Surgical Treatment of Renal Cell Carcinoma with Vena Cava Or Cavo-Atrial Involvement. Our Experience

Abstract

From January 1987 to September 1992, 290 patients were operated for renal cell carcinoma at the Department of Urology of Bergamo General Hospital. Among these, 22 had venous invasion, 13 of them with vena cava or cavo-atrial involvement. The Authors stress several technical details that they judge very helpful in the case of intrahepatic or supradiaphragmatic thrombi. Among them the routine use of transesophageal sonography, which gives precise details on the size, volume, and upper limit of the thrombus especially if floating. 4 patients were operated with the help of cardiopulmonary by-pass, circulatory arrest and profound hypothermia. The Authors stress the major advantages offered by this technique compared to simpler approaches like the control either of the supradiaphragmatic vena cava, or hepatic veins. Cardiopulmonary by-pass and circulatory arrest offers unsurpassed exposure of the IVC interior and allows easy and controlled extraction of the thrombus, previously the most difficult part of the procedure. Having no time limit imposed by liver ischemia (± 20 minutes), it also offers the possibility of resecting segments of caval wall and repairing it with patch grafts. Among 13 patients who underwent radical nephrectomy and intracaval thrombus removal, limited complications and no peri-operative mortalities are reported.