Surgical Tactics in Implantation Suprarenal Thrombi of the Inferior Vena Cava in Tumor of the Left Kidney

Abstract

Today, despite the presence of a great arsenal of immunochemotherapeutic agents and modern sources of radiation exposure, the main method of treating localized and locally advanced forms of renal cancer is surgical. Surgical treatment of uncomplicated forms of renal cancer is practically a solved problem and is beyond doubt, but in renal cancer with an implantation thrombus of the inferior vena cava (IVC) system, a number of questions arise that need to be resolved. Purpose. To propose and introduce into clinical practice the tactical techniques and the sequence of surgical procedures for a tumor of the left kidney with implantation thrombi of the suprarenal IVC. Materials and methods. The study included 144 patients with RC complicated by IVC tumor thrombosis. All patients were treated at the Transcarpathian Regional Clinical Hospital named after A. Novak in the period from 2005 to 2019. The age of the patients varied from 27 to 79 years, the average age was 58.4 years. There were 95 men (66%) and 49 women (34%). The level of extension of tumor thrombus by IVC was determined according to the classification of the Mayo clinic. The lesion of the left kidney with a tumor took place in 49 (34%) patients, of which 16 (32.7%) patients had 0 level thrombus, 17 (34.7%) – I level, 10 (20.4%) – II level, 4 (8.2%) – III level, and 2 (4.1%) – IV level. All patients underwent surgery with the “chevron” or “mercedes” transabdominal approach using the “en block” organ mobilization technique in the right and left abdominal and retroperitoneal regions. At the levels III and IV of the tumor thrombus during cavatrombectomy, the piggyback technique of liver mobilization, the liver-hanging maneuver, and Pringle were used. For the level IV tumor thrombus, the semi-oval or T-shaped diaphragmotomy was performed in the tendon center of the diaphragm above the IVC. Results. There were no cases of left renal cancer with implantable IVC thrombi with the episodes of perioperative pulmonary embolism or postoperative mortality. Conclusion. The proposed staging of transabdominal surgical tactics for the removal of the level II–IV tumor thrombi with initial cavathrombectomy and restoration of blood flow through the IVC predetermines the success and radicalism of treatment in patients with the left kidney tumors with implantation thrombi of the suprarenal IVC.