[Surgery for renal carcinoma with supradiaphragmatic tumor thrombus: avoiding sternotomy and cardiopulmonary bypass].

OBJECTIVE: To describe a feasible surgical technique for patients with renal cell carcinoma associated with a supradiaphragmatic tumor thrombus that avoids cardiopulmonary bypass procedure.

METHODS: We retrospectively analyzed 2 cases with right kidney tumor and tumor thrombus above the diaphragm treated in April and August, 2015. The two patients were both female, aged 73 and 67 years. The tumor sizes of right kidneys were 7.0 cm×6.3 cm×5.7 cm and 8.7 cm×7.0 cm×5.2 cm, and the tumor thrombuses were 1.3 cm and 1.8 cm above the diaphragm. The second patient had synchronous metastasis in right adrenal gland , and the tumor thrombus arose from the adrenal vein but not the renal vein. Intraoperative transesophageal echocardiography (TEE) was used to assess real-time mobility of the thrombus. A modified chevron incision was used, the right kidney was mobilized laterally and posteriorly, and the renal artery was identified, ligated, and divided. The infradiaphragmatic inferior vena cava (IVC) was exposed and isolated by mobilizing the liver off the diaphragm or to the left (piggyback liver mobilization, case 2). The central diaphragm tendon was dissected or incised in the midline until the supradiaphragmatic intrapericardial IVC was identified and gently pulled beneath the diaphragm and into the abdomen. The tumor thrombus was then "milked" downward out of the intrapericardial IVC under the guidance of TEE. The distal and proximal IVC to the tumor thrombus, porta hepatis, and left renal vein were clamped. Tumor thrombus was removed from the IVC. The IVC was sutured and vascular clamps were placed below the major hepatic veins. Pringle's maneuver was then released and hepatic blood drainage was permitted during closure of the remaining IVC. Related literature was reviewed.

RESULTS: Complete resection was successful through the transabdominal approach without CBP in both patients. Estimated blood loss was 1 500 mL and 2 000 mL, and 1 200 mL and 800 mL of blood were transfused. The postoperative courses were uneventful. Both patients subsequently underwent tyrosine-kinase inhibitor therapy. Both patients were alive without tumor recurrence or new metastasis during the follow-up of 6 months and 9 months.

CONCLUSION: In selected cases, renal cell carcinoma extending into the IVC above the diaphragm can be resected without sternotomy, CBP or DHCA.