Multidisciplinary surgical treatment under cardiopulmonary bypass for non-metastatic renal cell carcinoma with Mayo level 4 inferior vena cava thrombus extending into right atrium

To present a multidisciplinary open surgical treatment under cardiopulmonary bypass (CPB) for a renal cell carcinoma (RCC) with Mayo level 4 inferior vena cava (IVC) thrombus extending into the right atrium. A 57 years old man with macrohematuria was diagnosed 8.5 cm left kidney tumor with venous tumor thrombus (VTT) from left renal vein along IVC extending into right atrium. The patient was clinically staged as cT3cN0M0. Normal cardiac ejection fraction and no additional cardiac risk was detected by echocardiography and coronary arterial angiography. The patient underwent ‘Left Radical Nephrectomy (RN) + Excision of VTT in IVC and Right Atrium under CPB’ by a multidisciplinary team consisting of Urologic Oncology Division at Urology Department, Cardio-Vascular Surgery and Hepatobiliary Surgery. A video of operative details was submitted as supplement of the article. The duration of operation, CPB, myocardial ischemia, renal and hepatic ischemia were 650, 42, 23 and 17 minutes, respectively. The estimated blood loss was 2000 cc., and it was replaced intraoperatively by transfusion of 5 unit erythrocyte suspensions and 2 unit fresh frozen plasmas. The patient was discharged at postoperative 10 days after being monitored at intensive care unit for 3 days and at urology service for 7 days. The pathology was WHO/ISUP Grade 3 clear cell RCC staged as pT3cN0M0. The patient received adjuvant sunitinib treatment for 12 months, and he is alive with no evidence of tumor progression for 48 months after surgery. Radical Nephrectomy and thrombectomy is the standard treatment in non-metastatic RCC with Mayo level 4 IVC thrombus extending into right atrium. The multidisciplinary approach is the key factor determining decreased perioperative morbidity and mortality, and increased survival outcomes. Preoperative planning with experiences on urologic oncology, cardiopulmonary bypass surgery and hepatobiliary surgery are hallmarks of success in this complex surgery.