Elsevier

Urology

Volume 72, Issue 2, August 2008, Pages 268-272
Urology

Laparoscopy and Robotic
Hand-Assisted Laparoscopic Nephrectomy for Renal Cell Cancer with Renal Vein Tumor Thrombus

https://doi.org/10.1016/j.urology.2008.02.026Get rights and content

Objectives

To assess outcomes after hand-assisted laparoscopic nephrectomy (HALN) for renal cell cancer tumor thrombus confined to the renal vein and to compare outcomes with published series in this setting.

Methods

Thirteen patients underwent HALN for radiologic T3b disease (tumor thrombus confined to the renal vein on preoperative computed tomography) under the care of three surgeons at two centers between 1997 and 2006.

Results

Median patient age was 69 years. Median duration of surgery was 176 minutes. Median blood loss was 250 mL. Median postoperative stay was 3 days. Two patients were converted to open surgery: 1 owing to unsuspected invasion of the subdiaphragmatic vena cava requiring vascular clamping with direct excision and suture, and 1 for control of bleeding. No patients suffered major morbidity associated with surgery, and there was one minor complication (aside from blood transfusion in 5 patients). After 2.7 years median follow-up, 3 of the 12 patients with pT3bN0 disease had metastases, but there were no local recurrences.

Conclusions

These data demonstrate that HALN for renal cell cancer with tumor thrombus limited to the renal vein is feasible. Our outcomes compare favorably to published data on open surgical radical nephrectomy in this setting, and HALN should be considered in centers with experience with this technique.

Section snippets

Material and Methods

Histopathology and surgical databases at East Surrey Hospital, Redhill, Surrey, United Kingdom and at Michigan Medical Center, Ann Arbor, Michigan were queried for operations on renal cell carcinoma with tumor thrombus involving the renal vein but not extending into the vena cava (TNM 2002 stage T3b, excluding caval thrombus cases) between 1997 and 2006. Thirteen patients who underwent HALN for nonmetastatic RCC with level 1 tumor thrombus were identified.

Notes and images were reviewed, and

Results

Thirteen patients underwent HALN for T3b disease limited to the renal vein, diagnosed on CT scan. Demographics are shown in Table 1. Perioperative and pathological outcomes are summarized in Table 2.

Five patients (38%) required blood transfusion, including 2 with preoperative anemia and 3 (23%) who experienced major blood loss of more than 1000 mL. One patient was converted to open surgery because of inferior vena cava invasion requiring vascular clamping followed by excision of a segment of

Comment

Tumor thrombus at the level of the renal vein represents a surgical challenge in the laparoscopic era. The accepted treatment has been open surgical nephrectomy with caudal and cephalad control of the vena cava and control of the contralateral renal vein, usually with vascular clamps.10, 11, 12

Several investigators have reported series of laparoscopic operations for tumors with either microscopic13 or macroscopic13, 14, 15, 16, 17 renal vein involvement (summarized in Table 3). Patients have

Conclusions

Hand-assisted laparoscopic nephrectomy provides a safe and effective alternative to open nephrectomy for T3b renal cell carcinoma for which the thrombus is confined to the renal vein; this has allowed us to approach all of the T3b renal tumors referred to us laparoscopically (when thrombus is confined to the renal vein). In common with open surgery and LRN, significant intraoperative bleeding may be encountered when locally advanced tumors are approached with the hand-assisted technique, but in

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