Vascular Stapling Of The Inferior Vena Cava: Refinement Of The Excision Of Extensive Renal Cell Carcinoma With Unresectable Vena-Caval Involvement

Main Category: Vascular
Also Included In: Cancer / Oncology;  Urology / Nephrology
Article Date: 31 Dec 2009 - 0:00 PDT


UroToday.com - Management of advanced renal cell carcinoma remains an extremely difficult scenario in urologic oncology. In the setting of non-metastatic renal carcinoma with tumor thrombus invading into the inferior vena cava, complete extirpirative surgery, including thrombectomy and nephrectomy has been shown to have acceptable oncologic and long-term outcomes for the patients [1, 2].

Surgical techniques for such operations have been extensively debated in the literature. Some authors have advocated hypothermia, circulatory arrest, and cardiopulmonary bypass for some Level III and IV tumor thrombi [3]. Others have reported effective outcomes of excision of Level IV thrombi without the use of bypass techniques and using a solely abdominal approach [4]. Clearly, optimal management strategies should be tailored to the individual patient situation and modified accordingly.

Treatment of the caval thrombus may present another problem to the surgeon. In the case of a densely adherent tumor thrombus, the decision must be made as to the most safe and effective method of excision. Options include excision of the thrombus with a segment of caval wall and primary closure, excision of the caval wall of patching, and replacement of a complete circumferential segment of the cava with a graft. This paper introduces another effective method of caval management: vascular staple ligation.

In the setting of completely obstructing, adherent tumor thrombus, the cava may be stapled using a vascular stapler above the most cranial extent of the thrombus (Fig 1 and 2). Collateral circulation will allow lower extremity drainage, and the speed and effectiveness of the stapling procedure poses less risk of morbidity to the patient such as blood loss or delayed vascular leak. The experience with this technique has been extremely promising, with no related complications.

In conclusion, vascular staple ligation of the IVC is a safe, effective, and efficient method of IVC removal in the setting of completely obstructing tumor thrombus that cannot be circumferentially separated from the caval walls.

References:

[1] Mattos RM, Libertino JA. Survival of patients with renal cell carcinoma invading the inferior vena cava. Semin Urol Oncol. 1996;14:223-226.

[2] Skinner DG, Pfister RF, Colvin R. Extension of renal cell carcinoma into the vena cava: the rationale for aggressive surgical management. J Urol. 1972;107:711-716.

[3] Boorjian SA, Blute ML. Surgery for vena caval tumor extension in renal cancer. Curr Opin Urol. 2009 Sep;19(5):473-7.

[4] Ciancio G, Soloway MS. Renal cell carcinoma with tumor thrombus extending above diaphragm: avoiding cardiopulmonary bypass. Urology. 2005 Aug;66(2):266-70.

Written by Samir Shirodkar, MD, and Gaetano Ciancio, MD, MBA as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations, etc., of their research by referencing the published abstract.

UroToday - the only urology website with original content written by global urology key opinion leaders actively engaged in clinical practice. To access the latest urology news releases from UroToday, go to: www.urotoday.com

Copyright © 2009 - UroToday

• Additional
• References
• Citations