Extension - surgical technique

Introduction: Surgical technique for left renal cell carcinoma with infradiaphragmatic caval extension is presented. Technique: A transperitoneal bilateral subcostal approach was used. After left colon reflection, the renal artery is ligated and divided, the left renal vein is dissected on. The right colon reflection is perform ed, the right renal vein and vena cava is dissected. Satinsky clamp is placed on infrarenal vena cava, a bulldog clamp is placed on the right renal vein and a Satinsky clamp is placed on vena cava above the thrombus. Circular incision on vena cava at the level of left renal vein is performed and en block perifascial nephrectomy including the thrombus is done. The vena cava incision is repaired with a continuos 4-0 vascular suture. Extensive lymph node dissection is performed. Conclusions: Out of more than 1305 RCC operated in our Department between 1975 - 2000, 142 cases have had caval extension. Using appropriate surgical technique, the patient's survival is almost similar to those without caval extension

Managing of a complex case of synchronous bilateral kidney tumors associated with Hodgkin lymphoma

Abstract Introduction: Renal cell carcinoma is one of the most common tumors in adults, accounting for approximately 3% of all cancers. Association of renal tumors and other neoplasia is a rare event. Surgical treatment strategy of synchronous bilateral renal tumors and the value of lymph node dissection are subjects of debate. Objective: To present the management of a complex case of synchronous bilateral kidney tumors associated with Hodgkin lymphoma. Materials and method: We present the case of a 64 years-old woman admitted for abdominal pain, loss of appetite and weight. Abdominal CT showed a massive left kidney tumor with lateroaortic, interaoticocaval and laterocaval lymph node enlargement and extension in the subhepatic inferior vena cava, and a 4 cm upper pole tumor of the right kidney. No distant metastases were revealed on the thoracic CT. The surgical strategy involved a left radical nephrectomy, caval thrombectomy and extensive lymph node dissection as the first step. We made an anterior transperitoneal triradiate incision with bilateral coloparietal dissection. First we went on the right side in order to approach the thrombosed inferior vena cava. The left renal artery is ligated near the aorta. We applied a tourniquet on the suprarenal caval vein just above the tumor thrombus, on the infrarenal cava vein and on the right renal vein. Next we incised the inferior vena cava at the ostium of the left renal vein with the extraction of the thrombus and caval wall suture. Then we moved to the left side and standard perifascial nephrectomy and en bloc thrombectomy was performed. After that we performed an extensive periaortocaval lymph node dissection. Considering that we had no restant tumor tissue, and there was a wide exposure of the right kidney, we decided to perform a right superior polar nephrectomy in the same intervention, with electrothermal bipolar sealing system and a fat flap compression of the tumor bed. Results: Postoperative creatinine rose to 2.5 mg/dl and then slowly decreased to a normal value. Histopathological examination sowed bilateral clear cell carcinoma Fuhrman II and III and Hodgkin lymphoma in the LND specimen. Consequently specific treatment for Hodgkin lymphoma (chemotherapy with an EVA protocol -etoposide, vinblastine and doxorubicin) was initiated. Favorable response and oncological outcome were registered at 1 year follow-up. Conclusions: Although synchronous bilateral renal tumors surgical strategy usually involves two consecutive operations, first addressed to the largest tumor, a concomitant operation is possible in selected cases. LND in RCC has a double role, diagnostic and therapeutic and must be performed. Proper treatment of two simultaneous neoplasia could provide healing or increase the patients' survival