V1081: Radical nephrectomy intra-atrial tumor thrombectomy: Thoracoabdominal extraperitoneal intra-extrapleural approach

Video

Introduction and Objectives
Tumor thrombus protruding thorugh the major venous system inside to the atrium is determined in a few patients presenting with renal mass (1-4%). In this video, intra-extrapleural, extraperitoneal open radical nephrectomy and intra-atrial tumor thrombectomy technique are presented.

Methods
Between 1996 and 2012, 5 patients with renal masses and its tumor trombus extended to the right atrium, was operated. In all patients, extraperitoneal, extrapleural thoracoabdominal radical nephrectomy and tumor thrombectomy was performed by removal of the 8 rib at flank and first aid position. Flank incision extended midline supra and even infraumblical area in some cases, which had higher volume of thrombus, inside the inferior vena cava. The parietal peritoneum completely dissected from rectus sheat, and deviated towards to the contralateral side to provide better exposure of vena cava, thus process was continued retroperitoneally. After dissection of the kidney from the surrounding tissues was achieved, right away renal artery was ligated to reduce the congestion of the kidney. After dissection of the renal vein and vena cava, the dorsal lumbar veins ligated in some cases. In all cases, tumor thrombus extending to the atrium was removed by the inflated balloon of the 20 f foley catheter in the atrium. Vena cava was primarily repaired 4/0 prolen suture within a few minutes. After opening of the caval clampage, vena cava was stiched with second layer. Injuried pleura was closed together with the diaphragm muscle with no need of thoracic tube. Operation time, amount of blood loss, preoperative and postoperative complications and survival was recorded. Heart-lung machine was not used, and peroperative emboli was never seen.

Results
Mean operation time was 176 minutes. Mean blood loss was 2140 cc (range; 1400- 3500 cc). Mean hospital stay was 4,8 days (range; 3- 8 days). Postoperative paralytic ileus that was observed in no patients managed. Average survival was 21,6 (range; 8-45) months.

Conclusions
Thoracoabdominal intra-extrapleural extraperitoneal approach provides full control of the vena cava (also retrohepatic vena cava without mobilization of liver), aorta and even pericardium in patients with renal mass with atrial thrombus.

Funding: None