MP50-06: Radical nephrectomy and caval thrombectomy with heart beating technique for renal cell cancer with tumor thrombus extension into inferior vena cava and right atrium: a less invasive multidisciplinary approach

Sonia Guzzo, Sebastiano Nazzani*, Chiara Vaccaro, Roberto Di Benedetto, Claudia Signorini, Damiano Vizziello, Andrea Conti, Elisabetta Finkelberg, Giacomo Bortolussi, Pietro Acquati, Carlo De Vincentiis, Luca Carmignani, Milan, Italy

Introduction: Radical nephrectomy with inferior vena cava thrombectomy for renal cell carcinomas (RCCs) with Mayo levels III and IV thrombus is considered one of the most challenging urological procedures. Serious intraoperative complications, such as bleeding and embolism may occur. In this setting, extracorporeal circulation and deep hypothermic circulatory arrest has become the gold standard treatment for Mayo levels III and IV RCC. The latter involves full heparinization, coagulopathy secondary to hypothermia and long operative time. Hence, we describe a less invasive operative strategy aimed at minimizing the complication rate associated with treatment of tumour thrombus at Mayo level III and IV.

Methods: Between 2016 and 2020, 12 patients diagnosed with Renal Cell Cancer and extended venous tumour thrombus were treated with radical nephrectomy and thrombectomy at our Institution. Among them, 5 had supradiaphragmatic extension (Mayo level IV) seeking a complex and multidisciplinary surgical approach. Therefore, a coordinated thoracic and abdominal procedure was performed between urological and cardiosurgical teams. For level IV thrombus, a beating heart surgery using a simplified cardiopulmonary bypass (CPB) technique was used for thrombus retrieval from the right atrium. On the other hand, Mayo level III only needed abdominal access. Perioperative complication and mortality rates within 30 and 90 days of surgery were recorded.

Results: Of 12 patients 5 were male (41.7%) and 7 were female (58.3%). Median age was 70,5 years [Interquartile Range (IQR): 6,1]. Median BMI was 26,6 (IQR:20,8-28). ASA score was 2 in 4 (33.3%) and 3 in 8 (66.6%). According to tumour characteristics, cT stage was cT3b in 3 (25%), cT3c in 5 (41,7%) and cT4 in 4 (33,3%). cN stage was cN0 in 9 (75%) and cN+ in 3 (25%). Finally, 4 patients (33,3%) had metastatic disease.  Median surgical time was 240 minutes (IQR:210-281). Median CPB time was 40 minutes (IQR:40-48). Median blood loss was 1500 mL (IQR:1200-2500). Median intensive care stay was 2 days (IQR:1-3) and median duration of hospitalization was 10,5 (IQR: 8-15,3). No patients died during the procedure. Overall 50% of patients had postoperative complications. Specifically, 4 (33,3%) patients had Grade II surgical complications, according to the Clavien-Dindo classification, 1 (8,3%) had Grade IIIb and 1 (8,3%) Grade IV. All patients were discharged home or for rehabilitation. At final pathology pT stage was pT3b in 5 (41,7%), pT3c in 6 (50%) and pT4 in 1 (8,3%).

Conclusions: The use of beating heart on simplified CPB is a less invasive method for radical resection of renal cell carcinomas with intracardiac tumour extension, while extended intracaval tumour thrombus, as Mayo level III, can still be treated exclusively with abdominal approach.

Source of Funding: None.

Encore presentation at EAU21 Congress.