Images in Clinical Urology Renal Cell Carcinoma With Infrahepatic Vena Caval Tumor Thrombus Treated With a Novel Combined Retroperitoneal and Transperitoneal Pure Laparoscopic Procedure Qi Tang, Tianyu Wang, Xuesong Li, Zheng Zhang, Gang Song, Zhisong He, and Liqun Zhou A 61-year-old male patient presented with intermittent gross hematuria. A right renal mass with infrahepatic vena caval tumor thrombus was found using magnetic resonance imaging. We undertook a novel combined retroperitoneal and transperitoneal pure laparoscopic nephrectomy with vena caval thrombectomy for this patient. The patient recovered well after surgery and discharged on day 6. A clear cell renal cell carcinoma with venous extension was confirmed by pathologic assay. To our knowledge, this is the first report of such a novel hybrid surgical strategy. UROLOGY 83: e9ee10, 2014. 2014 Elsevier Inc.
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61-year-old male patient presented with intermittent gross hematuria for 1 month. Using magnetic resonance imaging, a 6.4-cm right renal mass with tumor extending into the inferior vena cava (IVC) was shown (Fig. 1). A novel combined retroperitoneal and transperitoneal pure laparoscopic procedure was adopted. The patient was first placed in a left lateral position, and 3 trocars were placed for the retroperitoneal approach (Fig 2A). After the mobilization of kidney, the renal artery was easily found and ligated (Fig 3A). Then, a wide incision on posterior peritoneum was made, and the patient was changed to a semisupine position. After replacement of other 3 trocars flabellate beside the umbilicus (Fig 2B), we continued the transperitoneal procedure. We carefully dissected and ligated the lumbar tributaries and then completed the IVC thrombectomy (Fig 3B). Either retroperitoneal laparoscopic nephrectomy combined with open thrombectomy or pure transperitoneal laparoscopic procedures had been reported.1-3 However, each of these procedures had some shortages. By combining 2 laparoscopic approaches, we took both
the advantages of retroperitoneal procedure in rapid renal pedicle control and transperitoneal procedure in IVC mobilization and thrombectomy.1,4,5 However, more cases of patients are needed to evaluate the potential perioperative outcome advantages of this novel procedure. References 1. Xu B, Zhao Q, Jin J, et al. Laparoscopic versus open surgery for renal masses with infrahepatic tumor thrombus: the largest series of retroperitoneal experience from China. J Endourol. 2014;28:201-207. 2. Hoang AN, Vaporcyian AA, Matin SF. Laparoscopy-assisted radical nephrectomy with inferior vena caval thrombectomy for level II to III tumor thrombus: a single-institution experience and review of the literature. J Endourol. 2010;24:1005-1012. 3. Romero FR, Muntener M, Bagga HS, et al. Pure laparoscopic radical nephrectomy with level II vena caval thrombectomy. Urology. 2006; 68:1112-1114. 4. Disanto V, Pansadoro V, Portoghese F, et al. Retroperitoneal laparoscopic radical nephrectomy for renal cell carcinoma with infrahepatic vena caval thrombus. Eur Urol. 2005;47:352-356. 5. Stewart GD, Ang WJ, Laird A, et al. The operative safety and oncological outcomes of laparoscopic nephrectomy for T3 renal cell cancer. BJU Int. 2012;110:884-890.
Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Beijing, China Reprint requests: Liqun Zhou, M.D., Ph.D., Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, No. 8 Xishiku St, Xicheng District, Beijing 100034, China. E-mail: zhoulqmail@ sina.com Submitted: December 30, 2013, accepted (with revisions): January 24, 2014
ª 2014 Elsevier Inc. All Rights Reserved
0090-4295/14/$36.00 http://dx.doi.org/10.1016/j.urology.2014.01.025
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Figure 1. Right renal mass with infrahepatic vena caval tumor thrombus (arrows).
Figure 2. Trocars placement. (A) Trocars for the retroperitoneal approach (Trocar 1-3). (B) Trocars for the transperitoneal approach (Trocar 3-6, trocar 3 can be used for both retroperitoneal and transperitoneal approaches).
Figure 3. Intraoperative images. (A) The renal artery was exposed and ligated. (B) Procedure of thrombectomy.
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UROLOGY 83 (5), 2014
A
61-year-old male patient presented with intermittent gross hematuria for 1 month. Using magnetic resonance imaging, a 6.4-cm right renal mass with tumor extending into the inferior vena cava (IVC) was shown (Fig. 1). A novel combined retroperitoneal and transperitoneal pure laparoscopic procedure was adopted. The patient was first placed in a left lateral position, and 3 trocars were placed for the retroperitoneal approach (Fig 2A). After the mobilization of kidney, the renal artery was easily found and ligated (Fig 3A). Then, a wide incision on posterior peritoneum was made, and the patient was changed to a semisupine position. After replacement of other 3 trocars flabellate beside the umbilicus (Fig 2B), we continued the transperitoneal procedure. We carefully dissected and ligated the lumbar tributaries and then completed the IVC thrombectomy (Fig 3B). Either retroperitoneal laparoscopic nephrectomy combined with open thrombectomy or pure transperitoneal laparoscopic procedures had been reported.1-3 However, each of these procedures had some shortages. By combining 2 laparoscopic approaches, we took both
the advantages of retroperitoneal procedure in rapid renal pedicle control and transperitoneal procedure in IVC mobilization and thrombectomy.1,4,5 However, more cases of patients are needed to evaluate the potential perioperative outcome advantages of this novel procedure. References 1. Xu B, Zhao Q, Jin J, et al. Laparoscopic versus open surgery for renal masses with infrahepatic tumor thrombus: the largest series of retroperitoneal experience from China. J Endourol. 2014;28:201-207. 2. Hoang AN, Vaporcyian AA, Matin SF. Laparoscopy-assisted radical nephrectomy with inferior vena caval thrombectomy for level II to III tumor thrombus: a single-institution experience and review of the literature. J Endourol. 2010;24:1005-1012. 3. Romero FR, Muntener M, Bagga HS, et al. Pure laparoscopic radical nephrectomy with level II vena caval thrombectomy. Urology. 2006; 68:1112-1114. 4. Disanto V, Pansadoro V, Portoghese F, et al. Retroperitoneal laparoscopic radical nephrectomy for renal cell carcinoma with infrahepatic vena caval thrombus. Eur Urol. 2005;47:352-356. 5. Stewart GD, Ang WJ, Laird A, et al. The operative safety and oncological outcomes of laparoscopic nephrectomy for T3 renal cell cancer. BJU Int. 2012;110:884-890.
Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Beijing, China Reprint requests: Liqun Zhou, M.D., Ph.D., Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, No. 8 Xishiku St, Xicheng District, Beijing 100034, China. E-mail: zhoulqmail@ sina.com Submitted: December 30, 2013, accepted (with revisions): January 24, 2014
ª 2014 Elsevier Inc. All Rights Reserved
0090-4295/14/$36.00 http://dx.doi.org/10.1016/j.urology.2014.01.025
e9
Figure 1. Right renal mass with infrahepatic vena caval tumor thrombus (arrows).
Figure 2. Trocars placement. (A) Trocars for the retroperitoneal approach (Trocar 1-3). (B) Trocars for the transperitoneal approach (Trocar 3-6, trocar 3 can be used for both retroperitoneal and transperitoneal approaches).
Figure 3. Intraoperative images. (A) The renal artery was exposed and ligated. (B) Procedure of thrombectomy.
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UROLOGY 83 (5), 2014
