Outcomes of laparoscopic radical nephrectomy in the setting of vena caval and renal vein thrombus: Seven-year experience

Purpose: We present our experience with laparoscopic radical nephrectomy for T_3b disease focusing on thrombus within the vena cava. Patients and Methods: A total of 14 patients with T_3b disease were identified from a retrospective laparoscopic renal cancer database from 2000 to 2007. Patient demographics, clinical stage, preoperative imaging, intraoperative parameters, final pathology, and postoperative course were analyzed. In patients with a large tumor thrombus, the infraumbilical extraction excision was performed early and a gel port was placed. This was used when laparoscopic milking or determination of the distal extent of the tumor thrombus was difficult. Results: Preoperative imaging identified T_3b disease in all but four patients. Four patients had caval involvement seen on imaging, with one extending well above 2 to 3 cm above the renal vein. Of the 14 patients, procedures in 13 were completed laparoscopically. There was one conversion early in the experience because of a positive frozen section of the renal vein; however, additional vein and caval margins were negative. There was one complication - a pulmonary embolism 5 days postoperatively, managed with anticoagulation, with no disease recurrence 4 years later. Conclusion: In patients with T_3b disease, laparoscopy is feasible and safe. Using advanced laparoscopic techniques to milk the tumor thrombus into the proximal renal vein with laparoscopic vascular instruments is critical to success in a purely laparoscopic thrombectomy. Placement of a gel port in the extraction incision early in the procedure may aid in hand-milking of the tumor thrombus into the renal vein in cases of extensive inferior vena cava involvement.