Pure Laparoscopic Radical Nephrectomy and Inferior Vena Caval Tumor Thrombus Removal in Patients with Complicated Renal Tumor

Introduction

Renal cell carcinoma (RCC) represents 2%–3% of all adult malignancies, with mortality exceeding 40%. Advances in surgical techniques and adjuvant therapies have transformed outcomes for high-risk patients, including those with inferior vena caval (IVC) tumor thrombi. Historically challenging, these cases now benefit from minimally invasive approaches such as pure laparoscopic radical nephrectomy combined with IVC thrombus removal. This article details a study of five patients undergoing this procedure, highlighting technical considerations, perioperative outcomes, and clinical implications.

Patient Characteristics

Five patients (two males, three females; age range: 39–71 years; mean age: 59 years) with renal carcinoma and IVC thrombi were included. Presenting symptoms included flank pain (n=2), hematuria (n=2), and incidental diagnosis (n=1). Three tumors originated in the left kidney, and two in the right. Tumor size ranged from 3.8 to 11.2 cm. Thrombus classification (Mayo Clinic grading) included three grade I thrombi (limited to the IVC below the hepatic veins) and two grade II thrombi (extending to the intrahepatic IVC but below the diaphragm). Metastatic disease was present in two patients: one with hilar lymph node involvement and another with bone metastases.

Surgical Techniques

Preoperative Considerations

All patients underwent detailed imaging, including computed tomography (CT) to assess thrombus extent and vascular anatomy (Figure 1A). One patient with concurrent distant venous thrombosis received a temporary IVC filter, later removed post-anticoagulation. Preoperative targeted therapy was not administered due to limited evidence supporting thrombus regression.

Right-Sided Tumors (Grade I Thrombus)

For right renal tumors with grade I thrombi (n=2), a retroperitoneal approach was used. After renal artery ligation, the IVC was exposed, and lateral clamping applied at the renal vein-IVC junction. Thrombectomy was performed with primary suturing of the IVC.

Left-Sided Tumors (Grade I Thrombus)

Left renal tumors (n=3) required a transperitoneal approach. Patients were initially positioned at a 30° right oblique angle for kidney mobilization and renal artery ligation. Repositioning to a left oblique angle allowed access to the right paracolic sulcus, exposing the left renal vein-IVC junction. Lateral IVC clamping preceded thrombus extraction and venous repair (Figure 1B-D).

Grade II Thrombi

For grade II thrombi (n=2), extensive IVC isolation was necessary. Proximal and distal IVC clamping, combined with temporary renal artery occlusion, enabled thrombus removal under controlled conditions. Venous repair utilized laparoscopic suturing techniques.

Operative Outcomes

All procedures were completed laparoscopically without conversion to open surgery. Mean operative time was 360 ± 45 minutes, with intraoperative blood loss of 500 ± 180 mL. One patient required an 800 mL red blood cell transfusion. Postoperative creatinine levels showed no significant elevation (72 ± 11 mg/dL vs. 84 ± 7 mg/dL; P=0.15). Histopathology confirmed transitional cell carcinoma (Fuhrman grade II) in four patients and sarcomatoid carcinoma in one.

Postoperative Management

Patients received targeted therapy (sorafenib, n=4; sunitinib, n=1) and were monitored for 2–18 months (median survival: 11 months). No thrombus-related embolic events occurred. Hospital stay averaged 11 ± 3 days.

Technical and Anatomic Considerations

Right vs. Left Renal Tumors

Right-sided tumors permitted retroperitoneal access and simplified IVC management due to the short renal vein and collateral venous drainage (gonadal, adrenal, and lumbar veins). Left-sided tumors posed greater complexity, necessitating positional changes and transperitoneal routes to achieve IVC control.

Thrombus Grading and Vascular Control

Grade I thrombi allowed lateral IVC clamping, whereas grade II thrombi required proximal and distal IVC occlusion. Temporary renal artery clamping minimized bleeding during venous repair.

Laparoscopic Vascular Suturing

Proficiency in laparoscopic suturing was critical for IVC repair. The study emphasized meticulous closure to prevent stenosis or leakage, with no postoperative complications reported.

Clinical Implications

Role of Targeted Therapy

Preoperative tyrosine kinase inhibitors (TKIs) remain controversial. While some studies suggest thrombus reduction in 12% of cases, this series avoided neoadjuvant TKIs due to concerns about increased adhesions and surgical complexity.

IVC Filter Placement

Selective use of IVC filters in patients with preoperative venous thrombosis proved effective, with one patient successfully weaned from anticoagulation post-thrombus resolution.

Survival and Follow-Up

Median survival of 11 months aligns with historical data for advanced RCC. Targeted therapy post-surgery may improve outcomes, though longer follow-up is needed.

Challenges and Limitations

Laparoscopic IVC thrombectomy demands expertise in vascular and oncologic laparoscopy. Left-sided tumors require advanced techniques due to anatomic constraints. The small cohort size limits generalizability, but the study demonstrates feasibility in carefully selected patients.

Conclusion

Pure laparoscopic radical nephrectomy with IVC thrombectomy is a viable option for renal carcinoma patients with venous thrombi. Success relies on preoperative planning, vascular control strategies, and surgical proficiency. This approach offers reduced morbidity compared to open techniques, though further studies are warranted to establish long-term efficacy.

doi: 10.1097/CM9.0000000000000436

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