










































This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2022 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

Key Words Competing Interests Article Information

Renal cell carcinoma, venous tumor thrombus, 
inferior vena cava tumor thrombus

None declared. Received on July 14, 2022 
Accepted on September 14, 2022 
This article has been peer reviewed.

Soc Int Urol J. 2022;3(6):451–463

DOI: 10.48083/EGWH6536

2022 WUOF/SIU International Consultation on 
Urological Diseases: Management of Locally 
Advanced Renal Cell Carcinoma

Vsevolod B. Matveev,1 Sarah P. Psutka,2 Grant D. Stewart,3 Gennady Bratslavsky,4 E. Jason Abel5

1 Department of Urology, N. N. Blokhin National Research Institute of Oncology, Moscow, Russia 2 University of Washington Medical Center, Seattle Cancer Care 
Alliance, Seattle, United States 3 Department of Surgery, University of Cambridge, Cambridge Biomedical Campus, Cambridge, United Kingdom 4 Department of Urology,  
SUNY Upstate Medical University, Syracuse, New York, United States  5 Departments of Urology and Radiology, University of Wisconsin School of Medicine and  
Public Health, Madison, United States

Abstract

Renal cell carcinoma (RCC) has a natural tendency to invade the venous system with formation of a venous tumor 
thrombus in the renal vein, which can extend proximally into the inferior vena cava (IVC) and in some cases into 
the right atrium. The presence of venous involvement significantly worsens prognosis. Despite recent advances in 
systemic therapies, surgery remains the most effective method of treatment and in the case of complete removal 
of all tumor, it provides satisfactory long-term survival and must be attempted whenever possible. Several surgical 
techniques have been proposed, but all are associated with a high rate of perioperative complications and mortality. 
Minimally invasive approaches are mainly applicable for less extended IVC thrombi, while open surgery remains the 
gold standard for this category of patients. Most IVC thrombi can be managed without use of circulatory support 
by using different methods of IVC control depending on the thrombus level. However, use of cardiac bypass with or 
without deep hypothermic cardiac arrest is indicated in some patients with bulky intraatrial tumor thombi. In select 
patients presenting with IVC tumor thrombus and synchronous distant metastases, cytoreductive nephrectomy with 
IVC tumor thrombectomy may be considered with or without neoadjuvant systemic therapy. Surgery for RCC with 
venous thrombus is complex and requires experienced multidisciplinary surgical, anesthesia, and critical care teams 
at high-volume centers to achieve the best outcomes.

Introduction

Venous tumor thrombus (VTT) involvement is identified in up to 10% of patients with RCC[1]. Currently, surgery 
remains the only curative approach for M0 RCC with IVC invasion. While an open approach is most commonly 
utilized, there is growing interest regarding the role for minimally invasive approaches in appropriately selected 
patients; however, there is limited data regarding long-term outcomes regarding these approaches. In select patients 
presenting with IVC tumor thrombus and synchronous distant metastases, cytoreductive nephrectomy with IVC 
tumor thrombectomy may be considered with or without neoadjuvant systemic therapy.

Classification of VTT in Renal Cell Carcinoma
An unusual hallmark of RCC is its predilection for vascular invasion. The VTT can then form a cast of the main 
renal vein (pT3a) and extend proximally into the inferior vena cava (IVC; pT3b), in some cases extending into the 
right atrium of the heart (pT3c) or can invade directly from the venous lumen into the endothelium (pT3c)[2]. 

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Recent estimates suggest that VTT is identified in 
approximately 1 in 10 patients with newly diagnosed 
RCC[3–12]. Involvement of the right cardiac chambers is 
encountered in 1% of cases[13].

VTT is classically categorized according to the 
height or extent of the VTT, according to the Mayo 
Classification system[14] (Table 1). The level of tumor 
thrombus is relevant not only from the perspective of 
oncologic prognosis but also in terms of anticipating 
surgical complexity and surgical planning[12].

Other features of the VTT such as direct invasion of 
the tumor thrombus into the endothelium and presence 
of bland thrombus are associated with both increased 
surgical complexity[15,16] and inferior cancer-specific 
survival[17–19].

Macroscopically, venous tumor thrombi can also be 
categorized according to their consistency, and may be 
described as either solid or friable, where friability has 
been associated with worse pathologic features and 
prognosis[20,21].

Pathophysiology of Tumor Venous 
Thrombosis and Clinical Manifestations  
of RCC with IVC Tumor Thrombus
Complete occlusion of the IVC by VTT or by proximal 
bland thrombus propagation has multiple potential 
physiologic consequences. IVC obstruction may result in 
lower-extremity edema, development of varicoceles, and 
pelvic pain from gonadal vein obstruction.

Reduced venous return to the right atrium (reduc-
tion in preload) may lead to hemodynamic instability, 
and altered mental status and death. Other commonly 
reported symptoms may include fatigue, dizziness, 
weight loss, night sweats, anorexia, palpitations, diapho-
resis, dizziness, and shortness of breath on exertion[22].

Failure of the kidneys to have adequate venous drain-
age can result in progression of renal insufficiency. 
Similarly, obstruction of the hepatic veins can lead to 
hepatic congestion, which presents with transami-
nitis, hepatic insufficiency, ascites, and Budd-Chiari 
syndrome[23–26].

Up to 5% of patients with RCC and IVC tumor throm-
bus may present with pulmonary embolism[27–29]. 
Finally, level IV IVC tumor thrombus that grows into 

the right atrium can cause atrioventricular blockage 
with acute heart failure and death.

Collateral venous return in the setting of IVC 
obstruction may include drainage via the azygos-hemi-
azygos circulation, vertebral pathways via prominent 
lumbar veins, collateralization of the portal-venous 
system, as well as via aberrant parasitic vessels or super-
ficial/subcutaneous veins, as is observed in patients 
presenting with a “Caput medusa”[30,31]. The degree of 
collateralization depends on the duration and extent of 
the IVC obstruction.

Diagnostic Imaging and Staging
Staging evaluation consists of cross-sectional imaging of 
the chest, abdomen, and pelvis to characterize the size of 
the primary tumor and assess for potential involvement 
of adjacent structures or distant metastases. Cross-
sectional imaging provides critical details regarding 
the level of the thrombus, the presence or absence of 
IVC occlusions, the degree of venous collateralization, 
and the volume and location of association bland 
thrombus[22,32,33]. Multiphase computed tomography 
(CT) and magnetic resonance imaging (MRI) are 
acceptable staging imaging modalities. In patients 
with lower-extremity edema, a Doppler ultrasound 

Abbreviations 
IO immuno-oncology therapy 
RCC renal cell carcinoma
VTT venous tumor thrombus

TABLE 1. 

Classification of VTT level in RCC:  
The Mayo Classification system14 

Level Anatomic landmark

0
Thrombus is limited to the segmental or main renal vein, 

detected clinically or during pathologic evaluation.

I
Thrombus extends into the infradiaphragmatic IVC,  

within 2 cm of the renal vein ostium.

II
Thrombus extends into the infradiaphragmatic  

IVC, > 2 cm above the renal vein ostium but below  
the confluence of the hepatic veins.

III
Thrombus extends into the infradiaphragmatic IVC,  

above the confluence of the hepatic veins.

IV
Thrombus extends above the diaphragm, and  

may involve the right atrium.

IVC: inferior vena cava; RCC: renal cell carcinoma;  
VTT: venous tumor thrombus.

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(US) is indicated to assess the venous patency of the 
lower extremities. Also, in patients with neurological 
symptoms, head imaging (CT or MRI) should be 
obtained to rule out brain metastases. Venography 
is not currently utilized to evaluate for VTT due to 
its invasiveness and moderate risk for associated 
complications[34].

At the time of surgery, transesophageal echocardi-
ography can provide real-time, additional information 
regarding the upper extent of the thrombus and involve-
ment of the intra- and supra-hepatic IVC, hepatic veins, 
and right atrium. It can also provide helpful information 
regarding the mobility of the thrombus[35].

Neoadjuvant Therapy Before Radical 
Nephrectomy and Thrombectomy

There is no level I or II evidence of presurgical 
systemic therapy in either nonmetastatic or metastatic 
RCC VTT. Retrospective studies have been undertaken 
and these have focused on mixed groups of targeted 
therapies[36–39]: sunitinib[40,41], axitinib[42], and 
pazopanib[43]. NAXIVA is a phase 2 feasibility clinical 
trial (NCT03494816) that was undertaken to determine 
the safety, efficacy, and effect of neoadjuvant axitinib on 
VTT[44].

Drug and surgery-related adverse events were as 
expected, with Clavien-Dindo grade ≥3 complications 
observed in 11.8% (2 of 17) of patients. The trial provided 
initial evidence that vascular endothelial growth factor 
receptor tyrosine kinase inhibitors (VEGFR TKIs) 
can successfully downstage VTT (75% [15 of 20] with 
reduction in VTT length, 35.3% [7 of 20] with reduc-
tion in Mayo level), leading to a reduction in the extent 
of surgery in 41.2% (7 of 17) of patients[44]. However, 
before this strategy can be considered for routine clinical 
practice, future randomized studies evaluating contem-
porary standard of care treatment combinations (immu-
no-oncology therapy [IO]/IO or IO/TKI) are needed.

Surgical Technique of Radical 
Nephrectomy with IVC Thrombectomy
Surgery in patients with level III and IV VTT is 
generally performed through midline, chevron, or 
thoracoabdominal incision.

To minimize the morbidity associated with a thora-
coabdominal approach, radical nephrectomy and 
thrombectomy may be performed via midline abdom-
inal approach, which can be used for all levels of VTT.

Regardless of the primary tumor laterality, the access 
to the retroperitoneum is achieved by incising the poste-
rior peritoneum lateral to the ascending colon. The 
right colon is reflected medially, and the duodenum is 

kocherized to expose the anterior surface of the IVC 
and aorta. Early ligation of the renal artery decreases 
the bleeding from venous collaterals and may permit for 
retraction of the cephalad most extent of the VTT. The 
mobilization of the kidney should be deferred until after 
complete vascular control is achieved.

Thrombectomy in Patients with Level I-III 
Tumor Thrombus
After ligation of the renal artery, the vena cava is 
completely dissected from the surrounding structures 

above and below the renal vein. Rummel tourniquets or 
vascular clamps are placed around the infrarenal IVC, 
contralateral renal vein, and suprarenal IVC cephalad to 
the superior extent of the VTT.

In patients with a subhepatic level II VTT, several 
(2–4) accessory hepatic veins from the caudate lobe 
of the liver are ligated and divided. As a result of this 
maneuver, 3 to 5 cm of additional IVC is exposed.

In the case of the right-sided primary, the right 
kidney is then completely mobilized outside Gerota's 
fascia, leaving the kidney attached only by the renal vein. 
In the case of a left-sided tumor, the kidney is mobilized 
only after completion of thrombectomy.

The tourniquets on infrarenal IVC, contralateral 
renal vein, and IVC above the upper extent of the throm-
bus are sequentially closed (Figure 1A). The antero-lat-
eral wall of the subhepatic vena cava is longitudinally 
incised, and the thrombus is extracted with blunt and 
sharp dissection from the vessel wall, followed by a 
circumferential excision of the ostium of the renal vein 
(Figure 1B). After evaluating for remnant thrombus 
fragments adhering to the IVC intima, the defect of the 
IVC is closed with a 4–0 running vascular suture, the 
cavorraphy is backbled to avoid an air embolism, and the 
clamps are removed in the following order: (1) suprare-
nal IVC, (2) contralateral renal vein, (3) infrarenal IVC.

The management of patients with level III VTT 
requires mobilization of the liver, which allows for expo-
sure of the intrahepatic and subdiaphragmatic segments 
of the IVC (Figure 2A). Resection of a level III VTT can 
be safely performed in most of the cases without circu-
latory support[45,46]. IVC above the upper extent of 
the thrombus is controlled at the intrapericardial level 
by using the transdiaphragmatic approach. Absence of 
tributaries makes circular mobilization of the intraperi-
cardial part of the IVC significantly easier to perform 
compared with subdiaphragmatic circular mobiliza-
tion. To accomplish a transdiaphragmatic IVC clamp, 
the diaphragm and underlying pericardium are incised 
above the IVC. Incision of the pericardium on both sides 
of the intrapericardial IVC allows for passing a tourni-
quet around the intrapericardial IVC[47] (Figure 2A). 

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Alternatively, the pericardium can be separated from 
the incised diaphragm and left intact. The advantages 
of approaching the intrapericardial IVC through a 
diaphragmatic incision include simplicity, decreased 
surgical trauma, and the ability to perform the proce-
dure by one surgical team using a strictly abdominal 
approach[46,47].

The hepatoduodenal ligament is isolated to control 
the hepatic circulation with a Pringle maneuver. After 
closure of all tourniquets with a Pringle maneuver, the 
IVC is incised at the retrohepatic level. Widely opening 
the IVC at this level allows the surgeon to perform visual 
inspection of the ostium of the major and minor hepatic 
veins.

Following thrombectomy, the closure of the upper 
part of the cavotomy is started. As soon as the suture line 
reaches the subhepatic portion of the IVC, a Satinsky 
clamp is placed above the last stitch, the tourniquet 
from the intrapericardial IVC and the Satinsky clamp 
from the hepatoduodenal ligament are released, thereby 
restoring hepatic circulation and venous blood return to 
the right atrium. The rest of the procedure is similar to 
cases with level II VTT. Ideally, the thrombus is removed 
en bloc with the kidney (Figure 2B).

In patients with level III VTT and left-sided primary, 
the tourniquets are placed on the right renal vein (or 
right renal artery), while the left renal vein is sutured 
and divided with a TA stapler prior to thrombectomy. 
Contraindication for this approach includes partial left 
renal vein and IVC occlusion by a thin tumor thrombus, 
which may dislodge and cause pulmonary embolization. 
Transection of the left renal vein in patients with fixed 
IVC thrombi is safe and allows for greater IVC mobility, 
provides good access to the left renal artery and aorta, 
and facilitates en bloc removal of the thrombus with the 
ostium and VTT-containing stump of the left renal vein.

In cases where a level III thrombus is free floating, 
the thrombus can be extracted via an infrahepatic-only 
cavotomy similar to patients with level II VTT.

Thrombectomy in Patients with 
Supradiaphragmatic (Level IV) Tumor 
Thrombus
In general, the approaches used for supradiaphragmatic 
thrombectomy can be divided into those that use 
any type of circulatory support, and those that avoid 
it. No surgical method was shown to be superior for 
the excision of VTT. Most patients with nonadherent 
intraatrial thrombus can be managed without circula-
tory support[45–47].

FIGURE 1. 

Radical nephrectomy with thrombectomy in cT3bN0M0 RCC of the right kidney with level IV tumor thrombus 

1A   Tourniquets are closed on the infrarenal IVC and RRV;  
Satinsky clamp is positioned above the thrombus.

1B   IVC is incised, and tumor thrombus is visualized in the IVC lumen.IVC: 
inferior vena cava; LRV: left renal vein; RCC: renal cell carcinoma;  
RRV: right renal vein

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From a practical point of view, level IV thrombi 
can be subdivided into intrapericardial and intraatrial 
VTT. The first steps of the procedures are the same for 
either case, and follow the techniques described above 
for patients with level III tumor thrombi. In patients 
with intrapericardial thrombus only, there is no need 
for complete mobilization of the intrapericardial IVC. 
Instead, only incisions of the pericardium on both sides 
of the intrapericardial IVC are performed for tourniquet 
placement.

On the contrary, in the case of an intraatrial throm-
bus, the intrapericardial IVC needs to be completely 
mobilized so that it can be encircled at the cavoatrial 
junction. The diaphragm at the IVC hiatus must be 
completely mobilized from the IVC to widen the natu-
ral narrowing for safer extraction of the thrombus from 
the right atrium (Figure 3A) The upper tourniquet on 
the intrapericardial IVC is left unclamped until the 
apex of the thrombus is removed from the heart. After 
all other tourniquets are sequentially clamped with a 
Pringle maneuver, the incision of the retrohepatic IVC is 

continued up to the cavoatrial junction. The thrombus is 
gently mobilized from the retrohepatic IVC (Figure 3B). 
If the head of the thrombus is mobile, the retrograde 
blood f low from the right atrium will evacuate the 
thrombus. If the thrombus is adherent to the vessel wall, 
the incision is extended on the intrapericardial IVC and 
the thrombus is resected from the intima of the intra-
pericardial IVC under direct visualization. In the case 
of a large head of the tumor thrombus, the incision may 
even be extended 5 to 10 mm on the right atrium wall 
(Figure 4). As soon as the thrombus is evacuated from 
the right atrium and the intrapericardial IVC, the upper 
tourniquet is closed. The rest of the procedure progresses 
as described above for patients with level III thrombus.

The majority of cases with level IV thrombus can be 
managed without circulatory support unless the head of 
the thrombus is too bulky for removal without perform-
ing wide atriotomy. Thrombi that have a long history 
of surveillance and those that shrank after preoper-
ative systemic therapy may be adherent to the vessel 
wall. Removal of the thrombus in these patients may be 

FIGURE 2. 

Radical nephrectomy with thrombectomy in cT3bN0M0 RCC of the right kidney with level III tumor thrombus 

2A   Mobilization of the liver. Several short hepatic veins have been 
divided (green arrows). Tourniquets have been applied to the 
infrarenal IVC, left renal vein, and intrapericardial IVC. 2B   Surgical specimen: kidney with the tumor thrombus en bloc.

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associated with excessive blood loss. Circulatory support 
in these circumstances helps to maintain hemodynamic 
stability.

Thrombectomy in Patients with Tumor IVC 
Wall Invasion and/or Descending Bland 
Thrombosis
Vena cava resection is required in cases where the wall 
of the IVC is directly invaded by tumor. Repairs of the 
IVC include primary repair by venorrhaphy, prosthetic 
and autologous patch repair, and circumferential 
complete IVC replacement. In the majority of cases, 
resection of the dilated part of IVC does not result in 
clinically significant IVC narrowing, and primary 
cavorraphy is preferred. Indications for prosthetic repair 
include narrowing of IVC of > 50%. However, grafts 
expose patients to an increased risk for infection and 
thrombosis. Therefore, the optimal management of the 
IVC after resection is controversial[47].

Descending thrombosis in patients with RCC and 
VTT is quite frequent and occurs in 9.8% of patients[48]. 
Bland infrarenal IVC thrombus carries the risk for 
embolization, and recurrence from residual tumor cells, 
which can be found in 16% at the margin of tumor and 
bland thrombus. IVC interruption or segmental resec-
tion is required in most of the cases. The infrarenal IVC 
can be safely resected without reconstruction below the 
level of the proximal bland thrombus or just above the 
IVC bifurcation without any consequences[46,48–50]. 

FIGURE 3. 

Radical nephrectomy with thrombectomy in cT3bN0M0 
RCC of the left kidney with level II tumor thrombus 

3A.  Tourniquet on the intrapericardial IVC.

3B.   The cephalad part of the thrombus is evacuated from the IVC lumen. IVC: inferior vena cava; RCC: renal cell carcinoma.

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Most authors indicate that lower-extremity edema after 
ligation of the IVC occurs rarely, is well tolerated, and 
resolves spontaneously[49,50].

The suprarenal IVC can be safely resected with liga-
tion of the left renal vein in patients with right-sided 
RCC with VTT. The collateral venous return from 
the left kidney is sufficient to preserve normal renal 

function. Thus, resection of the IVC en bloc with right-
sided RCC and tumor thrombus from the level of the 
major hepatic veins to the level of IVC bifurcation (en 
bloc cavectomy) can be performed without reconstruc-
tion[20,48] (Figure 5).

In patients with left-sided RCC, the right renal vein 
must be spared to preserve adequate venous drainage 
from the kidney.

Minimally Invasive Radical Nephrectomy and 
IVC Thrombectomy
Since the first report of laparoscopic IVC thrombectomy 
in 2000, numerous studies have highlighted the 
feasibility of minimally invasive techniques[51–62].

Most minimally invasive IVC thrombectomies have 
been performed on right-sided renal tumors[52]. Some 
have advocated that in individuals with left-sided renal 
tumors, preoperative arterial embolization may be bene-
ficial due to the limited access to the left renal artery 
while the patient is in the flank position with the right 

FIGURE 4. 

Radical nephrectomy with thrombectomy in cT3bN0M0 RCC of the right kidney with large intraatrial level IV  
tumor thrombus 

4A.   CT scan shows large intraatrial thrombus.

4B.   Surgical Specimen: right kidney with tumor thrombus  
removed en bloc.

4C.   Suture line on the intrapericardial IVC ending at the cavoatrial 
junction.

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side up[57]. Regardless of the tumor laterality and the 
decision regarding embolization, the “thrombus first” 
approach is necessary: the IVC thrombectomy should be 
completed prior to nephrectomy.

Most surgeons performing minimally invasive IVC 
thrombectomies prefer a transperitoneal approach. 
Applied in both pure laparoscopic and robot-assisted 
techniques, a transperitoneal approach may be used for 
thrombi associated with both right- and left-sided renal 
tumors[57,58]. Regardless of the laterality of the renal 
mass, the patient is placed in the left lateral decubitus 
position with the right side up. A12-mm camera port is 
inserted with additional three or four ports placed in a 
paramedian or mid-clavicular vertical line. Typically, 
one small port is placed at the sub-xiphoid region for 
liver retraction as well as an additional 12-mm assistant 
port[52,57,62,63]. The dissection is begun with an inci-
sion to the posterior peritoneum, followed by mobiliza-
tion of the colon medially, duodenal kocherization, and 
exposure of the IVC and the renal vessels[51,52,61–66].

Minimally Invasive Level 0-I-II Thrombectomy
Early arterial ligation may help to slightly reduce the 
size of the thrombus. Ligation of the renal artery (with 
either an endo-GIA stapler or Hem-o-lok clips) may be 
performed at the hilum or in the interaortocaval space.

For thrombi limited to the renal vein, the latter may 
become f lattened and allow for the thrombus to be 
“milked” away from the IVC. An interoperative US is help-
ful to identify of the extent of the thrombus[58,67]. For 
left-sided level I tumor thrombi, one should consider doing 
the surgery in the right lateral decubitus (if th  e thrombus 
appears that it can be milked away from the IVC).

For IVC thrombi projecting less than 2 cm into the 
IVC, dissection of the contralateral renal vein and 
preplacement of a vessel loop with a secured Hem-o-lock 
clip (Rummel tourniquet) for later identification and 
cinching is often performed[68]. Simple use of laparo-
scopic bulldogs can be safely performed to cross-clamp 
the cava and contralateral vein[66].

FIGURE 5. 

En bloc resection of the IVC with RCC and associated caval thrombus

LRV

IVC
Bifurcation

Main
Hepatic Veins

5A.   Schema.

5B.   Surgical specimen: resected IVC with tumor thrombus en bloc with 
the kidney. Resected IVC: pink arrow; tumor thrombus: blue arrow. 
IVC: inferior vena cava; LRV: left renal vein; RCC: renal cell 
carcinoma.

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Similar to level 0 thrombi, VTT exclusion with exci-
sion of a small IVC cuff surrounding the renal vein 
ostium may be employed via the laparoscopic Satinsky 
clamp and vascular stapler[52,69]. For larger level I and 
level II thrombi, the IVC must be cross-clamped and the 
right adrenal vein may require ligation. For right-sided 
thrombi, Rummel tourniquets or the vascular bulldogs 
should be cinched in the following order: (1) infrare-
nal IVC, (2) left renal vein, and (3) suprarenal IVC. For 
left-sided thrombi, the right renal artery should also 
be controlled with a vascular bulldog to prevent right 
renal engorgement[62]. Incision of the IVC is performed 
until the cephalad extent of the thrombus is delivered. 
The renal vein is circumferentially excised at the level 
of the ostium of the IVC. Upon thrombus removal, 
irrigation of the IVC lumen with heparinized saline is 
performed[52,55,60,69]. Closure of the IVC with 4–0 
prolene sutures in a single layer allows for excellent 
hemostasis.

Minimally Invasive Level III Thrombectomy
Initially performed by Bratslavsky and Cheng in March 
of 2013 for an 11-cm IVC thrombus, this surgery 
remains technically demanding and dangerous[51].

Incision of the right triangular ligament and cephalad 
retraction of the liver will expose the retrohepatic IVC. 
Short hepatic veins from the caudate lobe can be ligated 
using laparoscopic clips[51,56]. Rummel tourniquets are 
cinched in the same order as in cases of level II thrombi.

For left-sided thrombi, transecting the ipsilat-
eral renal vein with an endo-GIA vascular stapler is 
often employed, as the rest of the left renal vein will be 
removed with the specimen[57]. Upon en bloc throm-
bus removal with the renal vein stump closure of the 
cavatomy is performed with restoration of blood flow 
via the IVC. The patient is then repositioned and the left 
nephrectomy is completed.

Results of Surgical Management of RCC 
with VTT 
Invasion of the venous system by RCC has long 
been associated with a poor prognosis[70]. However, 
the ability to provide a durable cure for some RCC 
patients provided a rationale for aggressive surgical 
management[71].

A systematic review of surgery for RCC with IVC 
thrombus cited major perioperative complication rates 
as high as 70% and perioperative mortality rates ranging 
from 3% to 16%[72].

Most data demonstrate increased mortality as throm-
bus height increases, with higher mortality observed 
in patients with IVC thrombus that extends above the 
diaphragm or above the hepatic conf luence of veins 

(Neves/Mayo level III and IV)[14]. Early mortality rates 
from notable studies range from 8% to 22%[8,11,12,73–76].

No difference in mortality was observed between 
centers or among patients treated with cardiopulmonary 
bypass, similar to later reports[73]. Hospital volume 
and surgeon volumes are associated with early mortal-
ity[77–79]. Patients with metastatic RCC have a signifi-
cantly worse prognosis compared to locally advanced 
RCC, with a cumulative mortality of 32% in the  
9 months following surgery for metastatic patients[80].

Perioperative Complications
In population-level data, Toren et al. estimated the 
overall complication rate to be 78% in 633 patients 
treated with nephrectomy and IVC thrombectomy, 
including a 37% rate of surgical complications[79]. 
Similar overall rates of complications have been reported 
at large centers[72,81], with Blute et al. demonstrating 
that 30-day complication rates varied from 9% to 30% 
stratifying from thrombus level 0 to IV[28].

Commonly reported intraoperative complications 
include hemorrhage, injury of adjacent structures, and 
cardiac events[28]. Tumor thrombus embolization is a 
feared complication that occurs in 1.5% of patients and 
is associated with a reported 75% risk for mortality[82]. 
Early postoperative complications include hemor-
rhage requiring transfusion, venous thromboembolic 
events, cardiac events, pulmonary events, renal fail-
ure, and infectious complications. Late complications 
may include lower-extremity edema, chronic renal 
insufficiency, and incisional hernia[28]. Independent 
predictors of major complications include preoperative 
systemic symptoms (weight loss or fatigue) and throm-
bus level[83]. Use of cardiac bypass or deep hypothermic 
cardiac arrest was not identified as a predictor of major 
complications in this study[83] or subsequent analy-
ses[73]. Complication rates are lower at higher-volume 
centers[77] and with more experienced surgeons[79].

Oncologic Outcomes
Managed expectantly, RCC with VTT is associated with 
a median survival of 5 months with increased risk for 
cancer-specific mortality observed with pT3b/c and 
metastatic disease[84]. In a population-based study of 
patients treated with nephrectomy and venous tumor 
thrombectomy, 1-year overall survival in patients with 
localized disease was 90%[85]. A 5-year, cancer-specific 
mortality in patients with RCC and VTT ranges from 
40% to 60%[28,86–88]. Prognostic factors associated 
with cancer-specific mortality include increasing level 
of VTT, nodal and systemic metastases, advanced 
Fuhrman grade, non-clear cell histology, and increasing 
tumor size[10,81,82,86,89–91].

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Conclusion
Renal cell carcinoma with venous thrombus provides 
a fascinating example of seemingly implausible tumor 
biology. Although these aggressive tumors have acquired 
the ability to invade and shed tumor cells into the largest 
blood vessel in the human body, some patients do not 
develop metastatic disease and may be cured when 
treated with definitive, aggressive surgery resulting in 
complete extirpation.

Surgery for RCC with venous thrombus is complex 
and requires experienced multidisciplinary surgi-
cal, anesthesia, and critical care teams at high-volume 
centers to achieve ideal outcomes. The use of presur-
gical and postsurgical systemic therapies is likely to 
increase with advances in systemic therapy in the future 
and represents a high-priority area for contemporary 
investigation.

References 

1. Ali AS, Vasdev N, Shanmuganathan S, Paez E, Dark JH, Manas 
D, et al. The surgical management and prognosis of renal cell 
cancer with IVC tumour thrombus: 15-years of experience using 
a multi-specialty approach at a single UK referral center. Urol 
Oncol.2013;31(7):1298-1304.

2. Amin MB, Greene F, Edge S, Compton CC, Gershenwald JE, Brookland 
RK, et al. AJCC Cancer Staging Manual. 8 ed: Springer International 
Publishing; 2017.

3. Marshall FF. Surgery of renal cell carcinoma with inferior vena caval 
involvement. Semin Urol. 1989;7(3):186-190.

4. Slaton JW, Balbay MD, Levy DA, Pisters LL, Nesbitt JC, Swanson DA, 
et al. Nephrectomy and vena caval thrombectomy in patients with 
metastatic renal cell carcinoma. Urology.1997;50(5):673-677.

5. Kim HL, Zisman A, Han KR, Figlin RA, Belldegrun AS. Prognostic 
significance of venous thrombus in renal cell carcinoma. Are renal 
vein and inferior vena cava involvement different? J Urol.2004;171(2 
Pt 1):588-591.

6. Moinzadeh A, Libertino JA. Prognostic significance of tumour 
thrombus level in patients with renal cell carcinoma and VTTombus 
extension. Is all T3b the same? J Urol.2004;171(2 Pt 1):598-601.

7. Sosa RE, Muecke EC, Vaughan ED Jr, McCarron JP Jr. Renal 
cell carcinoma ex tending into the inferior vena cava: the 
prognostic significance of the level of vena caval involvement.  
J Urol.1984;132(6):1097-1100.

8. Wagner B, Patard JJ, Méjean A, Bensalah K, Verhoest G, Zigeuner V,  
et al. Prognostic value of renal vein and inferior vena cava involvement 
in renal cell carcinoma. Eur Urol.2009;55(2):452-459.

9. Boorjian SA, Blute ML. Surgery for vena caval tumour extension in 
renal cancer. Curr Opin Urol. 2009;19(5):473-477.

10. 0. Boorjian SA, Sengupta S, Blute ML. Renal cell carcinoma: vena caval 
involvement. BJU Int.2007;99(5 Pt B):1239-1244.

11. Granberg CF, Boorjian SA, Schaff HV, Orszulak TA, Leibovich BC, Lohse 
CM, et al. Surgical management, complications, and outcome of radical 
nephrectomy with inferior vena cava tumour thrombectomy facilitated 
by vascular bypass. Urology.2008;72(1):148-152.

12. Blute ML, Boorjian SA, Leibovich BC, Lohse CM, Frank I, Karnes RJ. 
Results of inferior vena caval interruption by greenfield filter, ligation 
or resection during radical nephrectomy and tumour thrombectomy.  
J Urol.2007;178(2):440-445; discussion 444.

13. Chiappini B, Savini C, Marinelli G, Martin Suarez S, Di Eusanio M, 
Fiorani V, et al. Cavoatrial tumour thrombus: single-stage surgical 
approach with profound hypothermia and circulatory arrest, including a 
review of the literature. J Thorac Cardiovasc Surg.2002;124(4):684-688.

14. Neves RJ, Zincke H. Surgical treatment of renal cancer with vena cava 
extension. BJU Int.1987;59(5):390-395.

15. Gohji K, Yamashita C, Ueno K, Shimogaki H, Kamidono S. Preoperative 
computerized tomography detection of extensive invasion of the 
inferior vena cava by renal cell carcinoma: possible indication for 
resection with partial cardiopulmonary bypass and patch grafting. J 
Urol.1994;152(6 Pt 1):1993-1996; discussion 1997.

16. Psutka SP, Boorjian SA, Thompson RH, Schmit GD, Schmitz JJ, Bowere 
TC, et al. Clinical and radiographic predictors of the need for inferior 
vena cava resection during nephrectomy for patients with renal cell 
carcinoma and caval tumour thrombus. BJU Int.2015;116(3):388-396.

17. Hutchinson R, Rew C, Chen G, Woldu S, Krabbe L-M, Mieissner M, et 
al. The adverse survival implications of bland thrombus in renal cell 
carcinoma with venous tumor thrombus. Urology. 2018;115:119-124.

18. Wang H, Li X, Huang Q, Panic A, Shen D, Jia W, et al. Prognostic 
role of bland thrombus in patients treated with resection of renal 
cell carcinoma with inferior vena cava tumour thrombus. Urol Oncol. 
2021;39(5):302.e301-302.e307.

19. Liu Z, Li L, Hong P, Zhu G, Tang S, Zhao X, et al. A predictive model 
for tumour invasion of the inferior vena cava wall using multimodal 
imaging in patients with renal cell carcinoma and inferior vena cava 
tumour thrombus. Biomed Res Int.2020;2020:9530618.

20. Weiss VL, Braun M, Perner S, Harz A, Vorreuther R, Kristiansen G, et 
al. Prognostic significance of VTT consistency in patients with renal 
cell carcinoma (RCC). BJU Int.2014;113(2):209-217.

21. Bertini R, Roscigno M, Freschi M, Strada E, Angiolilli D, Petralia G, et al. 
Impact of VTT consistency (solid vs friable) on cancer-specific survival 
in patients with renal cell carcinoma. Eur Urol.2011;60(2):358-365.

460 SIUJ  •  Volume 3, Number 6  •  November 2022 SIUJ.ORG

2022 WUOF/SIU INTERNATIONAL CONSULTATION ON UROLOGICAL DISEASES

http://SIUJ.org


22. Psutka SP, Leibovich BC. Management of inferior vena cava tumour 
thrombus in locally advanced renal cell carcinoma. Ther Adv 
Urol.2015;7(4):216-229.

23. Ciancio G, Soloway M. Renal cell carcinoma invading the hepatic veins. 
Cancer.2001;92(7):1836-1842.

24. Ciancio G, Vaidya A, Savoie M, Soloway M. Management of renal 
cell carcinoma with level III thrombus in the inferior vena cava.  
J Urol.2002;168(4 Pt 1):1374-1377.

25. Kume H, Kameyama S, Kasuya Y, Tajima A, Kawabe K. Surgical 
treatment of renal cell carcinoma associated with Budd-Chiari 
syndrome: report of four cases and review of the literature. Eur J 
Surg Oncol.1999;25(1):71-75.

26. Lessard L, Bach D, Wall W, Luke PP. Intrahepatic extension of renal 
cell carcinoma tumour thrombus causing Budd-Chiari syndrome. Can 
Urol Assoc J.2011;5(6):383-384.

27. Abel EJ, Thompson RH, Margulis V, Heckman JE, Merril MM, Darwish 
OM, et al. Perioperative outcomes following surgical resection of 
renal cell carcinoma with inferior vena cava thrombus extending 
above the hepatic veins: a contemporary multicenter experience. Eur 
Urol.2014;66(3):584-592.

28. Blute ML, Leibovich BC, Lohse CM, Cheville JC, Zincke H. The 
Mayo Clinic experience with surgical management, complications 
and outcome for patients with renal cell carcinoma and V TT. BJU 
Int.2004;94(1):33-41.

29. Parekh DJ, Cookson MS, Chapman W, Harrell F Jr, Wells N, Chang 
SS, et al. Renal cell carcinoma with renal vein and inferior vena caval 
involvement: clinicopathological features, surgical techniques and 
outcomes. J Urol.2005;173(6):1897-1902.

30. Kapur S, Paik E, Rezaei A, Vu DN. Where there is blood, there is a 
way: unusual collateral vessels in superior and inferior vena cava 
obstruction. Radiographics.2010;30(1):67-78.

31. Wotkowicz C, Wszolek MF, Libertino JA. Resection of renal tumours 
invading the vena cava. Urol Clin North Am.2008;35(4):657-671; viii.

32. Lawindy SM, Kurian T, Kim T, Mangar D, Armstrong PA, Alsina AE, et 
al. Important surgical considerations in the management of renal cell 
carcinoma (RCC) with inferior vena cava (IVC) tumour thrombus. BJU 
Int.2012;110(7):926-939.

33. Woodruff DY, Van Veldhuizen P, Muehlebach G, Johnson P, Williamson 
T, Holzbeierlein JM. The perioperative management of an inferior vena 
caval tumour thrombus in patients with renal cell carcinoma. Urol 
Oncol.2013;31(5):517-521.

34. Guo HF, Song Y, Na YQ. Value of abdominal ultrasound scan, CT and 
MRI for diagnosing inferior vena cava tumour thrombus in renal cell 
carcinoma. Chin Med J (Engl). 2009;122(19):2299-2302.

35. Calderone CE, Tuck BC, Gray SH, Porter KK, Rais-Bahrami S. The role 
of transesophageal echocardiography in the management of renal cell 
carcinoma with VTTombus. Echocardiography. 2018;35(12):2047-2055.

36. Cost NG, Delacroix SE Jr, Sleeper JP, Smith PJ, Youssef RF, Chapin BF, et 
al. The impact of targeted molecular therapies on the level of renal cell 
carcinoma vena caval tumour thrombus. Eur Urol.2011;59(6):912-918.

37. Bigot P, Fardoun T, Bernhard JC, Xylinas E, Berger J, Rouprêt M, et 
al. Neoadjuvant targeted molecular therapies in patients undergoing 
nephrectomy and inferior vena cava thrombectomy: is it useful? World 
J Urol.2014;32(1):109-114.

38. Peng C, Gu L, Wang L, Huang Q, Wang B, Guo G, et al. Role of 
presurgical targeted molecular therapy in renal cell carcinoma with an 
inferior vena cava tumour thrombus. OncoTargets Ther.2018;11:1997-
2005. doi:10.2147/OTT.S158114

39. Fukuda H, Kondo T, Takagi T, Iizuka J, Nagashima Y, Tanabe K. Limited 
benefit of targeted molecular therapy for inferior vena cava thrombus 
associated with renal cell carcinoma. Int J Clin Oncol.2017;22(4):767-
773. doi:10.1007/s10147-017-1119-9

40. Ujike T, Uemura M, Kawashima A, Nagahara A, Fujita K, Miyagawa Y, 
et al. Clinical and histopathological effects of presurgical treatment 
with sunitinib for renal cell carcinoma with inferior vena cava tumour 
thrombus at a single institution. Anticancer Drugs.2016;27(10):1038-
1043. doi:10.1097/CAD.0000000000000422

41. Horn T, Thalgott MK, Maurer T, Hauner K, Schulz S, Fingerle A, et 
al. Presurgical treatment with sunitinib for renal cell carcinoma 
with a level III/ IV vena cava tumour thrombus. Anticancer 
Res.2012;32(5):1729-1735.

42. Tanaka Y, Hatakeyama S, Hosogoe S, Tanaka T, Hamano I, Kusaka A, 
et al. Presurgical axitinib therapy increases fibrotic reactions within 
tumour thrombus in renal cell carcinoma with thrombus extending to 
the inferior vena cava. Int J Clin Oncol.2018;23(1):134-141. doi:10.1007/
s10147-017-1169-z

43. Terakawa T, Hussein AA, Bando Y, Guru KA, Furukawa J, Shigemura 
K, et al. Presurgical pazopanib for renal cell carcinoma with 
inferior vena caval thrombus: a single-institution study. Anticancer 
Drugs.2018;29(6):565-571. doi:10.1097/CAD.0000000000000627

44. Stewart GD, Welsh SJ, Ursprung S, Gallagher FA, Mendichovszky 
I, Riddick A, Eisen T, et al. NAXIVA: A phase II neoadjuvant study of 
axitinib for reducing extent of VTTombus in clear cell renal cell cancer 
(RCC) with venous invasion. J Clin Oncol.2021;39(6_suppl):275-275. 
doi:10.1200/JCO.2021.39.6_suppl.275

45. Skinner DG, Pritchett TR, Lieskovsky G, Boyd SD, Stiles QR. Vena 
caval involvement by renal cell carcinoma. Surgical resection provides 
meaningful long-term survival. Ann Surg.1989 Sep;210(3):387-392; 
discussion 392-4. doi: 10.1097/00000658-198909000-00014. PMID: 
2774709; PMCID: PMC1358008.

46. Ciancio G, Livingstone AS, Soloway M. Surgical management of renal 
cell carcinoma with tumour thrombus in the renal and inferior vena 
cava: the University of Miami experience in using liver transplantation 
techniques. Eur Urol.2007 Apr;51(4):988-94; discussion 994-5. doi: 
10.1016/j.eururo.2006.11.055. Epub 2006 Dec 8. PMID: 17175095

461SIUJ.ORG SIUJ  •  Volume 3, Number 6  •  November 2022

Management of Locally Advanced Renal Cell Carcinoma

http://SIUJ.org


47. Dav ydov MI, Mat veev VB. Surgical management of renal cell 
carcinoma with tumour thrombosis of renal vein and inferior vena 
cava. Cancer Urology.2005;1(2):8-15. 

48. Dav ydov MI, Matveev VB, Volkova MI, et al. Predictors of the 
immediate results of thrombectomy in kidney cancer patients with 
venous tumour thrombosis.  Cancer Urology. 2014;10(3):31-39.  

49. Daylami R, Amiri A, Goldsmith B, Troppmann C, Schneider PD, Khatri 
VP. Inferior vena cava leiomyosarcoma: is reconstruction necessary 
after resection? J Am Coll Surg.2010 Feb;210(2):185-190. doi: 10.1016/j.
jamcollsurg.2009.10.010. PMID: 20113938.

50. Ayyathurai R, Garcia-Roig M, Gorin MA, González J, Manoharan M, 
Kava BR, et al. Bland thrombus association with tumour thrombus 
in renal cell carcinoma: analysis of surgical significance and role of 
inferior vena caval interruption. BJU Int.2012 Dec;110(11 Pt B):E449-
55. doi: 10.1111/j.1464-410X.2012.11128.x. Epub 2012 Apr 30. PMID: 
22540981

51. Bratslavsky G, Cheng JS. Robotic-assisted radical nephrectomy with 
retrohepatic vena caval tumour thrombectomy (Level III) combined 
with extended retroperitoneal lymph node dissection. Urology.2015 
Dec;86(6):1235-40. doi: 10.1016/j.urology.2015.05.042. Epub 2015 
Aug 5. PMID: 26254172.

52. Sun Y, de Castro Abreu AL, Gill IS. Robotic inferior vena cava thrombus 
surger y: novel strategies. Curr Opin Urol.2014;24 (2):140 –147. 
doi:10.1097/MOU.000000000000003 

53. Varkarakis IM, Bhayani SB, Allaf ME, Inagaki T, Gonzalgo ML, Jarrett 
TW. Laparoscopic-assisted nephrectomy with inferior vena cava tumor 
thrombectomy: preliminary results. Urology.2004;64(5):925–929. 
doi:10.1016/j.urology.2004.05.044 

54. Kovac JR, Luke PP. Hand-assisted laparoscopic radical nephrectomy 
in the treatment of a renal cell carcinoma with a level II vena 
cava thrombus. Int Braz J Urol.2010;36(3):327–331. doi:10.1590/ 
s1677-55382010000300009 

55. Shao P, Li J, Qin C, Lv Q, Ju X, Li P, et al. Laparoscopic radical 
nephrectomy and inferior vena cava thrombectomy in the treatment 
of renal cell carcinoma. Eur Urol.2015;68(1):115–122. doi:10.1016/j.
eururo.2014.12.011 

56. Ramirez D, Maurice MJ, Cohen B, Krishnamurthi V, Haber, G-P. Robotic 
level III IVC tumor thrombectomy: duplicating the open approach. 
Urology.2016;90:204–247. doi:10.1016/j.urology.2016.01.011 

57. Gill IS, Metcalfe C, Abreu A, Duddalwar V, Chopra S, Cunningham M, 
et al. Robotic level III inferior vena cava tumor thrombectomy: initial 
series. J Urol.2015;194(4):929–938. doi:10.1016/j.juro.2015.03.119 

58. Savage SJ, Gill IS. Laparoscopic radical nephrectomy for renal cell 
carcinoma in a patient with level I renal vein tumor thrombus. J 
Urol.2000;163(4):1243–1244. 

59. Fergany AF, Gill IS, Schweizer DK, Kaouk JH, ElFettouh HA, Cherullo 
EE, et al. Laparoscopic radical nephrectomy with level II vena caval 
thrombectomy: survival porcine study. J Urol.2002;168(6):2629–2631. 
doi:10.1097/01. ju.0000034999.02786.9a 

60. Abaza R, Shabsigh A, Castle E, Allaf M, Hu JC, Rogers C, Memon 
M, et al. Multi-institutional experience with robotic nephrectomy 
with inferior vena cava tumor thrombectomy. J Urol.2016:195(4 Pt 
1):865–871. doi:10.1016/j.juro.2015.09.094 

61. Abaza R. Initial series of robotic radical nephrectomy with vena caval 
tumor thrombectomy. Eur Urol.2011;59(4):652–656. doi:10.1016/j.
eururo.2010.08.038 

62. Wang B, Li H, Ma X, Zhang X, Gu L, Li X, et al. Robot-assisted 
laparoscopic inferior vena cava thrombectomy: different sides require 
different techniques. Eur Urol.2016;69(6):1112–1119. doi:10.1016/j.
eururo.2015.12.001 

63. Romero FR, Muntener M, Bagga HS, Brito FAR, Sulman A, Jarrett 
T W. Pure laparoscopic radical nephrectomy with level II vena 
caval thrombectomy. Urology.2006;68(5):1112–1114. doi:10.1016/j.
urology.2006.08.1084 

64. Ball MW, Gorin MA, Jayram G, Pierorazio PM, Allaf ME. Robot-assisted 
radical nephrectomy with inferior vena cava tumor thrombectomy: 
technique and initial outcomes. Can J Urol.2015;22(1):7666–7670. 

65. Gupta NP, Ansari MS, Khaitan A, Sivaramakrishna MS, Hemal AK, 
Dogra PN, et al. Impact of imaging and thrombus level in management 
of renal cell carcinoma extending to veins. Urol Int.2004;72(2):129–134. 
doi:10.1159/000075966 

66. Scott K, Manwaring J, Amankwah K, Bratslavsky G. Robotic assisted 
caval replacement for recurrent renal cell carcinoma invading the wall 
of the inferior vena cava. Urology.2022;161:131–134. doi:10.1016/j. 
urology.2021.11.027 

67. Desai MM, Gill IS, Ramani AP, Matin SF, Kaouk JH, Campero JM, et 
al. Laparoscopic radical nephrectomy for cancer with level I renal 
vein involvement. J Urol.2003;169(2):487– 491. doi:10.1097/01.
ju.0000041955.93458.f5 

68. Ball MW, Gorin MA, Jayram G, Pieroazio PM, Allaf M. Robot-assisted 
radical nephrectomy with inferior vena cava tumor thrombectomy: 
technique and initial outcomes. Can J Urol.2015;22(1):7666–7670. 

69. Lee JY, Mucksavage P. Robotic radical nephrectomy with vena caval 
tumor thrombectomy: experience of novice robotic surgeons. Korean 
J Urol.2012;53(12):879–882. doi:10.4111/kju.2012.53.12.879 

70. Riches EW, Griffiths, IH, Thackray AC. New growths of the kidney and 
ureter. Br J Urol.1951;23(4):297–356. doi:10.1111/j.1464-410x.1951.
tb03625.x 

462 SIUJ  •  Volume 3, Number 6  •  November 2022 SIUJ.ORG

2022 WUOF/SIU INTERNATIONAL CONSULTATION ON UROLOGICAL DISEASES

http://SIUJ.org


71. 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(5):711–716. doi:10.1016/s0022-5347(17)61122-4 

72. Kirkali Z, Van Poppel H. A critical analysis of surgery for kidney cancer 
with vena cava invasion. Eur Urol.2007;52(3):658–662. doi:10.1016/j.
eururo.2007.05.009 

73. Nguyen HG, Tilki D, Dall’Era MA, Durbin-Johnson B, Carballido JA, 
Chandrasekar T, et al. Cardiopulmonary bypass has no significant 
impact on survival in patients undergoing nephrectomy and level 
III-IV inferior vena cava thrombectomy: multi-institutional analysis. J 
Urol.2015;194(2):304–308. doi:10.1016/j.juro.2015.02.2948 

74. Shuch B, Crispen PL, Leibovich BC, LaRochelle JC, Pouliot F, 
Pantuck AJ, et al. Cardiopulmonary bypass and renal cell carcinoma 
with level IV tumour thrombus: can deep hypothermic circulatory 
arrest limit perioperative mortality? BJU Int.2011;107(5):724–728. 
doi:10.1111/j.1464-410X.2010.09488.x 

75. Ciancio G, Gonzalez J, Shirodkar SP, Angulo JC, Soloway MS. Liver 
transplantation techniques for the surgical management of renal 
cell carcinoma with tumor thrombus in the inferior vena cava: step-
by-step description. Eur Urol.2011;59(3):401– 406. doi:10.1016/j.
eururo.2010.07.028 

76. Casey RG, Raheem OA, Elmusharaf E, Madhavan P, Tolan M, Lynch TH. 
Renal cell carcinoma with IVC and atrial thrombus: a single centre’s 10 
year surgical experience. Surgeon.2013;11(6):295–299. doi:10.1016/j.
surge.2013.02.007 

77. Hsu RCJ, SalikaT, Maw J, Lyratzopoulos G, Gnanapragasam VJ, 
Armitage JN. Influence of hospital volume on nephrectomy mortality 
and complications: a systematic review and meta-analysis stratified 
by surgical t ype. BMJ Open. 2017;7(9):e016833. doi:10.1136/ 
bmjopen-2017-016833 

78. Yap SA, Horovitz D, Alibhai SM, Abouassaly R, Timilshina N, Finelli 
A. Predictors of early mortality after radical nephrectomy with renal 
vein or inferior vena cava thrombectomy - a population-based study. 
BJU Int.2012;110(9):1283–1288. doi:10.1111/j.1464-410X.2012.11125.x 

79. Toren P, Abouassaly R, Timilshina N, Kulkarni G, Alibhai S, Finelli A. 
Results of a national population-based study of outcomes of surgery 
for renal tumors associated with inferior vena cava thrombus. 
Urology.2013;82(3):572– 577. doi:10.1016/j.urology.2013.04.054 

80. Abel EJ, Spiess PE, Margulis V, Master VA, Mann M, Zargar-Shostari 
K, et al. Cytoreductive nephrectomy for renal cell carcinoma with 
venous tumor thrombus. J Urol.2017;198(2):281–288. doi:10.1016/j.
juro.2017.03.011 

81. Martinez-Salamanca JI, Linares E, González J, Bertini R, Carballido 
JA, Chromecki T, et al. Lessons learned from the International Renal 
Cell Carcinoma-Venous Thrombus Consortium (IRCC-VTC). Curr Urol 
Rep.2014;15(5):404. doi:10.1007/ s11934-014-0404-7 

82. Shuch B, Larochelle JC, Onyia T, Vallera C, Margulis D, Pantuck AJ, 
et al. Intraoperative thrombus embolization during nephrectomy and 
tumor thrombectomy: critical analysis of the University of California-
Los Angeles experience. J Urol.2009;181(2):492–498; discussion 
498-499. doi:10.1016/j.juro.2008.10.036 

83. Abel EJ, Thompson RH, Margulis V, et al. Perioperative outcomes 
following surgical resection of renal cell carcinoma with inferior vena 
cava thrombus extending above the hepatic veins: a contemporary 
multicenter experience. Eur Urol.2014;66(3):584–592. doi:10.1016/j.
eururo.2013.10.029 

84. Reese AC, Whitson JM, Meng MV. Natural history of untreated 
renal cell c ar cinoma wit h venous t umor t hrombus. Urol 
Oncol.2013;31(7):1305–1309. doi:10.1016/j.urolonc.2011.12.006 

85. Whitson J M, Reese AC, Meng MV. Population based analysis 
of sur vival in patients with renal cell carcinoma and venous 
tumor thrombus. Urol Oncol.2013;31(2):259 –263. doi:10.1016/j.
urolonc.2010.11.017 

86. Haddad AQ, Wood CG, Abel EJ, Krabbe L-M, Darwish OM, Thompson 
RH, et al. Oncologic outcomes following surgical resection of 
renal cell carcinoma with inferior vena caval thrombus extending 
above the hepatic veins: a contemporar y multicenter cohor t.  
J Urol.2014;192(4):1050–1056. doi:10.1016/j.juro.2014.03.111 

87. Hirono M, Kobayashi M, Tsushima T, Obara W, Shinohara N, Ito K, 
et al.; Members of the Japanese Society of Renal Cancer. Impacts 
of clinicopathologic and operative factors on short-term and long-
term survival in renal cell carcinoma with venous tumor thrombus 
extension: a multi-institutional retrospective study in Japan. BMC 
Cancer.2013;13:447. doi:10.1186/1471-2407-13-447 

88. Pouliot F, Shuch B, Larochelle JC, Panticuk A, Belledegrun AS. 
Contemporary management of renal tumors with venous tumor 
thrombus. J Urol.2010;184(3):833–841; quiz 1235. doi:10.1016/j.
juro.2010.04.071 

89. Martinez-Salamanca JI, Huang WC, Millan I, Bertini R, Bianco FJ, 
Carballido JA, et al.; International Renal Cell Carcinoma-Venous 
Thrombus Consortium. Prognostic impact of the 2009 UICC/AJCC 
TNM staging system for renal cell carcinoma with venous extension. 
Eur Urol.2011;59(1):120–127. doi: 10.1016/j. eururo.2010.10.001 

90. Kaushik D, Linder BJ, Thompson RH, Eisenberg MS, Lohse CM, Cheville 
JC, et al. The impact of histology on clinicopathologic outcomes for 
patients with renal cell carcinoma and venous tumor thrombus: a 
matched cohort analysis. Urology.2013;82(1):136–141. doi:10.1016/j.
urology.2013.02.034 

91. Tilki D, Hu B, Nguyen HG, Dall’Era MA, Bertini R, Carballido JA, et 
al. Impact of synchronous metastasis distribution on cancer specific 
survival in renal cell carcinoma after radical nephrectomy with 
tumor thrombectomy. J Urol.2015;193(2):436–442. doi: 10.1016/j.
juro.2014.07.087 

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