Stages of surgical manipulations in the left renal cancer with implantation venous thrombus

Abstract

Introduction. Defeat of the left kidney by cancer and left-sided tumor venous invasion are diagnosed almost half as often as the right one. Only radical treatment for renal cancer (RC) complicated by a tumor thrombus of the inferior vena cava (IVC) is considered to be surgical. The use of aggressive surgery, which involves the implementation of radical nephrectomy and thrombectomy with IVC, leads to a number of complications that can be prevented by improving surgical techniques. Insufficiently covered issues of surgical tactics in left kidney cancer with implantation venous thrombus lead to their detailed discussion. Objective. To improve the results of surgical treatment of left renal cancer complicated by implantation thrombus of IVC by developing a differentiated approach to access and stages of surgical procedures. Materials and methods. The study included 147 patients with RC complicated by IVC tumor thrombosis, of which 96 (65.3%) – with right renal cancer, 51 (34.7%) – with left renal cancer. All patients underwent surgical treatment at the Transcarpathian Regional Clinical Hospital named after Andriy Novak or the Transcarpathian Antitumor Center in the period from 2005 to 2020. The level of spreading of tumor thrombus by IVC was determined according to the classification of the Mayo clinic. At defeat of the left kidney by a tumor 0 the level of a thrombus was diagnosed in 17 (33,3%) patients, I level – in 17 (33,3%), II level – in 10 (19,6%), III level – in 5 (9,8%), IV level – in 2 (3,4%). In 6 (11,8%) cases, the implantation thrombus of the IVC was combined with retrograde spread to the left adrenal and left gonadal veins, and in 12 (23,5%) – with descending phlebothrombosis of the IVC and the common iliac vein. All patients underwent surgery with a «chevron» or «mercedes» transabdominal approach using the en block organ mobilization technique in the right and left abdominal and retroperitoneal regions. Results. The average time of the operation was 196 minutes, the average volume of blood loss was 400 ml. The spleen was injured during surgery in 2 (3.9%) patients. Tumor IVC thrombus was removed in all (100%) cases. Postoperative complications of I-II degrees according to the Clavien-Dindo classification were recorded in 12 (23,5%) cases. Overall 1, 3, 5 year survival was 98,0%; 70,6%; 47,1% respectively. The use of the presented stages in the surgical treatment of left kidney tumors with implantation IVC thrombus made it possible to perform radical intervention in all cases: cavatrombectomy and nephrectomy, without episodes of pulmonary embolism, without significant bleeding and without repeated thrombosis. Conclusion. Transabdominal «chevron» or «mercedes» access with the use of the «en block» organ mobilization technique in the right and left sides of the abdominal cavity and retroperitoneal space, priority complete control of IVC and renal veins with priority performance of the venous stage of the operation and transfer of the stump of the left renal vein through the mesenteric window of the small intestine to the left provide successful radical surgical treatment of patients with left renal cancer with implantation venous thrombus.