Nephrectomy and thrombectomy in renal cell carcinoma patients with extensive tumor venous thrombosis: how to minimize surgical risks?

Objective: to evaluate the outcomes of thrombectomy performed using different surgical techniques in renal cell carcinoma (RCC) patients with extensive tumor venous thrombosis.Materials and methods. This study included 345 RCC patients with extensive tumor venous thrombosis who underwent surgical treatment.The median age was 57 years (range: 16—79 years); the male-to-female ratio was 1:1.9. Two hundred and sixty patients (75.4 %) had their tumor thrombus originating from the right renal vein, 85 patients (24.6 %) — from the left renal vein. In 169 patients (49.0 %), the thrombus spread to the retrohepatic inferior vena cava (IVC), while in 176 patients (51.0 %), it spread above the diaphragm (to the intrapericardial IVC in 59 patients (17.1 %) and to the right heart cameras in 117 patients (33.9 %)). Regional metastases were found in 90 individuals (26.1 %), while distant metastases were observed in 124 patients (35.9 %). All patients underwent surgical treatment (radical in 251 patients (72.8 %) and cytoreductive — in 94patients (27.2 %)); the technique of vascular control and circulatory support was chosen individually. In 97 patients (28.1 %), the control over the cranial thrombus boarder did not require opening of the chest cavity; eleven patients (3.2 %) were operated on with cardiopulmonary bypass.Results. The median surgery time was 215 minutes; the median blood loss was 4500 mL. Intraoperative complications were registered in 209 patients (60.6 %) and postoperative complications were observed in 118 patients (35.1 %) (including those of grade I—II in 43 individuals (12.8 %) and grade III—V in 75 individual (22.3 %)). The in-hospital mortality rate was 10.7 % (37/345). At a median follow-up of 32.3 months, overall and diseasespecific survival rates among all patients were 51.9 % and 68.3 %, respectively; relapse-free survival rate in 226patients who have undergone radical surgeries and discharged from the hospital was 61.5 %; progression-free survival rate in 82 patients who have undergone cytoreductive surgery was 33.0 %. The method ofIVC control and circulatory support had no effect on both short-term and long-term treatment outcomes (p >0.05 for both).Conclusion. The use of minimally invasive techniques of vascular control and avoidance of cardiopulmonary bypass in carefully selected RCC patients with extensive tumor venous thrombosis do not worsen the outcomes of nephrectomy and thrombectomy.