Hand assisted laparoscopic radical nephrectomy for renal cell carcinoma with inferior vena caval thrombus

To our knowledge we present the initial clinical report of hand assisted laparoscopic radical nephrectomy for renal cell carcinoma with tumor thrombus extending into the inferior vena cava.

A 76-year-old man was referred to our medical center with a 12.5 x 10 cm. stage T3b right renal tumor extending into the inferior vena cava. The caval thrombus was limited and completely below the level of the hepatic veins. After preoperative renal embolization via the hand assisted transperitoneal approach the right kidney was completely dissected with the renal hilum. Proximal and distal control of the inferior vena cava was obtained with vessel loops and a single lumbar vein was divided between clips. An endoscopic Satinsky vascular clamp was placed on the inferior vena cava just beyond its juncture with the right renal vein, thereby, encompassing the caval thrombus. The inferior vena cava was opened above the Satinsky clamp and a cuff of the inferior vena cava was removed contiguous with the renal vein. The inferior vena cava was repaired with continuous 4-zero vascular polypropylene suture and the Satinsky clamp was then removed. A literature search failed to reveal any similar reports of laparoscopic radical nephrectomy for stage T3b renal cell cancer.

Surgery was completed without complication with an estimated 500 cc blood loss. Pathological testing confirmed stage T3b grade 3 renal adenocarcinoma with negative inferior vena caval and soft tissue margins.

The introduction of vascular laparoscopic instrumentation and the hand assisted approach enabled us to extend the indications for laparoscopic radical nephrectomy to patients with minimal inferior venal caval involvement.