**Surgical Strategy for the Management of Renal Cell Carcinoma with Inferior Vena Cava Tumor Thrombus Carcinoma with Inferior Vena Cava Tumor Thrombus**

**Surgical Strategy for the Management of Renal Cell** 

DOI: 10.5772/intechopen.73294

Cheng Peng, Liangyou Gu, Luojia Yang, Baojun Wang, Qingbo Huang, Dan Shen, Songliang Du, Xu Zhang and Xin Ma Qingbo Huang, Dan Shen, Songliang Du, Xu Zhang and Xin Ma Additional information is available at the end of the chapter

Cheng Peng, Liangyou Gu, Luojia Yang, Baojun Wang,

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.73294

#### **Abstract**

The hallmark of renal cell carcinoma is its biological characteristic of invading the renal vein and/or inferior vena cava (IVC), which occurs in 4–10% of patients. Radical nephrectomy (RN) with tumor thrombectomy is the standard approach for treating such challenging cases. Except tumor thrombus height, several factors can determine the surgical strategy, including the effect of targeted molecular therapy (TMT), invasion of the IVC wall, venous occlusion, establishment of collateral circulation, IVC thromboembolism, and primary tumor location. The surgical strategy for patients with retrohepatic vena cava tumor thrombi depends on the upper extent of the tumor thrombus. In addition, the first porta hepatis and hepatic veins are important anatomical boundaries. Based on previous studies, the effect of pre-surgical TMT is limited. The safety of IVC venography, an imaging modality that can observe congestion of the tumor thrombus and show the collateral circulation, has considerably improved. IVC interruption plays an important role in tumor thrombectomy for patients with invasion of the venous walls, complete occlusion of the vena cava, and the presence of distal thrombus. A series of retrospective and prospective studies are needed to be conducted, which will provide our clinical work with more powerful reference and basis.

**Keywords:** renal cell carcinoma, tumor thrombus, targeted molecular therapy, inferior vena cava venography, vascular resection, surgical strategy

#### **1. Introduction**

The Chinese Cancer Registry Annual Report of 2015 indicates that renal cell carcinoma (RCC) represents approximately 2–3% of new cases of malignant tumor in China annually and the

Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons

trend in the morbidity of RCC has been increasing [1]. The hallmark of RCC is its biological characteristic of invading the renal vein and/or inferior vena cava (IVC), which occurs in 4–10% of patients [2]. Past clinical decision making mostly adopts conservative treatment, in terms of high morbidity and mortality rates during this kind of procedures. Radical nephrectomy (RN) with tumor thrombectomy is the standard approach for treating such challenging cases [3]. These patients were able to obtain, as literature reported, better long-term survival, and the tumor-specific survival rate is in up to 50% [4–7].

With the development of laparoscopy and robotic technology and the accumulation of practical experience in surgery, we noted that the height of IVC thrombus could not sufficiently guide the choice of surgical strategy, considering that only the thrombus height was assessed. Several factors, such as the effect of neoadjuvant targeted molecular therapy (TMT), invasion of the IVC wall, venous occlusion, establishment of collateral circulation, IVC thromboembolism, and primary tumor location, can determine the surgical strategy. The present comprehensive review describes how those factors influence surgical strategy and patient outcomes.

> reported the particular steps of robot-assisted surgery and concluded that RAL-IVCTE is safe, and different sides require different techniques [18]. Gu and colleagues performed a retrospective comparison between open and robotic surgeries in IVC thrombus. The study indicated that level I–II IVC tumor thrombectomy performed with robot-assisted surgery resulted in better perioperative periodical outcomes and analogous oncological outcomes compared with open surgery, marking that such surgery has entered the era of mini-trau-

IV Tumor thrombus is above diaphragm Intraoperative extracorporeal circulation is requisite

**Definition Surgical strategy**

I Tumor thrombus extend into IVC with <2 cm above the renal vein

above the renal vein but below the hepatic

**Table 1.** The grading standards and surgical strategies tumor thrombus.

II Tumor thrombus extends in to IVC >2 cm

III Tumor thrombus which extends above the hepatic veins but below diaphragm

veins

0 Tumor thrombus is limited to the renal vein Radical nephrectomy of renal cell carcinoma

Tumor thrombus could be extruded to renal vein

http://dx.doi.org/10.5772/intechopen.73294

199

The traction of liver is required; blocking-up the section of IVC underneath hepatic vein

The mobilization of the liver; vena-venous bypass

and then radical nephrectomy

is required

Surgical Strategy for the Management of Renal Cell Carcinoma with Inferior Vena Cava Tumor Thrombus

After general anesthesia induction and Foley catheter placement, the patients were positioned in a left lateral decubitus position with a 60–70° bump (**Figure 1A** and **B**). For right RCC, R-IVCTE and RN can be both completed with this position. For left RCC, R-IVCTE can be completed with this position. After R-IVCTE, the placement of patients was converted to a

The hepatocolic, hepatorenal, and chain ligaments were incised. The liver required to be upretracted. The anterior layer of the perirenal fascia was opened, the duodenum was dissected and retracted inside, and the IVC was exposed. Full dissection of the IVC, left renal vein, and part of the lumbar vein were required at the location of the tumor thrombus (**Figure 1C**). For level II IVC thrombus, the hepatic short vein, and even right central vein of the adrenal gland, was also clipped and divided (**Figure 1D**). Sequential clamping of the caudal IVC, left renal vein, and cephalic IVC were performed using vessel loops (**Figure 1E**). After the vessels were clamped, the IVC wall was cut, and the thrombus was removed (**Figure 1F**). After the IVC

right lateral decubitus position with a 60–70° bump, and left RN was performed.

matic surgery [19].

IVC = inferior vena cava.

**Tumor thrombus level**

**3. Surgical procedure**

**3.1. Anesthesia and patient position**

**3.2. Right RN and IVC thrombectomy**
