Surgical management of renal cell carcinoma with levels III and IV tumor thrombus using the « flush » technique
To determinate feasibility and results of the flush technique by hands for the surgical management of renal cell carcinoma (RCC) with levels III and IV inferior vena cava thrombus (CVT)
We conducted a retrospective study for all patients who underwent a surgical treatment for RCC with levels III and IV VCT in our department between June 2010 and July 2017. Sixteen patients were identified.
All tumors were resected using a subcostal incision for right RCC and a chevron incision for the left RCC. Vena cava control was performed only on its subhepatic portion. After renal artery ligature, anesthesiologists were asked to generate a positive pressure in the small circulation. Then the vena cava was incised longitudinally to the orifice of the renal vein and the thrombus dissected and extracted of the upper part of the vena cava. Only once the supra renal part of the vena cava was free of thrombus, the supra renal portion of the vena cava could be clamped. We have never had to perform neither thoracotomy nor hepatic mobilization. Therefore, no help of a hepatic, vascular or cardiac surgeon was necessary. The mean operative time was 201 minutes. The mean estimated blood loss was 2040 ml. No patient died during hospitalization and mean hospitalization stay duration was 16,6 days.
The flush technique allows a limitation of the dissection extent, neither hepatic mobilization nor thoracotomy, resulting in a decreasing operative time and less blood loss, without any increase of perioperative morbi-mortality. It requires a good collaboration with the anesthetic team for achieving the adequate venous pressure required during the vena cava purge.