Hand-assisted laparoscopic radical nephrectomy in the treatment of a renal cell carcinoma with a level ii vena cava thrombus

Abstract

Excision of renal cell carcinoma (RCC) with corresponding vena cava thrombus is a technical challenge requiring open resection and vascular clamping. A 58 year old male with a right kidney tumor presented with a thrombus extending 1 cm into the vena cava. Using a hand-assisted transperitoneal approach through a 7 cm gel-port, the right kidney was dissected and the multiple vascular collaterals supplying the tumor were identified and isolated. The inferior vena cava was mobilized 4 cm cephalad and 4 cm caudal to the right renal vein. Lateral manual traction was applied to the right kidney allowing the tumor thrombus to be retracted into the renal vein, clear of the vena cava. After laparoscopic ultrasonographic confirmation of the location of the tip of the tumor thrombus, an articulating laparoscopic vascular stapler was used to staple the vena cava at the ostium of the right renal vein. This allowed removal of the tumor thrombus without the need for a Satinsky clamp. The surgery was completed in 243 minutes with no intra-operative complications. The entire kidney and tumor thrombus was removed with negative surgical margins. Estimated blood loss was 300 cc. We present a laparoscopic resection of a renal mass with associated level II thrombus using a hand-assisted approach. In patients with minimal caval involvement, our surgical approach presents an option to the traditional open resection of a renal mass.

Pure Conventional Laparoscopic Radical Nephrectomy with Level II Vena Cava Tumor Thrombectomy

“…In 1996, McDougall et al presented the first successful LRN with level I thrombectomy (3). During the following years, many case series studies involving LRN with level I thrombectomy were reported proving that the procedure was feasible (4,5). In this procedure, the tumor thrombus was "milked back" into the renal vein so as to block the vein with vascular clips or an endoscopic stapling device (13).…”

“…Since the first description of laparoscopic radical nephrectomy (LRN) with level I vena cava thrombectomy in 1996 (3), several medical centers presented laparoscopic approach to deal with RCC with level I thrombus with encouraging outcomes (4,5). One case of renal tumor with IVTT extended 3cm above the renal vein (level II tumor thrombus) managed with pure LRN with tumor thrombectomy was reported in 2006 (6).…”

Modified IVC Clamping Technique in the Left Radical Nephrectomy and Mayo II-III IVC Thrombectomy: A Preliminary Experience

“…At present, open surgery is still the standard approach for RCC with IVCTT [4]. Recently, laparoscopy is increasingly being used in RCC patients with IVCTT due to the improvement of the minimally invasive techniques and the accumulation of surgical experiences, and it has been proved to be safe and effective in selected patients [5][6][7][8][9][10][11][12]. Whether open surgery or laparoscopic surgery, it is necessary to clamp the inferior vena cava (IVC) below the inferior margin of TT and above the superior margin of the TT, followed by removing of the TT.…”

Technical considerations in robotic nephrectomy with vena caval tumor thrombectomy

“…[1] Laparoscopy has gained only limited application for IVC tumor thrombi and only for short thrombi that could be milked out of the IVC or in conjunction with an open incision for the IVC manipulation and tumor extraction. [2345678]…”