Laparoscopy-Assisted Radical Nephrectomy with Inferior Vena Caval Thrombectomy for Level II to III Tumor Thrombus: A Single-Institution Experience and Review of the Literature

PURPOSE: Laparoscopy-assisted radical nephrectomy and vena caval thrombectomy (LARN-VCT) is reported to be an alternative to open surgery for renal-cell carcinoma (RCC). We describe our experience and review the current literature evaluating the feasibility and safety of LARN-VCT. PATIENTS AND METHODS: We retrospectively reviewed the medical records of all patients who underwent laparoscopic radical nephrectomy for RCC at our institution between June 2004 and May 2009, and selected those who underwent LARN-VCT. We analyzed patients' clinical, radiographic, intraoperative, pathologic, and postoperative parameters. For the literature review, we performed a MEDLINE search to identify publications that focused on laparoscopic radical nephrectomy with VCT. RESULTS: LARN-VCT was completed in six of seven patients; elective conversion in one patient to open surgery occurred because of disease progression. Five of the six patients with RCC had no evidence of disease recurrence at a median follow-up of 16 months. The literature review revealed case reports and small series demonstrating the technical feasibility and safety of LARN-VCT in selected patients. CONCLUSIONS: LARN-VCT is a technically feasible approach in carefully selected patients with right-sided level II to III tumor thrombus. Optimal patient selection, extensive laparoscopic experience, and multidisciplinary support are critical elements for the safe application of this approach. Fluid and volume resuscitation must be thoughtfully considered given the transition from laparoscopy to open cross clamping of the vena cava. The worldwide literature on LARN-VCT is still limited and additional data are needed.