Surgical treatment of renal cell carcinoma involving the inferior vena cava.

Renal cell carcinoma extends into the inferior vena cava in 5% of patients undergoing exploratory surgery for this malignancy. If the tumor is left unresected, death within 1 year is certain. In addition, caval occlusion may result in massive lower extremity edema, ascites, hepatic failure, and pulmonary embolus. During the past 17 years, 12 patients with renal cell carcinoma extending into the inferior vena cava were treated at a single institution by radical nephrectomy and caval tumor extraction. There were 10 men (83%) and ages ranged from 50 to 78 years (mean 63 years). There was one operative death (8%) caused by refractory coagulopathy. Long-term follow-up was achieved for all survivors. One- and 3-year survival rates by life-table method were 73% and 27%, respectively. Mean survival time after resection was 32 months. Careful preoperative planning is essential. The optimal approach for venacaval tumor extraction or resection is dictated by the cephalad extent of tumor seen on preoperative thoracoabdominal CT scan, ultrasound, or inferior venacavography. Disease limited to the infrahepatic vena cava is best approached with a thoracoabdominal incision through the eighth intercostal space. Extension of tumor to the hepatic veins or right atrium requires median sternotomy in combination with an abdominal incision for complete removal. An ellipse of vena cava around the origin of the renal vein is excised with the specimen. The resultant incision is closed by lateral phleborrhaphy. Late sequelae of the mild caval narrowing were not observed. An aggressive multispecialty surgical policy for caval extraction and resection of renal cell carcinoma resulted in extended patient survival and excellent palliation.