Elsevier

Urology

Volume 77, Issue 1, January 2011, Pages 217-222
Urology

Surgical Techniques in Urology
Stapled Renal Vein With In Situ Tumor Thrombus: A Useful Intraoperative Maneuver to Facilitate Radical Nephrectomy and Inferior Vena Cava Thrombectomy

https://doi.org/10.1016/j.urology.2010.02.047Get rights and content

Objectives

Patients with genitourinary tumors and inferior vena cava thrombus often have large lesions and significant neovascularity. Early division of the renal vein with the in situ thrombus is desirable; however, concerns have been raised regarding tumor spillage and thrombus migration. We describe a novel technique using a stapling device to secure the renal vein during resection of renal tumors associated with an inferior vena cava thrombus.

Methods

Since 2005, 38 patients have undergone surgery for genitourinary tumors and inferior vena cava tumor thrombus by a single surgeon. We examined the utility of an endovascular stapler (Endo-GIA) to transect the renal vein and the in situ thrombus. The renal vein containing the tumor thrombus was divided with an endovascular stapler in 14 of 38 patients. The outcomes of this technique were assessed.

Results

The stapled group included more level III-IV thrombi than the nonstapled group. The tumors removed in the stapled group were larger (median 11.5 versus 9 cm), and the median intraoperative transfusion requirements were greater (9.5 versus 3 U). One patient developed an intraoperative pulmonary embolus, and another experienced hemodynamic changes suggestive of an embolus. Local recurrence developed in 1 and 2 patients in the stapled and conventional groups, respectively, during a median follow-up period of 3 months.

Conclusions

The Endo-GIA stapler is a safe and effective instrument for division of the in situ renal vein component of the tumor thrombus, allowing the surgeon to complete the nephrectomy, achieve hemostasis, and, subsequently, concentrate on the vena cava and tumor thrombus aspects of the procedure.

Section snippets

Material and Methods

From April 2005 to May 2009, a single surgeon performed 494 extirpative renal surgical procedures, most commonly for suspected renal cell carcinoma. Of these, 38 were radical nephrectomies for genitourinary tumors with an associated tumor thrombus extending into the IVC. A retrospective review was conducted from an institutional review board-approved database, identifying the patient and tumor characteristics and postoperative complications and local and distant recurrences. Complications were

Results

A total of 38 patients (7.7%) underwent planned partial or total nephrectomy with an associated IVC tumor thrombus. The patient, tumor, and operative characteristics in the stapled and nonstapled groups are summarized in Table 1. The operative procedure is shown in Figure 1, Figure 2. Of the 38 patients, 14 had an IVC thrombus that was stapled in situ and subsequently extracted by way of a separate cavotomy as an isolated specimen, and 24 had the renal tumor and IVC thrombus specimens removed

Comment

The use of an Endo-GIA stapling device to control the renal hilum has been previously described in laparoscopic published reports.12 It delivers 6 rows of staples, leaving 3 on either side of the cut. The use of this device has been advocated when perihilar reaction makes precise vascular identification and isolation difficult.10 At our institution, we have regularly used the Endo-GIA in laparoscopic cases to divide the renal vessels. Device malfunction can occur through user error, such as

Conclusions

The intraoperative findings and tumor characteristics, including continued hemorrhage through parasitic vessels and very large tumor size can be problematic, particularly for left-sided tumors. Our preference has been to excise renal tumors associated with IVC tumor thrombus en bloc. However, using well-established procedures to achieve proximal and distal vascular control of the IVC and venous contributaries, the Endo-GIA stapler appears to be safe and effective for division of the in situ

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