Renal Cell Carcinoma and Stage IV Inferior Vena Cava Thrombus: Resection Without Thoracotomy

Assessment of the 30-day mortality and major complications as well as long-term oncological outcomes of three patients undergoing radical nephrectomy combined with inferior vena cava (IVC) thrombectomy with a novel technique without thoracotomy for renal cell carcinoma with IVC level IV thrombus. This is a retrospective case series carried out at Attikon University Hospital between January 2018 to March 2020.

• Radical nephrectomy with inferior vena cava thrombectomy without thoracotomy (Procedure): The abdomen was accessed through a Makuuchi incision. After mobilization of the liver and assessment of the inferior vena cava infiltration (IVC), IVC was clamped below the level of the renal veins. In order to get access to the intrapericardial IVC, an incision was made through the tendon of the diaphragm and a clamp was placed first in the hepatoduodenal ligament (Pringle maneuver) and then in the endopericardial portion of the IVC, in that order. A longitudinal 3-4 cm incision was made incorporating the junction of IVC and right renal vein. After tumor removal thrombus was removed and a fine clamp was placed at the IVC just below the hepatocaval junction and immediate release of the clamping of the hepatoduodenal ligament. Total endopericardial clamp time was 4 minutes. Patients then underwent radical nephrectomy in a standard fashion with en bloc resection of the IVC thrombus.

Primary outcomes

• Short term mortality rate [30 days]: Percentage of patients' postoperative deaths

Secondary outcomes

• Short term major complications' rate [30 days]: Incidence of Clavien/Dindo grade 3 or more postoperative complications
• Recurrence rate [27 months]: Rate of local or systemic recurrence

Sex: All, ages: 18 Years to any

Inclusion Criteria:

* Adult patients
* Documented radiological and/or pathological diagnosis of renal cell carcinoma with level IV tumor thrombus

Exclusion Criteria:

* American Anesthesia Association (ASA) Class V and/or any contraindications to general anesthesia

• Nikolaos Arkadopoulos, MD, PhD, Study director, Attikon Hospital