Surgical management of renal cell carcinoma with tumor thrombus in the renal and inferior vena cava: the University of Miami experience in using liver transplantation techniques.

OBJECTIVES: Renal cell carcinoma (RCC) with tumor thrombus in the inferior vena cava (IVC) poses a challenge to the surgeon due to the potential for massive hemorrhage and tumor thromboemboli. We developed a technique for safe resection of these tumors through a transabdominal approach, without recourse to cardiopulmonary bypass (CPB).

MATERIALS AND METHODS: From August 1997 to February 2005, 66 patients underwent resection of a RCC with tumor thrombus in the IVC. The extent of the tumor thrombus was renal in 13, infrahepatic in 7; retrohepatic in 38; and intra-atrial in 8 patients.

RESULTS: Mean operative time was 6.16+/-0.32 hours. The estimated blood loss ranged from 200 cc to 16,000 cc, with a mean of transfusions being 3.56+/-0.94 U. CBP was required in only 3 patients. Three patients (4.5%) died in the immediate postoperative period. Median follow-up among the 56 survivors was 7.1 months. Six patients died due to metastasis and 1 died of a cause unrelated to the cancer. The estimated actuarial survival at 36 months was 66%.

CONCLUSIONS: An aggressive surgical approach is the only hope for curing patients having RCC with a tumor thrombus in the IVC. The extent of dissection is predicated on the extent and level of tumor thrombus. Our surgical approach uses liver transplant techniques to mobilize the liver off the IVC and to separate the IVC from the posterior abdominal wall. This maneuver provides excellent exposure and enables safe vascular control of the IVC.