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Control of the renal artery after removal of tumor thrombus from the inferior vena cava: Analysis of the efficacy and safety of a new surgical approach

Introduction & Objectives

The nephrectomy safety during removal of kidney tumors with intravenous extension mostly depends on control of the renal artery. We focused on efficacy and safety of a novel renal artery ligation technique after thrombectomy in comparison to the standard surgical techniques.

Material & Methods

The study included 132 patients with renal cell carcinoma extending into the main renal vein (n = 63), or the inferior vena cava (n = 69). The tumors originated from the right kidney in 61 (46.2%) cases, and from the left kidney in 71 (53.8%) cases. In 45 (65.2%) patients the tumor thrombi reached subhepatic segment of the IVC, in 16 (23.2%) cases – retrohepatic segment, and in 8 (11.6%) cases – supradiaphragmatic segment, or the right atrium. To remove the "high" caval thrombi the liver was mobilized with access to the right atrium via the diaphragm without cardiopulmonary bypass. All patients were split into two groups depending on the type of ligation of the renal artery. The first group had ligation done prior to thrombectomy (n = 79), and the second group had ligation done after thrombectomy ((n = 53). Comparison of the results in both groups was performed based on evaluation of the difficulty of this surgical maneuver, severity of complications and oncological features. In order to assess the technical difficulty the original scale of complexity and risk level of the stages of surgical intervention was used. The follow-up ranged from 6 to 72 months and averaged 30.6 ± 5.6 months.

Results

The use of thrombectomy surgical technique prior to ligation of the renal artery was not associated with worsening of oncological features. The level of metastatic spread was 66.1%, and 63.9%; (p> 0,764), the overall 5-year survival rate was 43.1%, and 38.5% (p <0.1872), the 5-year disease progression-free survival was 16.0%, and 11.5% (p> 0, 0687), respectively for groups with ligation of the renal artery before and after thrombectomy. The results of presented surgical approach considerably exceeded the efficiency of the standard techniques of thrombectomy in terms of technical feasibility (technical difficulty level was 15.1% compared to 30.4%; p <0.047), and safety due to less frequent bleeding (9.4% compared to 22.8%; p <0.049), and absence of embolic complications (0% compared to 2.5%; p <0.045).

Conclusions

Our study has demonstrated feasibility and safety of thrombectomy without prior ligation of the renal artery. The results of this technique were not related to the level of spread of intravenous tumor, and were significantly better than those with the use of the standard approaches to the renal artery in terms of technical feasibility and safety, due to the lower frequency of bleeding, and the absence of embolic complications.