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S267 Surgical treatment and prognosis in patients with locally advanced renal cell carcinoma and tumor invasion in inferior vena cava
S267
Surgical treatment and prognosis in patients with locally advanced renal cell carcinoma and tumor invasion in inferior vena cava Eur Urol Suppl 2013;12;e1375
Timev A.1, Yanev K.1, Petkov D.2, Georgiev M.1, Ormanov D.1, Vasilev V.1, Dimitrov P.1, Krustanov A.1, Simeonov P.1, Panchev P.1 1University
Hospital Alexandrovska, Dept. of Urology, Sofia, Bulgaria, 2University Hospital “St. Ekaterina”, Dept. of Cardiac
Surgery, Sofia, Bulgaria INTRODUCTION & OBJECTIVES: The purpose of the current study is to summarize the results of our experience in the diagnosis, surgical treatment and prognosis of patients with locally advanced renal cell carcinoma (RCC) with tumor invasion in inferior vena cava (IVC). MATERIAL & METHODS: For a period of 4 years (2009 – 05.2013) 19 patients with renal cell carcinoma and tumor thrombus in IVC underwent surgical treatment. 12 males and 7 females patients with medium age of 63 years (between 45 and 84). In 16 cases the primary tumor was in the right kidney and 3 cases the left kidney was involved. Organ metastases were found in two patients – contralateral supradrenal gland and lung. According to Novick classification of the tumor thrombus – infrahepatic in 6 cases, intrahepatic in 6, suprahepatic in 5 and 2 cases with thromub extending to the right atrium. All patients were managed by a hybrid team – cardio-vascular surgeon and urologist. In the 6 cases with infrahepatic thrombus only a transperitoneal approach was enough while in the other 13 a combined approach was used (upper transversal laparotomy and sternotomy). Before the thrombectomy a vessel clamps were used for control of contralateral renal vein and IVC under and over the tumor thrombus. Cardio-pulmonary bypass was needed in 3 cases with mild hypothermia of 32 C. The cavotomy was managed with primary suture in 15 cases and with patch plastic with Gore-Tex in 4 cases. RESULTS: In all cases a radical nephrectomy with complete excision of the tumor thrombus was done. In one case a contralateral supradrenalectomy was performed due to metastatic disease. Serious intraoperative complications appear in three cases in whom we didn’t use a tourniquet for occlusion of the thoracic segment of IVC – migration of the tumor thrombus to the right atrium in one case and pulmonary thromboembolisum in two cases. Two patients died in the intensive care unit on the fourth and sixteenth postoperative day respectively due to pulmonary embolism and hemorrhagic shock. Two patients were reexplored on the second and third postoperative day respectively due to bleeding. Hemodialysis was needed in three patients as in both of them a full recovery of the renal function was observed. With an average follow up of 17,6 months (from 1 to 46) 14 of our patients are still alive – 11 of them are without any evidence of metastatic disease. Three patients are with pulmonary metastases – in one of them they were present preoperatively and in the other two they develop on the sixth and fourteenth month after surgery. Three patients died on seventh, tenth and thirty sixth month postoperatively. CONCLUSIONS: The results of the current study are similar to those of the other authors and once again confirm the leading role of the radical surgical treatment as the only one therapeutic option improving considerably the prognosis of patients with locally advanced RCC and tumor invasion in IVC. According to us the radical removal of the primary tumor and the tumor
thrombus is completely possible in case of accurate preoperative staging, well-prepared team and a possibility if needed for cardio-pulmonary bypass. The grade of tumor invasion in IVC is of leading significance for the choosing of surgery approach and technique.
Surgical treatment and prognosis in patients with locally advanced renal cell carcinoma and tumor invasion in inferior vena cava Eur Urol Suppl 2013;12;e1375
Timev A.1, Yanev K.1, Petkov D.2, Georgiev M.1, Ormanov D.1, Vasilev V.1, Dimitrov P.1, Krustanov A.1, Simeonov P.1, Panchev P.1 1University
Hospital Alexandrovska, Dept. of Urology, Sofia, Bulgaria, 2University Hospital “St. Ekaterina”, Dept. of Cardiac
Surgery, Sofia, Bulgaria INTRODUCTION & OBJECTIVES: The purpose of the current study is to summarize the results of our experience in the diagnosis, surgical treatment and prognosis of patients with locally advanced renal cell carcinoma (RCC) with tumor invasion in inferior vena cava (IVC). MATERIAL & METHODS: For a period of 4 years (2009 – 05.2013) 19 patients with renal cell carcinoma and tumor thrombus in IVC underwent surgical treatment. 12 males and 7 females patients with medium age of 63 years (between 45 and 84). In 16 cases the primary tumor was in the right kidney and 3 cases the left kidney was involved. Organ metastases were found in two patients – contralateral supradrenal gland and lung. According to Novick classification of the tumor thrombus – infrahepatic in 6 cases, intrahepatic in 6, suprahepatic in 5 and 2 cases with thromub extending to the right atrium. All patients were managed by a hybrid team – cardio-vascular surgeon and urologist. In the 6 cases with infrahepatic thrombus only a transperitoneal approach was enough while in the other 13 a combined approach was used (upper transversal laparotomy and sternotomy). Before the thrombectomy a vessel clamps were used for control of contralateral renal vein and IVC under and over the tumor thrombus. Cardio-pulmonary bypass was needed in 3 cases with mild hypothermia of 32 C. The cavotomy was managed with primary suture in 15 cases and with patch plastic with Gore-Tex in 4 cases. RESULTS: In all cases a radical nephrectomy with complete excision of the tumor thrombus was done. In one case a contralateral supradrenalectomy was performed due to metastatic disease. Serious intraoperative complications appear in three cases in whom we didn’t use a tourniquet for occlusion of the thoracic segment of IVC – migration of the tumor thrombus to the right atrium in one case and pulmonary thromboembolisum in two cases. Two patients died in the intensive care unit on the fourth and sixteenth postoperative day respectively due to pulmonary embolism and hemorrhagic shock. Two patients were reexplored on the second and third postoperative day respectively due to bleeding. Hemodialysis was needed in three patients as in both of them a full recovery of the renal function was observed. With an average follow up of 17,6 months (from 1 to 46) 14 of our patients are still alive – 11 of them are without any evidence of metastatic disease. Three patients are with pulmonary metastases – in one of them they were present preoperatively and in the other two they develop on the sixth and fourteenth month after surgery. Three patients died on seventh, tenth and thirty sixth month postoperatively. CONCLUSIONS: The results of the current study are similar to those of the other authors and once again confirm the leading role of the radical surgical treatment as the only one therapeutic option improving considerably the prognosis of patients with locally advanced RCC and tumor invasion in IVC. According to us the radical removal of the primary tumor and the tumor
thrombus is completely possible in case of accurate preoperative staging, well-prepared team and a possibility if needed for cardio-pulmonary bypass. The grade of tumor invasion in IVC is of leading significance for the choosing of surgery approach and technique.