V07-01: Transthoracic Resection of Retrocrural Recurrence in Renal Cell Carcinoma
Surgical resection in the setting of isolated recurrence in RCC, when technically feasible, portends the best chance of cure among the treatment options available. Despite the challenges associated with retrocrural dissection, as well as the relative lack of description in urologic literature, there are various approaches to resection. We describe resection of a right retrocrural recurrence in a 56 year old male who previously underwent left radical nephrectomy for pT3a Chromophobe RCC. His recurrence was found on surveillance imaging, and the patient was started on sunitinib given his multiple medical comorbidities. The mass continued to grow on therapy, without other sites of disease. The patient's functional status was appropriate, and he elected to proceed with resection. Given the patient's prior abdominal surgery and the high location of the retrocrural mass, we planned a transthoracic approach.
After the patient was intubated with a dual lumen endotracheal tube, he was positioned in a modified left lateral decubitus position. The ninth rib served as a landmark for the incision; the external abdominal oblique muscle was split over this, and then elevated off the rib. This allowed incision of the intercostal muscles at the superior border of the rib, and ultimately entry into the pleural space. The diaphragm was retracted inferiorly, exposing the mass. We elevated the posterior parietal pleura and incised it with cautery. We split and rolled the mass off of the aorta, and controlled the thoracic duct above and below the mass with clips. Hemostasis was confirmed, and a 20Fr chest tube was placed one intercostal space below the incision. The external abdominal oblique was reapproximated and the wound was closed in the standard fashion. The chest tube was placed to suction overnight.
Operative time was two hours, with an estimated blood loss of 50mL. The patient was admitted to a telemetry ward and his chest tube was placed to suction overnight. He developed transient chylothorax which was managed conservatively with a very low fat diet. Pathology revealed metastatic chromophobe RCC, measuring 5cm, with negative margins.
Transthoracic resection is a safe, effective, and useful surgical approach when used in the appropriately selected urologic oncologic patient with challenging retrocrural disease.