Laparoscopic Management Of Advanced Renal Cell Carcinoma With Level I Renal Vein Thrombus

Main Category: Vascular
Also Included In: Cancer / Oncology;  GastroIntestinal / Gastroenterology
Article Date: 12 Mar 2007 - 0:00 PDT

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UroToday.com- Traditionally, venous involvement, bulky retroperitoneal adenopathy, and large tumors with extracapsular extension have served as relative contraindications to radical nephrectomy performed through a laparoscopic approach. Increased experience and skill with this approach over time has resulted in expanding the indications of laparoscopic surgical techniques to deal with more and more complex surgical issues. Here Kapoor and colleagues report on their experience with laparoscopic management of level I tumor thrombi during laparoscopic radical nephrectomy.

The authors report on 12 patients with level I tumor thrombi that were diagnosed preoperatively. This report differs from previous studies in the literature in that all patients were known to have tumor thrombi preoperatively. Of these 12, 6 were done with a hand assisted laparoscopic technique, primarily because of large tumors with hilar adenopathy precluded a pure laparoscopic approach. Intraoperative laparoscopic ultrasound was used in 4 to delineate the extent of the thrombus to facilitate surgical management of the renal vein. Two cases were electively converted to open surgery due to more extensive venous involvement than perceived preoperatively. Seven of the 12 patients had metastatic disease at the time of surgery and two of these died of progressive disease after surgery, prior to the administration of systemic therapy. Mean blood loss was 200 ml and mean OR time was 220 minutes. The median length of stay was 4 days. There were no intraoperative complications and no positive margins or local recurrences in the series. The authors noted that the hand assisted approach was particularly useful in "milking back" the thrombus prior to application of the vascular stapler.

Increasing use of laparoscopic approaches in the management of renal cell carcinoma has resulted in the development of surgical skills that allow approaches to more complex surgical problems. As a consequence, selected patients with even locally advanced disease can enjoy the decreased morbidity associated with laparoscopic surgery.

Kapoor A, Nguan C, Al-Shaiji TF, Hussain A, Fazio L, Al Omar M, Luke PPW
Urology 68(3): 514-517, 2006.

Reviewed by UroToday.com Contributing Editor Christopher G. Wood, MD, FACS

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