Surgical Management of Inferior Vena Cava Tumor Thrombus in Patients with Renal Cell Carcinoma

Renal cell carcinoma (RCC) is associated with a biological propensity for vascular invasion with extension of the tumor to the renal vein or inferior vena cava and total resection of the renal tumor and IVC tumor thrombus is considered the optimal therapy when no distant metastases are present. The surgical approach to a specific patient with RCC and IVC tumor thrombus should be selected according to the level of the tumor thrombus and the characteristics of the primary renal tumor such as size, location, regional lymphadenopathy and aberrant vascular anatomy. The surgical management of RCC and IVC tumour thrombus requires the commitment of a multidisciplinary surgical team particularly for a higher (level III and IV) tumor thrombus. Preoperative imaging is very important for the surgical planning and management. An extended chevron incision with or without a sternotomy provides excellent surgical exposure. Level 0, level I and most level II tumors can be removed using straightforward occluding maneuvers, while maintaining control of the caval thrombus and the contralateral renal vein. Vascular bypass can frequently be required for the safe and complete resection of level III tumor thrombus. The resection of level IV tumors is generally performed with the use of cardiopulmonary bypass and circulatory arrest. In this review, these surgical aspects and treatment of IVC tumor extension in patients with RCC will be summarized, hoping to provide a clear and comprehensive guideline for both urology and cardiovascular specialists. (JAREM 2013; 3: 47-52)