Upsala J Med Sci 90: 107-114, 1985 Surgery of Renal Cancer with Extensive Caval Invasion Suggestion for a new approach Thomas Andreen, Torkel Aberg and h e Fritjofsson Departments of Urology and Thoracic Surgery, Uniuersity Hospital, Uppsala, Sweden ABSTRACT R a d i c a l s u r g e r y f o r r e n a l c a n c e r w i t h i n v a s i o n o f t h e i n f e r i o r vena cava can i m p r o v e t h e p a t i e n t ’ s q u a l i t y o f l i f e and, i n some cases, o f f e r l o n g e r s u r v i v a l or even c u r e . With a c a r e f u l l y p l a n n e d s u r g i c a l approach i t i s p o s s i b l e t o re- move r e n a l tumours w i t h t h r o m b o t i c e x t e n s i o n t o t h e most p r o x i m a l p a r t o f t h e i n f e r i o r vena cava w i t h o u t n e c e s s i t y f o r c a r d i o p u l m o n a r y bypass and w i t h o u t un- due r i s k t o t h e p a t i e n t . I n t h e o p e r a t i v e p r o c e d u r e , good access and v i s u a l c o n t r o l o f t h e p r o x i m a l vena cava and a l l t h e c o n t r i b u t i n g v e i n s seem t o be c r u c i a l l y i m p o r t a n t . INTRODUCTION R e n a l c a n c e r i s known f o r i t s tendency t o i n v a d e t h e venous v a s c u l a r t r e e . O f a l l r e n a l c a n c e r s , one i n f o u r i n v a d e s t h e r e n a l venous system, a r o u n d one- f o u r t h o f t h e i n v a d i n g tumours w i l l i n v o l v e t h e vena cava i n g r e a t e r or lesser degree, and such i n v o l v e m e n t w i l l r e a c h t h e l e v e l o f t h e h e p a t i c v e i n s or h i g h - er i n a l m o s t one o f f o u r cases. Most a u t h o r s a g r e e t h a t vena c a v a l i n v o l v e m e n t does n o t i n d i c a t e a more a g g r e s s i v e f o r m o f tumour (l,ll), and t h a t t h e p r o g - n o s i s depends more on t h e h i s t o l o g i c c h a r a c t e r i s t i c s and l o c a l g r o w t h o f t h e tumour i n t h e k i d n e y and on o c c u r r e n c e o f tumour i n t h e l o c a l lymph nodes or d i s t a n t m e t a s t a s i s . Other a u t h o r s have a t t r i b u t e d p r o g n o s t i c s i g n i f i c a n c e t o t h e l e v e l o f vena c a v a l i n v o l v e m e n t ( 1 4 ) . I t i s g e n e r a l l y accepted, however, t h a t r e m o v a l o f n e o p l a s t i c c a v a l thrombus g i v e s good p a l l i a t i o n and i m p r o v e s t h e p r o s p e c t s f o r l o n g - t e r m s u r v i v a l ( 2 , 3 , 6 , 8 ) when t h e r e i s no p e r i n e p h r i c e x t e n s i o n o f tumour. As u n t r e a t e d vena c a v a l i n v o l v e m e n t c a r r i e s a n e a r l y 100 p e r c e n t s h o u l d b e a t t e m p t e d i n p a t i e n t s w i t h l o c a l l y r e s e c t a b l e r e n a l c a n c e r who a r e f i t enough f o r p r o t r a c t e d s u r g e r y . m o r t a l i t y w i t h i n one y e a r ( 1 5 ) , r e m o v a l o f c a v a l tumour thrombus The l i t e r a t u r e c o n t a i n s numerous e x c e l l e n t r e v i e w s o f d i f f e r e n t s u r g i c a l 8-858572 107 approaches (1,3,5-10,12,13). In this paper we present our own experience with a partly new approach that provides excellent access to the upper part of the in- ferior vena cava, thus permitting good control of bleeding and prevention of fatal pulmonary embolism. MATERIAL AND METHODS In the past f o u r years four patients were referred to o u r hospital because o f renal cancer with involvement o f the inferior vena cava up to o r past the entry o f the hepatic veins ( F i g . 1). Fig. 1. Level of caval involvement. 2) Cases 1 and 2, up to and above the hepatic veins, 5) Cases 3 and 4, up to but not above the hepatic veins. The age range of the two men and two women was 47 to 78 years. All underwent radical nephrectomy and caval thrombectomy. The postoperative observation time is short (at most 15 months), but at the time of writing a l l four patients are alive and well. Preoperative evaluation Excretory urography, including tomography, was performed preoperatively in 108 a l l cases. This e x a m i n a t i o n was f o l l o w e d by s e l e c t i v e r e n a l angiography, com- p u t e d tomography and i n f e r i o r venocavography. Bone scans and c h e s t r a d i o g r a p h y were p e r f o r m e d i n a l l cases f o r d e t e c t i o n o f d i s t a n t m e t a s t a s e s . O p e r a t i v e p r o c e d u r e I n t h r e e o f t h e f o u r cases t h e o p e r a t i o n was p r e c e d e d b y i n s e r t i o n o f a double-lumen Swan-Ganz c a t h e t e r i n t o t h e r e n a l a r t e r y on t h e a f f e c t e d s i d e and t h e b a l l o o n was i n f l a t e d under f l u o r o s c o p i c c o n t r o l a f t e r p r e m e d i c a t i o n . The o t h e r p a t i e n t was n o t c a t h e t e r i z e d . The p r i n c i p l e s o f t h e t e c h n i q u e a r e s c h e m a t i c a l l y p r e s e n t e d i n F i g . 2. The t e c h n i q u e can b e o u t l i n e d as f o l l o w s . A f t e r i n d u c t i o n o f a n a e s t h e s i a t h e p a t - i e n t i s p o s i t i o n e d on t h e o p e r a t i n g t a b l e w i t h a s m a l l p i l l o w under t h e l o w e r t h o r a c i c and upper lumbar s p i n e . A m i d l i n e i n c i s i o n i s made from t h e sternum t o j u s t below t h e u m b i l i c u s and t h e abdomen i s c a r e f u l l y e x p l o r e d f o r s i g n s o f m e t a s t a t i c d i s e a s e . The r e n a l turnour i s p a l p a t e d and i t s r e s e c t a b i l i t y assessed. When o p e r a b i l i t y has been a s c e r t a i n e d , t h e a s c e n d i n g o r descending c o l o n , i n - c l u d i n g t h e r i g h t or l e f t p a r t o f t h e t r a n s v e r s e c o l o n ( h e p a t i c o r s p l e n i c f l e x - u r e ) i s m o b i l i z e d , as i s t h e duodenum. The l i v e r i s m o b i l i z e d by d i v i d i n g t h e d i a p h r a g m a t i c a t t a c h m e n t s , a l l o w i n g t h e l i v e r t o b e r o t a t e d f r o m s i d e t o s i d e on t h e a x i s o f t h e i n f e r i o r vena cava. I n t h i s way good access i s o b t a i n e d t o t h e a n t e r i o r p a r t o f t h e vena cava. The hepatoduodenal l i g a m e n t i s i d e n t i f i e d and e n c i r c l e d w i t h a r u b b e r band. Rumel t o u r n i q u e t s a r e a p p l i e d t o t h e c o n t r a - l a t e r a l r e n a l v e i n and, d i s t a l l y , t o t h e vena cava. A l l lumbar v e i n s a r e i d e n t i - f i e d and d i v i d e d between s i l k l i g a t u r e s . S p e c i a l c a r e i s t a k e n t o i d e n t i f y and d i v i d e t h e second p a i r o f lumbar v e i n s , as o t h e r w i s e t h e y may be a m a j o r s o u r c e o f b l e e d i n g . A median s t e r n o t o m y i s t h e n p e r f o r m e d up t o t h e t h i r d i n t e r c o s t a l space and t h e i n c i s i o n i s c o n t i n u e d 5-7 cm i n t h a t space on t h e r i g h t s i d e , a v o i d i n g t h e p l e u r a . A s t e r n u m r e t r a c t o r i s i n t r o d u c e d and t h e p e r i c a r d i u m opened i n t h e m i d l i n e and sewn t o t h e wound edges. A Rurnel t o u r n i q u e t i s a p p l i e d on t h e i n - t r a p e r i c a r d i a l p a r t o f t h e i n f e r i o r vena cava. A p u r s e s t r i n g s u t u r e o f 3 / 0 p r o - l e n e i s p l a c e d r o u n d t h e r i g h t a u r i c u l a r appendage. The s u t u r e i s drawn t h r o u g h a s m a l l - b o r e r u b b e r t u b e . The a u r i c u l a r appendage i s opened and t h e r i g h t i n d e x f i n g e r i n t r o d u c e d t h r o u g h t h e p u r s e s t r i n g s u t u r e , w i t h t h e surgeon r e s p o n s i b l e f o r t h e t h o r a c i c p a r t o f t h e o p e r a t i o n s t a n d i n g t o t h e l e f t o f t h e p a t i e n t . The p r o x i m a l p a r t o f t h e i n f e r i o r vena cava can t h e n b e p a l p a t e d . By i n v e r t i n g t h e a u r i c l e a s f a r down as p o s s i b l e , t h e o r i f i c e s o f t h e l i v e r v e i n s c a n b e r e a c h - ed. The i n f e r i o r vena cava i s t e m p o r a r i l y o b s t r u c t e d within t h e p e r i c a r d i u m i n o r d e r t o assess t h e haemodynamic consequences o f t h i s p r o c e d u r e . I f t h e a r t e r - i a l p r e s s u r e d r o p s c o n s i d e r a b l y , t h e c a v a l o b s t r u c t i o n i s r e l e a s e d . The a o r t a i s t h e n m o b i l i z e d i n t h e d i a p h r a g m a t i c h i a t u s , t o e n a b l e i t s c l a m p i n g . F i g . 2. Schematic v i e w o f t h e anatomic s i t u a t i o n a t o p e r a t i o n o f r e n a l c a r - cinoma w i t h tumour i n v a s i o n o f t h e r e n a l v e i n and i n f e r i o r vena cava. Rumel t o u r n i q u e t s a r e a p p l i e d on t h e c o n t r a l a t e r a l r e n a l v e i n , l o w e r i n f e r i o r vena c a v a and t h e i n t r a p e r i c a r d i a l p a r t o f t h e i n f e r i o r vena cava. A p u r s e s t r i n g s u t u r e i s p l a c e d r o u n d t h e r i g h t a u r i c u l a r append- age w i t h t h e s u t u r e drawn t h r o u g h a s m a l l - b o r e r u b b e r tube. 110 A l l v e s s e l s c o n t r i b u t i n g t o t h e b l o o d f l o w i n t h e upper p a r t o f t h e i n f e r i o r vena cava a r e t h e n clamped - f i r s t t h e h e p a t i c a r t e r y and t h e p o r t a l v e i n i n t h e hepatoduodenal l i g a m e n t , t h e n t h e v e i n o f t h e c o n t r a l a t e r a l k i d n e y and, f i n a l l y , t h e l o w e r i n f e r i o r vena cava. I n one o f o u r cases t h e i n f r a d i a p h r a g - m a t i a a o r t a a l s o was clamped. The t o u r n i q u e t around t h e i n t r a p e r i c a r d i a l p a r t o f t h e i n f e r i o r vena cava i s now drawn t i g h t a r o u n d t h e f i n g e r , and t h e d i s s e c t i o n o f t h e tumour thrombus i s p e r f o r m e d b l u n t l y w i t h t h e f i n g e r as f a r down as i t can r e a c h . A t t h e same t i m e t h e abdominal team makes a 5-7 cm l o n g i t u d i n a l i n c i s i o n i n t o t h e vena cava. The tumour thrombus i s t h e n d i s s e c t e d from w i t h i n t h e v e i n , u s i n g a l t e r n a t i v e l y a s m a l l n e u r o s u r g i c a l d i s s e c t o r and tumour f o r c e p s . A f t e r c o m p l e t e r e m o v a l o f t h e tumour thrombus, t h e o p e n i n g i n t h e vena cava i s t e m p o r a r i l y o c c l u d e d w i t h a l a r g e v a s c u l a r clamp. A n o t h e r clamp i s a p p l i e d a c r o s s t h e e n t r a n c e o f t h e a f f e c t e d r e n a l v e i n . The i n c i s i o n i n t h e c a v a l w a l l i s c l o s e d w i t h a r u n n i n g v a s c u l a r s u t u r e and t h e clamp i s removed. The v a s c u l a r clamps a r e t h e n r e l e a s e d , b e g i n n i n g w i t h t h e a o r t i c clamp, t h e n t h e hepatoduo- d e n a l , f o l l o w e d b y t h e clamps o n t h e d i s t a l vena cava and t h e r e n a l v e i n o f t h e h e a l t h y k i d n e y . F i n a l l y t h e Rumel t o u r n i q u e t o b s t r u c t i n g t h e vena cava is r e - l e a s e d . The a f f e c t e d r e n a l v e i n i s opened and r e m a i n i n g tumour removed, t h e ca- v a l w a l l i s s u t u r e d and t h e clamp removed. T h e r e a f t e r a s t a n d a r d e x t r a c a p s u l a r nephrectomy i s performed, i n c l u d i n g d i s s e c t i o n o f t h e h i l a r lymph nodes. A suc- t i o n d r a i n i s p l a c e d i n t h e abdomen and two c h e s t t u b e d r a i n s i n t h e p e r i c a r d - ium. RESULTS The r e s u l t s i n o u r cases a r e summarized i n T a b l e 1. The e x c e s s i v e b l e e d i n g i n Case 1 a r o s e f r o m d e f e c t i v e c o n t r o l o f one lumbar v e i n . The p r o l o n g a t i o n o f T a b l e 1. c a v a l i n v a s i o n C u r r e n t e x p e r i e n c e o f t h e o p e r a t i o n f o r r e n a l c a n c e r w i t h e x t e n s i v e Case O p e r a t i n g P e r o p e r a t i v e P o s t o p e r a t i v e hos- F o l l o w - u p no Age/Sex t i m e ( h r s ) b l e e d i n g ( m l ) p i t a 1 s t a y ( d a y s ) (months) 1 47/M 6.5 20 700 3 1 15 2 58/F 6.0 6 900 11 10 4 64/M 4.0 8 100 11 2 3 78/F 6.0 7 800 10 6 1 1 1 hospital stay was due to subfebrility and general malaise, with liver tests in- dicating non-A, non-8 hepatitis. DISCUSSION Renal cell carcinoma has a tendency to grow along venous channels. Electron microscopy has revealed tumour cells t o surround thin-walled blood vessels that often have fenestrations, allowing tumour to prolapse into the lumen ( 4 , l l ) . In most cases there is no actual overgrowth of tumour on the wall of the vena cava, although the tumour thrombus can be strongly adherent to the vessel wall. Most authors agree that extension of renal tumour into the inferior vena cava does not necessarily imply a bad prognosis, if radical surgery is successful ( 2 , l l ) . The observation by others (14) that the prognosis worsens with increasing height of thrombus extension into the vena cava can probably be ascribed to the time factor. The higher the level of tumour thrombus, the greater is the prob- ability that the kidney tumour has been present for a long time and thus is loc- ally advanced. At present there is no effective therapeutic alternative to radical surgery, and we therefore believe that, whenever possible, such surgery should be at- tempted in cases of the described type. We have found that a sternum-splitting incision up to and extending into the third intercostal space on the right side, combined with a pursestring suture on the right auricle and introduction of the surgeon's finger into the inferior vena cava, gives excellent proximal vascular control and greatly assists the removal of tumour thrombus. Our experience also is that meticulous care in clamping and/or dividing all tributaries to the in- ferior vena cava gives an almost blood-free operating field. Clamping time has not given rise to problems in our cases. The left kidney has an excellent col- lateral venous flow clamping without ill effects. The liver can withstand a 30-minute interruption of blood supply. Introduction of a Swan-Ganz catheter into the renal artery and insufflation of the balloon before surgery facilitates the dissection of the renal vein, as preliminary clamping of the artery is not then required. and the right kidney can tolerate at least 20 minutes of Brief total obstruction of the inferior vena cava is tolerated by most pat- ients. The arterial blood pressure regularly falls. If the fall is too pro- nounced, the pressure is raised again by clamping the infradiaphragmatic aorta. This additional manoeuvre probably is not dangerous, as the liver and the con- tralateral kidney are already compromised. I t was necessary in only one of our four cases. No signs of embolism or metastases to the lungs have appeared in any of our patients. 112 I n one o f t h e f o u r p a t i e n t s t h e tumour thrombus extended i n t o t h e h e p a t i c v e i n s , o b s t r u c t i n g t h e b l o o d f l o w o f t h e l i v e r , w h i c h was g r o s s l y e n l a r g e d . 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