Marcello Bergonzini1, Enrico Citterio1, Alessandro Piccinelli2, Orazio Maugeri2, Roberto Gallotti1, Pierpaolo Graziotti2.
1Istituto Clinico Humanitas. Reparto di Cardiochirurgia, Rozzano (MI), Italy, 2Istituto Clinico Humanitas. Reparto di Urologia, Rozzano (MI), Italy.
OBJECTIVE: To our knowledge, we present the initial clinical report of standard radical nephrectomy associated with minimal invasive extracorporeal circulation for renal cell carcinoma with tumor thrombus extending into the inferior vena cava up to the right atrium.
METHODS: From January 1997 to November 2007 5 patients with renal cell carcinoma and tumor thrombus extending into the right atrium underwent radical nephrectomy with tumor thrombus extirpation in our Center. Extracorporeal circulation with deep hypothermic arrest was accomplished with a minimally invasive technique, using an Endoclamp® catheter. The clinical presentation, laboratory and imaging investigations, extent and level of caval involvement, operative details, and estimated blood loss, as well as the postoperative course, morbidity, and actuarial and disease-free survival were analyzed.
RESULTS: Patient population consisted of 2 males and 3 females, with a mean age of 69 years (range 37 to 79). Mean operative time was 4 hours 30 minutes (range: 4 to 5 hours). Conversion to standard sternotomy was necesssary in one case, due to tumor thrombus fracture. Mean intensive care unit stay was 2.1 days and overral hospital stay was 9.8 days. No patient experienced prolonged ventilatory support (> than 48 hours) nor pneumotorax. One patient died during the hospital stay from bowel infarction. Two patients with progressive disease are alive after a mean follow-up of 44 months (36-52) and 2 are alive free of disease after a mean of 17 months (8-31).
CONCLUSIONS: In case of patients in which the thrombus is suitable for retrograde extraction through caval incision, minimal invasive extracorporeal circulation can be associated to standard urologic techniques to resect renal masses with level IV thrombi. This technical strategy minimizes respiratory impairment and can improve early recovery, reducing significantly the huge invasiveness of this surgical procedure.
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