Lebret T, Bohin D, Richard F, Botto H
Service d'Urologie, Hôpital de la Pitié, Paris, France.
Prog Urol. 1998 Jun;8(3):352-7.
Almost 5% of renal tumours are associated with thrombus of the renal vein or inferior vena cava at the time of diagnosis. Radical nephrectomy with complete resection of the tumour nodule is the reference first-line treatment in this situation. This retrospective series was designed to analyse the surgical strategy according to the extent of the tumour nodule and the morbidity and mortality as a function of the prognostic factors of these renal tumours.
From 1982 to 1995, 51 patients (out of a series of 724 nephrectomies) presented with renal vein invasion involving all of the lumen of the inferior vena cava. The choice of medical imaging varied over time (cavography, Doppler ultrasound, CT, MRI and transoesophageal ultrasonography). Control of the inferior vena cava was always performed below the renal veins and above the thrombus.
MRI and transoesophageal ultrasonography were found to be the most reliable diagnostic examinations. The incision and vessel control technique must be selected as a function of the type of thrombus and the emboligenic risk. With a follow-up of 4.3 years, the overall 2-year survival was 46% and the 5-year survival was 31%. All recurrences at 1 year occurred in N+ patients.
Lymph node status and invasion of the perirenal fat are the most important prognostic factors, while the presence and length of the thrombus do not appear to influence survival. Radical nephrectomy of these tumours, invading all of the lumen of the inferior vena cava, requires complete resection of the thrombus. Adhesion of the thrombus constitutes a major technical problem that must be envisaged before the incision in order to correctly control the vessels.
近5%的肾肿瘤在诊断时伴有肾静脉或下腔静脉血栓形成。在这种情况下，根治性肾切除术并完整切除肿瘤结节是首选的一线治疗方法。本回顾性系列研究旨在根据肿瘤结节的范围分析手术策略，以及这些肾肿瘤预后因素与发病率和死亡率的关系。
1982年至1995年，在724例肾切除术患者中，有51例出现肾静脉侵犯并累及下腔静脉全部管腔。随着时间的推移，医学影像检查方法有所不同（腔静脉造影、多普勒超声、CT、MRI和经食管超声检查）。下腔静脉的控制始终在肾静脉下方和血栓上方进行。
发现MRI和经食管超声检查是最可靠的诊断方法。必须根据血栓类型和栓塞风险选择切口和血管控制技术。随访4.3年，总体2年生存率为46%，5年生存率为31%。所有1年时的复发均发生在N+患者中。
淋巴结状态和肾周脂肪侵犯是最重要的预后因素，而血栓的存在和长度似乎不影响生存率。对于侵犯下腔静脉全部管腔的这些肿瘤，根治性肾切除术需要完整切除血栓。血栓粘连是一个主要的技术问题，在切开前必须考虑到，以便正确控制血管。
