Renal Cancer pp 259-280 | Cite as

Surgery for Renal Cell Carcinoma with Thrombus Extension into the Vena Cava

  • John A. Libertino
  • Chad Wotkowicz
  • Jason R. Gee


The incidence of renal cell carcinoma continues to rise secondary to increased imaging utilization with the majority of new cases being lower stages based on size criteria. The incidence of larger renal tumors with known propensities for venous thrombus formation is still present and remains a challenge for the urological community in terms of surgical treatment with acceptable oncological outcomes and limited complications. Proper staging and preoperative imaging are crucial to determine the best approach with limited morbidity.

As previously described by multiple authors and institutions, the level of tumor thrombus is one if not the most important factor in determining the surgical approach. We detail our approach model and surgical technique in great detail with respect to thrombus within the renal vein, extending into the inferior vena cava and extending into the right atrium.

This chapter also provides data and technical descriptions from our contemporaries at other institutions describing alternative approaches. This latter section can be of utmost importance during any surgical procedures in which unanticipated complications can arise. We have also included our own personal experience with this patient population, which is one of the largest within the urological community.


Renal cell carcinoma Cardiopulmonary bypass Renal vein Radical nephrectomy Tumor thrombus 

Supplementary material

Video 15.1

Novel technique for preoperative removal of intracardiac thrombus prior to radical nephrectomy and IVC thrombectomy (MP4 457875 kb)


  1. 1.
    Marshall VF, Middleton RG, Holswade GR, Goldsmith EI. Surgery for renal cell carcinoma in the vena cava. J Urol. 1970;103:414–20.CrossRefGoogle Scholar
  2. 2.
    Scheft P, Novick AC, Strafton RA, Stewart BH. Surgery for renal cell carcinoma extending into the vena cava. J Urol. 1978;120:28–31.CrossRefGoogle Scholar
  3. 3.
    Robson CJ, Churchill BM, Anderson W. The results of radical nephrectomy for renal cell carcinoma. J Urol. 1969;101:297–301.CrossRefGoogle Scholar
  4. 4.
    Glaser A, Novick AC. Long-term follow-up after surgical treatment for renal cell carcinoma extending into the right atrium. J Urol. 1996;155:448–50.CrossRefGoogle Scholar
  5. 5.
    Zisman A, Wieder JA, Pantuck AJ. Renal cell carcinoma with tumor thrombus extension: biology, role of nephrectomy and response to immunotherapy. J Urol. 2003;169:909–16.CrossRefGoogle Scholar
  6. 6.
    Moinzadeh A, Libertino J. Prognostic significance of tumor thrombus level in patients with renal cell carcinoma and venous thrombus extension. Is all T3b the same? J Urol. 2004;171:598–601.CrossRefGoogle Scholar
  7. 7.
    Kim HL, Belledegrun AS, Freitas DG. Paraneoplastic signs and symptoms of renal cell carcinoma: implications for prognosis. J Urol. 2003;170:1742–6.CrossRefGoogle Scholar
  8. 8.
    Zini L, Destriuex-Garnier L, Leroy X. Renal vein ostium invasion of renal cell carcinoma with an inferior vena cava thrombus: prediction by renal and vena caval vein diameters and prognostic significance. J Urol. 2008;179(2):450–4.CrossRefGoogle Scholar
  9. 9.
    Lam JS, et al. Evolving principles of surgical management and prognostic factors for outcome in renal cell carcinoma. J Clin Oncol. 2006;24:5565–75.CrossRefGoogle Scholar
  10. 10.
    Nakano H, et al. Treatment of renal cancer patients by transcatheter embolization and its effects on lymphocyte proliferative responses. J Urol. 1983;130:24–7.CrossRefGoogle Scholar
  11. 11.
    Bakke A, et al. Augmentation of natural killer cell activity after arterial embolization of renal carcinomas. Cancer Res. 1982;42:3880–3.PubMedGoogle Scholar
  12. 12.
    Schwartz MJ, et al. Renal artery embolization: clinical indications and experience from over 100 cases. BJU Int. 2006;99:881–6.CrossRefGoogle Scholar
  13. 13.
    Libertino JA, Zinman L, Watkins E Jr. Long-term results of resection of renal cell cancer with extension into inferior vena cava. J Urol. 1987;137(1):21–4.CrossRefGoogle Scholar
  14. 14.
    Swierzewski DJ, Swierzewski MJ, Libertino JA. Radical nephrectomy in patients with renal cell carcinoma with venous, vena caval and atrial extension. Am J Surg. 1994;168(2):205–9.CrossRefGoogle Scholar
  15. 15.
    Kaag MG, Toyen C, Cronins RP. Radical Nephrectomy with vena caval thrombectomy: a contemporary experience. BJU Int. 2010;107:1386–93.CrossRefGoogle Scholar
  16. 16.
    Cianco G, Vaidya A, Savoie M. Management of renal cell carcinoma with tumor thrombus in the renal and inferior vena cava: the University of Miami experience in using liver transplantation techniques. Eur Urol. 2007;51(4):988–94.CrossRefGoogle Scholar
  17. 17.
    Shahian DM, Libertino JA, Zinman LN, et al. Resection of cavoatrial renal cell carcinoma employing circulatory arrest. Arch Surg. 1990;125:727–31. Discussion 731–2.CrossRefGoogle Scholar
  18. 18.
    Fitzgerald JM, Tripathy U, Svensson LG, Libertino JA. Radical nephrectomy with vena caval thrombectomy using a minimal access approach for cardiopulmonary bypass. J Urol. 1998;159(4):1292–3.CrossRefGoogle Scholar
  19. 19.
    Rabbani F, Hakimian P, Reuter V. Renal vain or inferior vena caval extension in patients with renal cortical tumors: impact of tumor histology. J Urol. 2004;172(3):1057–61.CrossRefGoogle Scholar
  20. 20.
    Kapoor A, Nguan C, Al-Ahaiji T. Laparoscopic management of advanced renal cell carcinoma with level I renal vein thrombus. Urology. 2006;68(3):514–7.CrossRefGoogle Scholar
  21. 21.
    Varkarakis I, Bhayani S, Allaf M. Laparoscopic-assisted nephrectomy with inferior vena cava tumor thrombectomy: preliminary results. Urology. 2004;64(5):925–9.CrossRefGoogle Scholar
  22. 22.
    Abaza R. Initial series of robotic radical nephrectomy with vena caval tumor thrombectomy. Eur Urol. 2011;59:652–6.CrossRefGoogle Scholar
  23. 23.
    Kim EH, Jain S, Bm B, Figneshau RS. Partial nephrectomy in two patients with known T3a tumours involving the renal vain. BJU Int. 2012;109(9):1345–8.CrossRefGoogle Scholar
  24. 24.
    Takeda H, Nakano Y, Kashiwgi Y, Yoshino Y, Gotoh M. Downsizing a thrombus of advanced renal cell carcinoma in a presurgical setting with sorafenib. Urol Int. 2012;88:235–7.CrossRefGoogle Scholar
  25. 25.
    Rini BI, Garcia J, Elson P, Wood L. The effect of sunitinib on primary renal cell carcinoma and facilitation of subsequent surgery. BJU Int. 2012;1987:1548–54.Google Scholar
  26. 26.
    Barney J, Churchill E. Adenocarcinoma of the kidney with metastases to the lung: cured nephrectomy and lobectomy. J Urol. 1939;42:269–76.CrossRefGoogle Scholar
  27. 27.
    Wotkowicz C, Libertino JA, Sorcini A, Mourtzinos A. Management of renal cell carcinoma with vena cava and atrial thrombus: minimal access vs median sternotomy with circulatory arrest. BJU Int. 2006;98:289–97.CrossRefGoogle Scholar
  28. 28.
    Faust W, D’Agostino R, Libertino J. Comparative Effectiveness of median sternotomy vs minimal access cardiopulmonary bypass and circulatory arrest for resection of RCC with IVC extension. JCT. 2016;7(10):752–61.CrossRefGoogle Scholar
  29. 29.
    Palmer D, Humpfrey J, Fredrick A, Piemonte T, Libertino J. Endovascular Removal of Intracardiac thrombus prior to radical nephrectomy and IVC thrombectomy. Urology. 2016;96:85–6.CrossRefGoogle Scholar
  30. 30.
    Marra G, Bratttoli M, Gontero P, Libertino JA. Is imperative partial nephrectomy feasible for kidney cancer with venous thrombus involvement? Outcomes of 42 cases and matched pair analysis with a large radical nephrectomy cohort. Urol Oncol. 2018;36(7):339.e1–8.CrossRefGoogle Scholar
  31. 31.
    Salamanca JI, Linares E, et al. Lessons learned from the International Renal Cell-Venous Thrombus Consortium (RCC-VTC). Curr Urol Rep. 2014;15:404.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • John A. Libertino
    • 1
    • 2
  • Chad Wotkowicz
    • 3
  • Jason R. Gee
    • 1
    • 2
  1. 1.Tufts University School of MedicineBostonUSA
  2. 2.Department of UrologyMGH Cancer Center, Emerson HospitalConcordUSA
  3. 3.Department of UrologyLahey Clinic Medical CenterBurlingtonUSA

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