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SIU 2019 39th Annual Society of International Urology Congress

SIU 2019: Surgical Management of Renal Cell Carcinoma with IVC Involvement

Athens, Greece (Urotoday.com) Dr. Leibovitch gave a detailed discussion on the surgical management of renal cell carcinoma (RCC) with inferior vena cava (IVC) tumor thrombus involvement. Venous tumor thrombus (VTT) occurs most often with clear cell RCC but can occur with multiple retroperitoneal tumors including urothelial carcinoma, germ cell tumor, adrenal tumors, metastases to kidneys, Wilm’s tumor and others.  Approximately 19% of VTT are found incidentally without any symptoms.

According to Dr. Leibovitch, the best imaging modality to use in these cases is MRI. MRI is superior for distinguishing tumor from a clot, as can be seen in Figure 1. The thrombus can progress rapidly and therefore performing an updated imaging scan (one week before surgery) is mandated. It is also important to consider anticoagulation when the IVC is severely occluded or nearly occluded, and when there is a bland thrombus. There is no need to place an IVC filter preoperatively. Lastly, staging as for any other advanced renal mass should be performed.

Figure 1 – MRI for distinguishing tumor thrombus and bland thrombus:

SIU 2019 MRI thrombus and bland thrombus

Data on patients with VTT who were not managed surgically showed poor prognosis.
Candidates for non-operative management include:
  • Patients with poor performance status
  • Acute/fulminant Budd-Chiari
  • Bulk/critical metastatic disease
There is a debate regarding when to give systemic therapy in these patients. Dr. Leibovitch believes that for M0 disease - resection is preferred, and systemic therapy should be given for poor surgical candidates. For M1 disease, the performance status and disease burden will eventually determine preoperative vs. postoperative systemic therapy vs. systemic therapy alone.

Dr. Leibovitch continued to describe his surgical principles for tumor thrombectomy:
  1. Assemble an experienced team – urologist, vascular, anesthesia, hepatobiliary surgeon, and cardiac surgeon if needed
  2. Operate on vessels first
  3. Ligate the renal artery, no need to embolize
  4. Isolate venous structures, consider the venous return
  5. Completely remove thrombus
  6. Mange any distal bland thrombus
  7. Repair/patch/replace IVC as needed

The incision itself should provide maximum exposure, whether it is done with a midline incision, bilateral subcostal (Chevron), or thoracoabdominal.

The volume of surgeries is important and impacts outcomes. In a large Canadian study assessing 816 cases between 1998 and 2007, the in-hospital mortality was 7.2%, with 75% of deaths occurring in the first 2 cases a surgeon performed.1 Increased surgeon volume was shown to be associated with lower in-hospital mortality.

Dr. Leibovitch believes that there is no need for preoperative embolization. There is data showing that embolization actually increased blood loss, complications, and mortality.2 Another important surgical tip is to pay attention to altered venous anatomy (Figure 2).

Next, Dr. Leibovitch showed how to manage a bland thrombus in the IVC or iliac veins (Figure 3). If the IVC needs to be resected due to complete occlusion caused by a bland thrombus, the cavotomy closure can be done as sewn or stapled closure (Figure 4).

Figure 2 – Altered venous anatomy:

SIU 2019 altered venous anatomy

Figure 3 – How to manage a bland thrombus:

SIU 2019 bland thrombus management

Figure 4 – Cavotomy closure techniques following IVC ligation:

SIU 2019 Cavotomy closure technique

The techniques for the surgical treatment of VTT at each level were described next. For level 1 or 2:
  • Occlude renal artery first
  • Ligate hepatic veins from the caudate lobe of the liver
  • Simple occluding maneuvers (contralateral renal vein, IVC inferior and superior to the VTT) (Figure 5)
Figure 5 – Tumor thrombus level 1 or 2 treatment:

SIU 2019 Tumor thrombus level 1 or 2 treatment

For level 3 tumor thrombus (Figure 6):
  • Renal artery ligation
  • Mobilize liver for supra-hepatic IVC access
  • Sequence for venous control:
    1. Contralateral renal vein
    2. Distal IVC
    3. Hepatic inflow (pringle maneuver)
    4. Supra-hepatic IVC (above thrombus)
  • Remove thrombus
  • Occlude IVC below the hepatic inflow
  • Release supra-hepatic IVC and pringle
  • Repair Vena cava leisurely
Figure 6 – Tumor thrombus level 3 treatment:

SIU 2019 Tumor thrombus level 3 treatment

For tumor thrombus level 4:
  • Requires constant hemodynamic monitoring
  • Monitor thrombus in the atrium and / or IVC
  • Assess the adequacy of resection
  • Use veno-veno bypass or cardiopulmonary bypass +/- hypothermic (16 degrees Celsius) circulatory arrest
Positive vascular margins can increase cancer-specific mortality (HR 1.49, p=0.05) after adjusting for fat invasion, VTT level, necrosis, nodal status, metastases, and sarcomatoid features.3 The cancer-specific survival is immensely affected by the stage of disease4 (Figure 7).

Figure 7 - Cancer-specific survival by stage:

SIU 2019 Cancer specific survival by stage

Dr. Leibovitch concluded his talk mentioning several future directions. These include the role of neoadjuvant therapy and minimally invasive surgery, which will be further explored.

Presented by: Bradley Leibovich, MD, Department of Urology, Mayo Clinic, Rochester, Minnesota

Written by: Hanan Goldberg, MD, Urology Department, SUNY Upstate Medical University, Syracuse, New York, USA, Twitter: @GoldbergHanan at the 39th Congress of the Société Internationale d'Urologie, SIU 2019, #SIUWorld #SIU2019, October 17-20, 2019, Athens, Greece

References:
1. Toren P, Abouassaly R, Timilshina N, Kulkarni G, Alibhai S, Finelli A. Results of a national population-based study of outcomes of surgery for renal tumors associated with inferior vena cava thrombus. Urology 2013; 82(3): 572-7.
2. Subramanian VS, Stephenson AJ, Goldfarb DA, Fergany AF, Novick AC, Krishnamurthi V. Utility of preoperative renal artery embolization for management of renal tumors with inferior vena caval thrombi. Urology 2009; 74(1): 154-9.
3. Psutka SP, Leibovich BC. Management of inferior vena cava tumor thrombus in locally advanced renal cell carcinoma. Ther Adv Urol 2015; 7(4): 216-29.
4. Blute ML, Leibovich BC, Lohse CM, Cheville JC, Zincke H. The Mayo Clinic experience with surgical management, complications and outcome for patients with renal cell carcinoma and venous tumour thrombus. BJU international 2004; 94(1): 33-41.