Radical nephrectomy and inferior vena caval thrombectomy: Outcomes in a lower volume practice

Introduction: Surgical volume correlates with improved outcomes for some complex urologic procedures. We reviewed the outcomes of a lower volume practice (1-2 cases per year) experience with radical nephrectomy with infra/retrohepatic vena caval thrombectomy (RNCT). Methods: We retrospectively reviewed 10 patients who underwent RNCT performed by a single surgeon at a single state institution over 7 years (2002-2009). Patient demographics, presenting symptoms, preoperative imaging, intraoperative findings, pathology, hospital course, outcomes, level of caval involvement, renal artery embolization, liver mobilization, blood loss, transfusion requirements and follow up times were recorded. Results: Median patient BMI (n = 8) was 25.7 (18.3-31.9). Eight patients underwent renal artery embolization prior to RNCT. A vascular or liver surgeon assisted in all 10 RNCT cases. Six thrombi were infrahepatic and four were retrohepatic requiring liver mobilization. Median operative time was 340 minutes (220-480) with a median vena cava clamp time of 17 minutes (11-22). Eight (80%) patients required intraoperative transfusion. Median pathologic tumor size was 9.5 cm (range 6-21). Median hospital stay was 7.5 days (5-15). Four patients had complications including colonic mesenteric rent (n = 2), abscess (n = 1), retroperitoneal hematoma (n = 1), distal pancreatic injury (n = 1), and splenic capsular tear (n = 1). One patient had postoperative liver metastasis. Two patients died from postoperative metastasis, at 5 months and 11 months. Conclusions: RNCT can be performed, with the assistance of a vascular/liver transplant surgeon, for an infrahepatic or retrohepatic thrombus satisfactorily in a lower volume practice.