Surgical Techniques in Urology

ntroduction. A combined abdominal and thoracic surgical approach is the treatment of choice for renal cell arcinoma with secondary thrombus extending to the supradiaphragmatic vena cava and initially into the ight atrium. This procedure usually requires a median sternotomy with cardiopulmonary bypass and deep ypothermic circulation arrest or, alternatively, venovenous bypass. In this report, we present a transdiahragmatic-intrapericardiac approach to supradiaphragmatic thrombus extending to the atrium that avoids he disadvantages, mortality, and morbidity related to cardiopulmonary bypass and deep hypothermic irculatory arrest or venovenous bypass. echnique. We describe a combined abdominal and transdiaphragmatic-intrapericardiac approach that was erformed in 3 patients with renal cell carcinoma with secondary thrombus extending to the atrium. The stimated blood loss of the patients ranged from 1.1 to 2.8 L (mean 1.5). The total operative time ranged rom 3 hours, 20 minutes to 4 hours. No postoperative complications were observed in any patient. onclusions. This technique allows excellent exposure of the supradiaphragmatic inferior vena cava through 10-cm incision and optimal control of the distal thrombus edge when it reaches the right atrium. This pproach is safer, faster, easier, and minimally invasive and avoids cardiopulmonary bypass with deep ypothermic cardiac arrest or venovenous bypass. UROLOGY 66: 1101–1105, 2005. © 2005 Elsevier Inc. a c m r r g a M p p c V e t p p t m w nferior vena cava (IVC) involvement by intraluminal extension of the tumor tissue has been eported in 4% to 10% of renal cell carcinoma RCC) cases.1 Radical nephrectomy with thrombecomy is the treatment of choice in patients suitable for urgical treatment; thrombectomy is associated with reater mortality and morbidity directly related to the istal extension.2 The crucial surgical point is control f the IVC, particularly above the thrombus to preent pulmonary embolism secondary to sudden hrombus migration. The surgical approach to the hrombus extending above the diaphragm (Stage 3c according to the International Union Against ancer) is more difficult; a simultaneous thoracic rom the Departments of Urology and Thoracic Surgery, Univerity of Padova Medical School, Padova, Italy Reprint requests: Pierfrancesco Bassi, M.D., Department of rology, University of Padova Medical School, Via Giustiniani 2, adova 35100, Italy. E-mail: [email protected] Submitted: March 17, 2005, accepted (with revisions): May 27, e 005