Laparoscopy and Robotics Laparoscopic Management of Advanced Renal Cell Carcinoma With Renal Vein and Inferior Vena Cava Thrombus Rahul Kumar Bansal, Hin Yu Vincent Tu, Darrel Drachenberg, Bobby Shayegan, Edward Matsumoto, J. Paul Whelan, and Anil Kapoor OBJECTIVE METHODS RESULTS
CONCLUSION
To report the results and oncological efficacy of laparoscopic radical nephrectomy (LRN) in patients with renal cell carcinoma with renal vein and inferior vena cava thrombus. We performed retrospective record review of 41 patients who underwent LRN along with venous thrombectomy at 2 Canadian centers from 2002 to 2012 by dedicated laparoscopic surgeons. The mean age and body mass index of the 41 study patients (34 males and 7 female) were 64.4 years and 28.7 kg/m2, respectively. Median tumor size was 9.3 cm; 39 patients had renal vein thrombus, and 2 had inferior vena cava thrombus. Nine patients (22%) had metastatic disease to begin with and underwent laparoscopic cytoreductive nephrectomy. Median estimated blood loss, operative time, and length of stay were 100 mL (range, 50-400 mL), 134.5 minutes (range, 99183 minutes), and 4 days (range, 4-6 days), respectively. There were 4 (9.7%) grade 2 complications. There was no intraoperative death. Mean duration of follow-up was 42 months (range, 6-107 months). Of 32 patients with localized disease, 4 (12.5%) died of progressive disease, 3 (9.3%) died of unrelated causes, and 3 patients (9.3%) were lost to follow-up. Twenty-two patients (68.7%) were alive at a mean follow-up of 47 months. LRN and venous thrombectomy for advanced renal tumors with venous thrombus are safe procedures in experienced hands with significant laparoscopic skills. The short-term oncological data are encouraging and advocate the efficacy of this procedure in this subset of patients, although longer follow-up is required in larger number of patients to further define its role. UROLOGY 83: 812e817, 2014. 2014 Elsevier Inc.
S
ince its first report in 1991, laparoscopic radical nephrectomy (LRN) has practically become the standard treatment for patients having clinical T1 and T2 renal cell carcinoma (RCC).1,2 In multiple studies, LRN has established its efficacy, safety, and tolerability profiles along with achievement of cancer control as compared with open surgery.3-5 As the experience with laparoscopy increased, it has been used for more complex and advanced renal tumors.2,6,7 Incidence of renal vein (RV) and inferior vena cava (IVC) thrombus has been reported to vary from 4% to 10% of all RCCs.8 Vascular thrombus in the setting of RCC presents some unique challenges in terms of oncological control and patient morbidity. Current standard of
Financial Disclosure: J. Paul Whelan is a trainer and lecturer for Green Light Laser by American Medical Systems. The remaining authors declare that they have no relevant financial interests. From the McMaster Institute of Urology, St. Joseph’s Healthcare, McMaster University, Hamilton, Ontario, Canada; and the Department of Surgery, Section of Urology, University of Manitoba, Winnipeg, Manitoba, Canada Reprint requests: Anil Kapoor, M.D., McMaster Institute of Urology, St. Joseph’s Healthcare, 50 Charlton Ave East, Hamilton, Ontario L8N 4A6, Canada. E-mail: [email protected] Submitted: June 1, 2013, accepted (with revisions): September 27, 2013
812
ª 2014 Elsevier Inc. All Rights Reserved
treatment for RCC with RV or IVC thrombus involves open radical nephrectomy and thrombectomy. However, with the advancement of technology and expertise in laparoscopy, there has been more and more interest in managing these tumors through minimally invasive approach. Multiple published case reports and case series have successfully described the use of pure laparoscopic, laparoscopic-assisted, or hand-assisted LRN, and venous thrombectomy.9-21 We hereby report results of our series of LRN in patients of RCC with RV and IVC thrombus along with short-term oncological outcome. The present series represents one of the largest experiences of patients undergoing LRN and venous thrombectomy for RCC with venous thrombus.
MATERIALS AND METHODS After Institutional Ethics Review Board approval, we performed retrospective record review of patients who underwent LRN with venous thrombectomy for RCC and venous thrombus in RV or IVC from 2 Canadian centers from October 2002 to February 2012. We identified 41 patients and collected their preoperative, intraoperative, and postoperative parameters (Tables 1, 2). 0090-4295/14/$36.00 http://dx.doi.org/10.1016/j.urology.2013.09.060
Table 1. Patient characteristics (n ¼ 44) Parameter
Table 2. Intraoperative and postoperative parameters Value
Age (y), mean (range) 64.4 (46-83) Gender (males and females) 34 and 7 BMI (kg/m2), mean (range) 28.7 (20.9-42.4) Median ASA 2 Side (right/left) 20/21 Preoperative imaging CT 41 MRI 13 Doppler USG 1 Venacavogram 3 Bone scan 18 Bilateral tumor, n (%) 1 (2.4) Thrombus known preoperatively, n (%) 31 (75.6) In renal vein, n (%) 29 (70.7) In IVC, n (%) 2 (4.8) Metastatic disease, n (%) 9 (22) Preoperative Cr, mean (range) 103.5 (50-228) Preoperative Hb, mean (range) 140.4 (80-182) Previous abdominal surgery, n (%) 7 (17) Preoperative angioembolization None ASA, American Society of Anesthesiologists; BMI, body mass index; Cr, creatinine; CT, computed tomography; Hb, hemoglobin; IVC, inferior vena cava; MRI, magnetic resonance imaging; USG; ultrasonography.
A standard transperitoneal laparoscopic approach was used with early control of renal artery. This was followed by milking back of thrombus into the distal portion of the RV using standard laparoscopic vascular clamps to make space for the division of RV using Endo-GIA stapler (Covidien Surgical, Mansfield, MA). With this technique, a minimal space of 1 cm is needed to adequately apply the Endo-GIA stapler. In using this technique, care has to be taken not to put the stapler on the side of the vena cava, with the theoretical possibility of splitting the staple line. In such cases, reinforcement of the staple line with intracorporeal caval suturing is recommended. In 3 patients, intracorporeal caval suturing was done to repair the IVC after applying a laparoscopic Satinsky clamp (Karl Storz, Tuttlingen, Germany) on the IVC and shaving off the specimen at the junction of the RV and IVC. In these patients, there was no space to place the Endo-GIA stapler, because there was less than 1 cm from the tumor thrombus margin to lateral border of the IVC. We therefore placed a single Satinsky clamp on the IVC through a separate 10-12 mm port. The IVC was repaired using an intracorporeal 4-0 Prolene (Ethicon, Somerville, NJ) suture in continuous double-layer fashion after shaving off the RV containing the tumor thrombus with laparoscopic scissors. Before dividing the RV, a large clip was placed on the distal vein to prevent back bleeding. The radical nephrectomy was then completed in a standard manner. The specimen was then placed in an Endo-catch bag and removed through port-site expansion. In 1 patient with RCC with IVC thrombus, the kidney was mobilized laparoscopically along with ligation and division of renal artery, leaving the kidney attached only by RV containing tumor thrombus extending into the IVC. A small subcostal incision was then made directly over the junction of the RV and IVC. We took control of bilateral RVs and IVC (above and below the thrombus) through the same incision and repaired the IVC after complete removal of thrombus along with the specimen. We did not consider this as open conversion because a subcostal incision was made just large enough to extract the specimen; otherwise, a much larger incision (chevron or UROLOGY 83 (4), 2014
Parameter
Value
Operative time (min), median (IQR) 134.5 (99-183) EBL (mL), median (IQR) 100 (50-400) Open conversion, n (%) 4 (9.7) LOS (d), median (IQR) 4 (4-6) Postoperative Cr, mean (range) 147.5 (58-210) Postoperative Hb, mean (range) 126.7 (90-157) Mean follow-up (mo) 42 (6-107) Alive without disease 18/41 (44%) Metastatic group 0 Localized group 18/32 (56.2%) Alive with disease 8/41 (19.5%) Metastatic group 4/9 (44.4%) Localized group 4/32 (12.5%) Deceased because of disease 8/41 (19.5%) progression Metastatic group 4/9 (44.4%) Localized group 4/32 (12.5%) Deceased because of unrelated causes 3/44 (7.3%) Metastatic group 0 Localized group 3/32 (9.3%) Lost to follow-up 4/41 (9.75%) Metastatic group 1/9 (1.1%) Localized group 3/32 (9.3%) Size of the tumor (cm), mean (range) 9.3 (4-22) Histology, n (%) Clear cell 38 (92.7) Papillary 2 (4.9) Rhabdoid and signet differentiation 1 (2.4) Fuhrman grade, n (%) 2 15 (36.6) 3 24 (58.5) 4 2 (4.9) Level of tumor thrombus, n (%) Renal vein 39 (95) IVC below the diaphragm 2 (5) EBL, estimated blood loss; IQR, interquartile range; LOS, length of stay; other abbreviations as given in Table 1.
extended subcostal) is made to do open radical nephrectomy and IVC thrombectomy. In 4 patients, open conversion was required: 2 for unexpected RV thrombus, 1 for inability to progress because of significant perihilar inflammation and reactive adenopathy, and 1 for significant IVC thrombus. Follow-up data were available for a mean duration of 42 months (range, 6-107 months).
RESULTS The mean age and mean body mass index of the 41 study patients (34 males and 7 females) were 64.4 years and 28.7 kg/m2, respectively (Table 1). Median American Society of Anesthesiologists score was 2. Preoperative mean serum creatinine and hemoglobin were 103.5 mmol/ L and 140.4 g/L, respectively. Seven patients (17%) had undergone previous abdominal surgeries. None of the patients underwent preoperative angioembolization. Preoperatively, all patients underwent computed tomography, with and without oral and intravenous contrast, to define tumor extent (Fig. 1). In some patients, additional imaging in the form of Doppler ultrasound, venacavogram, and magnetic resonance imaging were performed to delineate tumor thrombus. Preoperative imaging was 813
Figure 1. (A) Coronal section of contrast enhanced computed tomography scan of 54-year-old patient showing a large left renal mass with renal vein thrombus (arrows). (B) Axial section of contrast enhanced computed tomography scan of 67-yearold patient showing the right renal mass with renal vein thrombus abutting inferior vena cava (white arrow). (Color version available online.)
successful in defining tumor thrombus in 31 patients (75.6%). RV and IVC thrombus was found preoperatively in 29 (70.7%) and 2 patients (4.8%), respectively. In 5 patients (12%), RV involvement was identified only on the pathologic analysis, and in another 5 patients (12%), the RV thrombus was identified intraoperatively. One patient had von Hippel-Lindau disease with bilateral tumors: 9-cm tumor with RV tumor thrombus on the left side and multiple small (
CONCLUSION
To report the results and oncological efficacy of laparoscopic radical nephrectomy (LRN) in patients with renal cell carcinoma with renal vein and inferior vena cava thrombus. We performed retrospective record review of 41 patients who underwent LRN along with venous thrombectomy at 2 Canadian centers from 2002 to 2012 by dedicated laparoscopic surgeons. The mean age and body mass index of the 41 study patients (34 males and 7 female) were 64.4 years and 28.7 kg/m2, respectively. Median tumor size was 9.3 cm; 39 patients had renal vein thrombus, and 2 had inferior vena cava thrombus. Nine patients (22%) had metastatic disease to begin with and underwent laparoscopic cytoreductive nephrectomy. Median estimated blood loss, operative time, and length of stay were 100 mL (range, 50-400 mL), 134.5 minutes (range, 99183 minutes), and 4 days (range, 4-6 days), respectively. There were 4 (9.7%) grade 2 complications. There was no intraoperative death. Mean duration of follow-up was 42 months (range, 6-107 months). Of 32 patients with localized disease, 4 (12.5%) died of progressive disease, 3 (9.3%) died of unrelated causes, and 3 patients (9.3%) were lost to follow-up. Twenty-two patients (68.7%) were alive at a mean follow-up of 47 months. LRN and venous thrombectomy for advanced renal tumors with venous thrombus are safe procedures in experienced hands with significant laparoscopic skills. The short-term oncological data are encouraging and advocate the efficacy of this procedure in this subset of patients, although longer follow-up is required in larger number of patients to further define its role. UROLOGY 83: 812e817, 2014. 2014 Elsevier Inc.
S
ince its first report in 1991, laparoscopic radical nephrectomy (LRN) has practically become the standard treatment for patients having clinical T1 and T2 renal cell carcinoma (RCC).1,2 In multiple studies, LRN has established its efficacy, safety, and tolerability profiles along with achievement of cancer control as compared with open surgery.3-5 As the experience with laparoscopy increased, it has been used for more complex and advanced renal tumors.2,6,7 Incidence of renal vein (RV) and inferior vena cava (IVC) thrombus has been reported to vary from 4% to 10% of all RCCs.8 Vascular thrombus in the setting of RCC presents some unique challenges in terms of oncological control and patient morbidity. Current standard of
Financial Disclosure: J. Paul Whelan is a trainer and lecturer for Green Light Laser by American Medical Systems. The remaining authors declare that they have no relevant financial interests. From the McMaster Institute of Urology, St. Joseph’s Healthcare, McMaster University, Hamilton, Ontario, Canada; and the Department of Surgery, Section of Urology, University of Manitoba, Winnipeg, Manitoba, Canada Reprint requests: Anil Kapoor, M.D., McMaster Institute of Urology, St. Joseph’s Healthcare, 50 Charlton Ave East, Hamilton, Ontario L8N 4A6, Canada. E-mail: [email protected] Submitted: June 1, 2013, accepted (with revisions): September 27, 2013
812
ª 2014 Elsevier Inc. All Rights Reserved
treatment for RCC with RV or IVC thrombus involves open radical nephrectomy and thrombectomy. However, with the advancement of technology and expertise in laparoscopy, there has been more and more interest in managing these tumors through minimally invasive approach. Multiple published case reports and case series have successfully described the use of pure laparoscopic, laparoscopic-assisted, or hand-assisted LRN, and venous thrombectomy.9-21 We hereby report results of our series of LRN in patients of RCC with RV and IVC thrombus along with short-term oncological outcome. The present series represents one of the largest experiences of patients undergoing LRN and venous thrombectomy for RCC with venous thrombus.
MATERIALS AND METHODS After Institutional Ethics Review Board approval, we performed retrospective record review of patients who underwent LRN with venous thrombectomy for RCC and venous thrombus in RV or IVC from 2 Canadian centers from October 2002 to February 2012. We identified 41 patients and collected their preoperative, intraoperative, and postoperative parameters (Tables 1, 2). 0090-4295/14/$36.00 http://dx.doi.org/10.1016/j.urology.2013.09.060
Table 1. Patient characteristics (n ¼ 44) Parameter
Table 2. Intraoperative and postoperative parameters Value
Age (y), mean (range) 64.4 (46-83) Gender (males and females) 34 and 7 BMI (kg/m2), mean (range) 28.7 (20.9-42.4) Median ASA 2 Side (right/left) 20/21 Preoperative imaging CT 41 MRI 13 Doppler USG 1 Venacavogram 3 Bone scan 18 Bilateral tumor, n (%) 1 (2.4) Thrombus known preoperatively, n (%) 31 (75.6) In renal vein, n (%) 29 (70.7) In IVC, n (%) 2 (4.8) Metastatic disease, n (%) 9 (22) Preoperative Cr, mean (range) 103.5 (50-228) Preoperative Hb, mean (range) 140.4 (80-182) Previous abdominal surgery, n (%) 7 (17) Preoperative angioembolization None ASA, American Society of Anesthesiologists; BMI, body mass index; Cr, creatinine; CT, computed tomography; Hb, hemoglobin; IVC, inferior vena cava; MRI, magnetic resonance imaging; USG; ultrasonography.
A standard transperitoneal laparoscopic approach was used with early control of renal artery. This was followed by milking back of thrombus into the distal portion of the RV using standard laparoscopic vascular clamps to make space for the division of RV using Endo-GIA stapler (Covidien Surgical, Mansfield, MA). With this technique, a minimal space of 1 cm is needed to adequately apply the Endo-GIA stapler. In using this technique, care has to be taken not to put the stapler on the side of the vena cava, with the theoretical possibility of splitting the staple line. In such cases, reinforcement of the staple line with intracorporeal caval suturing is recommended. In 3 patients, intracorporeal caval suturing was done to repair the IVC after applying a laparoscopic Satinsky clamp (Karl Storz, Tuttlingen, Germany) on the IVC and shaving off the specimen at the junction of the RV and IVC. In these patients, there was no space to place the Endo-GIA stapler, because there was less than 1 cm from the tumor thrombus margin to lateral border of the IVC. We therefore placed a single Satinsky clamp on the IVC through a separate 10-12 mm port. The IVC was repaired using an intracorporeal 4-0 Prolene (Ethicon, Somerville, NJ) suture in continuous double-layer fashion after shaving off the RV containing the tumor thrombus with laparoscopic scissors. Before dividing the RV, a large clip was placed on the distal vein to prevent back bleeding. The radical nephrectomy was then completed in a standard manner. The specimen was then placed in an Endo-catch bag and removed through port-site expansion. In 1 patient with RCC with IVC thrombus, the kidney was mobilized laparoscopically along with ligation and division of renal artery, leaving the kidney attached only by RV containing tumor thrombus extending into the IVC. A small subcostal incision was then made directly over the junction of the RV and IVC. We took control of bilateral RVs and IVC (above and below the thrombus) through the same incision and repaired the IVC after complete removal of thrombus along with the specimen. We did not consider this as open conversion because a subcostal incision was made just large enough to extract the specimen; otherwise, a much larger incision (chevron or UROLOGY 83 (4), 2014
Parameter
Value
Operative time (min), median (IQR) 134.5 (99-183) EBL (mL), median (IQR) 100 (50-400) Open conversion, n (%) 4 (9.7) LOS (d), median (IQR) 4 (4-6) Postoperative Cr, mean (range) 147.5 (58-210) Postoperative Hb, mean (range) 126.7 (90-157) Mean follow-up (mo) 42 (6-107) Alive without disease 18/41 (44%) Metastatic group 0 Localized group 18/32 (56.2%) Alive with disease 8/41 (19.5%) Metastatic group 4/9 (44.4%) Localized group 4/32 (12.5%) Deceased because of disease 8/41 (19.5%) progression Metastatic group 4/9 (44.4%) Localized group 4/32 (12.5%) Deceased because of unrelated causes 3/44 (7.3%) Metastatic group 0 Localized group 3/32 (9.3%) Lost to follow-up 4/41 (9.75%) Metastatic group 1/9 (1.1%) Localized group 3/32 (9.3%) Size of the tumor (cm), mean (range) 9.3 (4-22) Histology, n (%) Clear cell 38 (92.7) Papillary 2 (4.9) Rhabdoid and signet differentiation 1 (2.4) Fuhrman grade, n (%) 2 15 (36.6) 3 24 (58.5) 4 2 (4.9) Level of tumor thrombus, n (%) Renal vein 39 (95) IVC below the diaphragm 2 (5) EBL, estimated blood loss; IQR, interquartile range; LOS, length of stay; other abbreviations as given in Table 1.
extended subcostal) is made to do open radical nephrectomy and IVC thrombectomy. In 4 patients, open conversion was required: 2 for unexpected RV thrombus, 1 for inability to progress because of significant perihilar inflammation and reactive adenopathy, and 1 for significant IVC thrombus. Follow-up data were available for a mean duration of 42 months (range, 6-107 months).
RESULTS The mean age and mean body mass index of the 41 study patients (34 males and 7 females) were 64.4 years and 28.7 kg/m2, respectively (Table 1). Median American Society of Anesthesiologists score was 2. Preoperative mean serum creatinine and hemoglobin were 103.5 mmol/ L and 140.4 g/L, respectively. Seven patients (17%) had undergone previous abdominal surgeries. None of the patients underwent preoperative angioembolization. Preoperatively, all patients underwent computed tomography, with and without oral and intravenous contrast, to define tumor extent (Fig. 1). In some patients, additional imaging in the form of Doppler ultrasound, venacavogram, and magnetic resonance imaging were performed to delineate tumor thrombus. Preoperative imaging was 813
Figure 1. (A) Coronal section of contrast enhanced computed tomography scan of 54-year-old patient showing a large left renal mass with renal vein thrombus (arrows). (B) Axial section of contrast enhanced computed tomography scan of 67-yearold patient showing the right renal mass with renal vein thrombus abutting inferior vena cava (white arrow). (Color version available online.)
successful in defining tumor thrombus in 31 patients (75.6%). RV and IVC thrombus was found preoperatively in 29 (70.7%) and 2 patients (4.8%), respectively. In 5 patients (12%), RV involvement was identified only on the pathologic analysis, and in another 5 patients (12%), the RV thrombus was identified intraoperatively. One patient had von Hippel-Lindau disease with bilateral tumors: 9-cm tumor with RV tumor thrombus on the left side and multiple small (
