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Nephron sparing surgery in patients with intravenous extension of renal cell carcinoma

Introduction & Objectives

We have conducted a retrospective evaluation of the results of open nephron sparing surgery in patients with macroscopic intravenous extension of RCC found either during operation or at final pathomorphological study.

Material & Methods

The study included 32 patients with renal tumours and intravenous extension who underwent NSS from 2007 to 2015 in two urological centers. Their charts were reviewed to identify clinical, operative, and pathology details, as well as oncological outcomes of these patients.

Results

The group of imperative indications included 15 (46.9%) patients, elective indications - 17 (53.1%) patients. Absolute imperative indications were recorded in 6 (18.8%) patients (4 with solitary kidney, 2 with bilateral tumours). Dimensions of renal tumour averaged 67.8±22.8 mm. Fat tissue invasion occurred in 5 patients (15.6%), kidney collecting system invasion - in 10 (31.3%) cases. Prior to surgery the intravenous extension of neoplasm was suspected in 11 (34.4%) patients, was identified during surgery in 18 (56.2%) patients, and at final morphological examination in 3 (9.4%) patients. Intravenous part of the tumour penetrated the segmental vein in 21 (65.6%) patients, the polar vein in 5 (15.6%) patients, the initial portion of the renal vein in 3 (9.4%), the main stem of the renal vein in 2 (6.3%), and the cavarenal portion of IVC in 1 (3.1%). The average length of tumour thrombus was 13.2 ±2.6 mm, and the width was 4.9±1.2 mm. Tumour thrombi were classified as intrarenal and extrarenal. In accordance with this principle surgical procedures were divided into standard partial nephrectomy (12.5%), partial nephrectomy with intrarenal (68.7%) and extrarenal thrombectomy (18.8%). In one patient hypothermic perfusion of the kidney in situ was used. In the other case the extracorporal partial nephrectomy with kidney autotransplantation was performed. 
Warm ischemia time averaged 14.9±6.4 minutes. The volume of blood loss did not exceed an average of 570.3±78.4 ml. The overall level of perioperative complications was 37.5%. Early postoperative complications occurred in 4 (12.5%) patients. Postoperative mortality occurred only in the group of imperative indications to NSS - 2 cases (6.3%). The follow-up period averaged 30.4±2.8 months. Distant metastases occurred in 5 (15.6%) patients within 17.3±2.1 months at an average. Local tumour recurrence in the remnant kidney after nephron sparing surgery was not detected in any case. 5-year overall survival reached 94.7%; 5-year free of tumour progression survival - 81.3%.

Conclusions

Nephron sparing surgery may be used to treat patients with kidney tumours and neoplastic venous thrombosis. Elective indications for this surgical approach are still to be developed.