus extended 3 mm beyond the right aortic border to within 1.6 cm of the left border of the inferior vena cava. The patient underwent left nephrectomy with renal vein thrombectomy using a hand-assisted laparoscopic approach. The tumor thrombus was “milked” proximally back into left renal vein, which was then divided with an endovascular stapler. Left renal vein thrombi extending to right margin of the aorta can be managed with handassisted laparoscopic approach. UROLOGY ■■: ■■–■■, 2016. © 2015 Elsevier Inc.
A
60-year-old male presented for evaluation of left flank pain. Computed tomography (CT) imaging demonstrated an 8.0 cm left renal mass and associated renal vein thrombus. Evaluation of the extent of the thrombus in relation to the inferior vena cava (IVC), left adrenal vein, left gonadal vein, and right border of the aorta was used to better elucidate the feasibility of a handassisted laparoscopic (HAL) approach of left renal vein thrombectomy. CT assessment of the thrombus demonstrated that it extended beyond the left gonadal vein and adrenal vein tributaries, and 3 mm beyond the right aortic border to within 1.6 cm of the left border of the IVC (Fig. 1). The patient then underwent left radical nephrectomy with renal vein thrombectomy using a hand-assisted laparoscopic approach. Intraoperatively, the tumor thrombus was “milked” proximally back into left renal vein using fingertip control (Fig. 2). The left renal vein was divided with an endovascular stapler (Fig. 2). Pathology demonstrated a Fuhrman grade IV, stage T3b clear cell renal carcinoma. This case illustrates that a left renal vein thrombus extending to the right margin of the aorta, even within 2 cm of the IVC, can be effectively managed with a handassisted laparoscopic approach.
Figure 1. CT abdomen and pelvis with intravenous and oral contrast demonstrating left renal mass and renal vein thrombus extending to within 1.6 cm of the left border of the inferior vena cava.
Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, IA Address correspondence to: George M. Ghareeb, M.D., Department of Urology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 3 RCP, Iowa City, IA 522421089. E-mail: [email protected] Submitted: November 7, 2015, accepted (with revisions): December 28, 2015
© 2015 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.urology.2015.12.045 0090-4295
1
ARTICLE IN PRESS
Figure 2. Intraoperative images demonstrating proximal “milking” of left renal vein thrombus (above) and division of left renal vein with endovascular staple (below). (Color version available online.)
2
UROLOGY ■■ (■■), 2016