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Resection of the Vena Cava for Renal Cell Carcinoma: An Experimental Study
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RESECTION OF THE VENA CAVA FOR RENAL CELL CARCINOMA: AN EXPERIMENTAL STUDY LEON G. LOME* c,Nn IRVING lVI. BUSH
From the Divisions of Urology, ivlounl Sinai Hospital lvledical Center and Chicago M~edicai School, Chicago, lllinoi.,
Renal cell carcinoma c:wa in 6 to 33 per cent of and disease with simple intracaval. tumor in carcinomatosis within a year Marshal.l. 1 Ney •·<>,~rn,.,",,, no survivors at 6 vena caval obstruction was undertaken to a of renal cell carci-
function were
on the conmeasurements of renal up to 9 months. The result8
studies of renal function n.one of these studies vvas the resection of the vena cava. METHODS
between 15
'"'"u,.,ut, serun1 and urograms
inferior venacavograms renal and liver funetion tests were obcrea tinine and urea clearances were venous repeat
Fm. J.. Diagram of renoportal Left nephrectorny with resection been done.
Accepted for publication June This tlie Plzak ta! Medical
Jr.: Canine revenous drainage via 165: 1967. A. R. D. and
Fm. 2. Specimen shows left kidney with 7 cm. segment of vena cava en bloc.
717
718
LOME AND BUSH
Fro. 3. A, IVP 30 weeks after renoportal venous anastomosis. B, rern?port_al venogram. Arrow shows patent renoportal anastomosis with opacification of liver and spleen. C, mfenor venacavogram 28 weeks after resection of vena cava. Vertebral plexus, venae azygos and hemiazygos and ascendmg lumbar collateral networks are seen. TABLE
Urea Clearance
Preoperative 63 cc/min. 3. 7 cc/min./kg. Postoperative 55 cc/min. 3.2 cc/min./kg.
1. Renal function tests Creatinine Clearance
BUN (mg.%)
TABLE
Serum Creatinine (mg.%)
60 cc/min. 3.5 cc/min./kg.
19 (11-24)
1.0 (O.H.3)
43 cc/min. 2.5 cc/min./kg.
20 (12-27)
1.2 (0.9-1.5)
laparotomy and the right kidney and the liver were biopsied. Surgical technique. The dogs were anesthetized with intravenous sodium pentobarbital and the abdomen was entered through a midline incision. Inferior vena ca val and portal venous pressures were measured with a saline manometer. The vena cava was mobilized from below the liver to the iliac bifurcation. Vertebral veins were ligated and divided, and 1-zero silk ligatures were placed loosely about the vena cava. The portal vein was dissected free. The right renal artery and vein were isolated, and the left renal artery was ligated anc1 divided. The inferior vena cava was now doubly ligated and divided below the liver and above its bifircation. The right renal vein, having been prepared, was sectioned from the vena cava and anastomosed end-to-side to the portal vein with 5-zero tevdek (fig. 1). During transposition of the right renal vein, the right renal artery was clamped for 20 to 35 minutes. The left kidney was then removed en bloc with a 6 to 7 cm. segment of vena cava (fig. 2). RESULTS
Six of the 11 dogs maintained excellent health and were followed for 2 to 9 months. Five dogs died postoperatively: 3 of these did not recover from anesthesia and one died 2.J.:i days postoperatively. The
2. Liver function tests
Bilirubin Total
Bilirubin Direct
Alkaline Phosphatase
Units)
Serum Glutamic Oxaloacetic Transaminase
(KingArmstrong
Preoperative
0.2
0.1
I. 4
56
Postoperative
0. 4
0.1
I. 6
40
renoportal venous anastomoses were patent. The fifth dog eviscerated 3 days postoperatively. Renal function tests. The mean values for renal function tests are presented in table 1. The control preoperative values were within the normal range given by Houck. 7 Two to 9 months after nephrectomy, vena caval resection and renoportal venous anastomosis, the creatinine clearance for the single right kidney was 72 per cent of control values for both kidnevs. The creatinine clearance of 2.5 cc per minute pe1: kg. for the solitary right kidney falls within the normal range for dogs. 7 Repeated serum creatinine and BUN determinations showed no significant change from preoperative levels. IVP and venograms. Postoperative IVPs revealed prompt excretion of dye by the intact, normal right kidney (fig. 3, A). The renoportal venogram shows the patent renoportal venous anastomosis, with rapid opacification of the liver and spleen (fig. 3, B). The inferior venacavogram demonstrates the collateral vertebral plexus, the venae azygos and hemiazygos and the ascending lumbar anastomotic network (fig. 3, C). Pressures in portal vein and inferior vena cava. The mean pressures in the portal vein and inferior vena cava at the initial operation were 10 and 5 cm. water, respectively. Two to 9 months postoperatively the 7 Houck, C.R.: Statistical analysis of filtration rate and effective renal plasma flow related to weight and surface area in dogs. Amer. J. Physiol., 153: 169, 1948.
RESECTION OF VENA CAVA FOR RENAL CELL CARCINOMA
system
mean pressure in the to 18 cm. water.
Liver
elevated
tests. The mean values for a
of liver function tests are
table 2. No de-
tectable anastomosis were well rn·Ps.PrvP•ri and free of basement membrane """''"''"''"' and increased The tubules were normaL The liver also "-""'''-''°' normal ,,,uv,v,.,,,.,,.V-·'"J DISCUSSION
The surgeon's effort and risk are cmoma
is to decide how much to remove renal cell car-
a segment of the vena cava contumor,1 · 8 , 9 However, excision of the vena cava been confined to eases of volvement below the renal. veins and to the the vena cava level of the left renal vein, cava :1bove the renal
hazardous v,ithout the assurance that sufficient collaterals venous anastornosis have been made and Corriere recorded BGNsof61 sections of the and tubular dibtation m1d destruction.
intact.. The venous system is kno'Nn to be a collateral vvhen the :mferior vena cava is obstructed,ll In our studies in r"'"""''"'t venous anastomosis combined '.vith resection of the
pressure, we were unable to detect any adverse effects on renal function. In sections showed no of passive renal ::\IcDermott12 indicated that draininto the circulation could be inin Addison's syn3 did not recover from
care was taken to of the adrenal veins. Adrenal induced by inadvertent of the adrenal veins or inactivation of cortisone by the liver have contributed to the Radical of canceL Our JR
feasible when venous anar3tornosis of the contralateral and that it can be done without renal function. Success well-funcsuch may increase survival if renal cell carcinoma involves the vena cava either thrombus or direct invasion, The
SUMMARY
of renal cell carcmoma vena cava has tried, Unilateral lw,ani·Arnu with en bloc tion of the inferior vena cava was carried out in An end-to-side venous anastomosis was on the contralateral 'l'he were observed for up to detected neither adverse effects on renal nor histovenous this extended radical can be done without function of the 1c:1mtl!uu16 and would seem to patients. Drs. K :Vfailick and H, assistance. Dr, William viewed the """"""-"-,~·
RESECTION OF THE VENA CAVA FOR RENAL CELL CARCINOMA: AN EXPERIMENTAL STUDY LEON G. LOME* c,Nn IRVING lVI. BUSH
From the Divisions of Urology, ivlounl Sinai Hospital lvledical Center and Chicago M~edicai School, Chicago, lllinoi.,
Renal cell carcinoma c:wa in 6 to 33 per cent of and disease with simple intracaval. tumor in carcinomatosis within a year Marshal.l. 1 Ney •·<>,~rn,.,",,, no survivors at 6 vena caval obstruction was undertaken to a of renal cell carci-
function were
on the conmeasurements of renal up to 9 months. The result8
studies of renal function n.one of these studies vvas the resection of the vena cava. METHODS
between 15
'"'"u,.,ut, serun1 and urograms
inferior venacavograms renal and liver funetion tests were obcrea tinine and urea clearances were venous repeat
Fm. J.. Diagram of renoportal Left nephrectorny with resection been done.
Accepted for publication June This tlie Plzak ta! Medical
Jr.: Canine revenous drainage via 165: 1967. A. R. D. and
Fm. 2. Specimen shows left kidney with 7 cm. segment of vena cava en bloc.
717
718
LOME AND BUSH
Fro. 3. A, IVP 30 weeks after renoportal venous anastomosis. B, rern?port_al venogram. Arrow shows patent renoportal anastomosis with opacification of liver and spleen. C, mfenor venacavogram 28 weeks after resection of vena cava. Vertebral plexus, venae azygos and hemiazygos and ascendmg lumbar collateral networks are seen. TABLE
Urea Clearance
Preoperative 63 cc/min. 3. 7 cc/min./kg. Postoperative 55 cc/min. 3.2 cc/min./kg.
1. Renal function tests Creatinine Clearance
BUN (mg.%)
TABLE
Serum Creatinine (mg.%)
60 cc/min. 3.5 cc/min./kg.
19 (11-24)
1.0 (O.H.3)
43 cc/min. 2.5 cc/min./kg.
20 (12-27)
1.2 (0.9-1.5)
laparotomy and the right kidney and the liver were biopsied. Surgical technique. The dogs were anesthetized with intravenous sodium pentobarbital and the abdomen was entered through a midline incision. Inferior vena ca val and portal venous pressures were measured with a saline manometer. The vena cava was mobilized from below the liver to the iliac bifurcation. Vertebral veins were ligated and divided, and 1-zero silk ligatures were placed loosely about the vena cava. The portal vein was dissected free. The right renal artery and vein were isolated, and the left renal artery was ligated anc1 divided. The inferior vena cava was now doubly ligated and divided below the liver and above its bifircation. The right renal vein, having been prepared, was sectioned from the vena cava and anastomosed end-to-side to the portal vein with 5-zero tevdek (fig. 1). During transposition of the right renal vein, the right renal artery was clamped for 20 to 35 minutes. The left kidney was then removed en bloc with a 6 to 7 cm. segment of vena cava (fig. 2). RESULTS
Six of the 11 dogs maintained excellent health and were followed for 2 to 9 months. Five dogs died postoperatively: 3 of these did not recover from anesthesia and one died 2.J.:i days postoperatively. The
2. Liver function tests
Bilirubin Total
Bilirubin Direct
Alkaline Phosphatase
Units)
Serum Glutamic Oxaloacetic Transaminase
(KingArmstrong
Preoperative
0.2
0.1
I. 4
56
Postoperative
0. 4
0.1
I. 6
40
renoportal venous anastomoses were patent. The fifth dog eviscerated 3 days postoperatively. Renal function tests. The mean values for renal function tests are presented in table 1. The control preoperative values were within the normal range given by Houck. 7 Two to 9 months after nephrectomy, vena caval resection and renoportal venous anastomosis, the creatinine clearance for the single right kidney was 72 per cent of control values for both kidnevs. The creatinine clearance of 2.5 cc per minute pe1: kg. for the solitary right kidney falls within the normal range for dogs. 7 Repeated serum creatinine and BUN determinations showed no significant change from preoperative levels. IVP and venograms. Postoperative IVPs revealed prompt excretion of dye by the intact, normal right kidney (fig. 3, A). The renoportal venogram shows the patent renoportal venous anastomosis, with rapid opacification of the liver and spleen (fig. 3, B). The inferior venacavogram demonstrates the collateral vertebral plexus, the venae azygos and hemiazygos and the ascending lumbar anastomotic network (fig. 3, C). Pressures in portal vein and inferior vena cava. The mean pressures in the portal vein and inferior vena cava at the initial operation were 10 and 5 cm. water, respectively. Two to 9 months postoperatively the 7 Houck, C.R.: Statistical analysis of filtration rate and effective renal plasma flow related to weight and surface area in dogs. Amer. J. Physiol., 153: 169, 1948.
RESECTION OF VENA CAVA FOR RENAL CELL CARCINOMA
system
mean pressure in the to 18 cm. water.
Liver
elevated
tests. The mean values for a
of liver function tests are
table 2. No de-
tectable anastomosis were well rn·Ps.PrvP•ri and free of basement membrane """''"''"''"' and increased The tubules were normaL The liver also "-""'''-''°' normal ,,,uv,v,.,,,.,,.V-·'"J DISCUSSION
The surgeon's effort and risk are cmoma
is to decide how much to remove renal cell car-
a segment of the vena cava contumor,1 · 8 , 9 However, excision of the vena cava been confined to eases of volvement below the renal. veins and to the the vena cava level of the left renal vein, cava :1bove the renal
hazardous v,ithout the assurance that sufficient collaterals venous anastornosis have been made and Corriere recorded BGNsof61 sections of the and tubular dibtation m1d destruction.
intact.. The venous system is kno'Nn to be a collateral vvhen the :mferior vena cava is obstructed,ll In our studies in r"'"""''"'t venous anastomosis combined '.vith resection of the
pressure, we were unable to detect any adverse effects on renal function. In sections showed no of passive renal ::\IcDermott12 indicated that draininto the circulation could be inin Addison's syn3 did not recover from
care was taken to of the adrenal veins. Adrenal induced by inadvertent of the adrenal veins or inactivation of cortisone by the liver have contributed to the Radical of canceL Our JR
feasible when venous anar3tornosis of the contralateral and that it can be done without renal function. Success well-funcsuch may increase survival if renal cell carcinoma involves the vena cava either thrombus or direct invasion, The
SUMMARY
of renal cell carcmoma vena cava has tried, Unilateral lw,ani·Arnu with en bloc tion of the inferior vena cava was carried out in An end-to-side venous anastomosis was on the contralateral 'l'he were observed for up to detected neither adverse effects on renal nor histovenous this extended radical can be done without function of the 1c:1mtl!uu16 and would seem to patients. Drs. K :Vfailick and H, assistance. Dr, William viewed the """"""-"-,~·