Flank Incision is A Safe and Effective Surgical Approach for Renal Carcinoma with Inferior Vena Cava Thrombus

PURPOSE: We present an Australian perspective on the use of flank incision as a surgical strategy in the management of renal cell carcinoma (RCC) with vena cava thrombus. METHOD: A retrospective analysis of all patients who had a flank incision for RCC with caval thrombus performed at our tertiary centre, from June 1997 to June 2011 was performed. The following parameters were studied: demographics, thrombus extension, tumour size, operative time, estimated blood loss, need for cardio-pulmonary bypass, complications and length of hospital stay. We also evaluated the disease progression and patient status at follow-up. RESULTS: From June 1997 to June 2011, a total of 29 patients had radical nephrectomy and caval thrombectomy for RCC with caval thrombus at our institution. Of them, 12 patients who had a flank incision were selected reviewed. We had 8 male and 4 female patients, with a mean age of 59.6 years old and median age of 64 years old. We used the Neves-Zincke classification to assess extent of caval thrombus, with classifications I (n=9), II (n=2), III (n=0) and IV (n=1). Mean tumour size was 88.0mm. 1 patient required cardio-pulmonary bypass, and the average blood loss intra-operatively was 589.16mls. Of these patients, 9 had negative margins. CONCLUSION: RCC with vena cava thrombus is associated with a high mortality rate. A flank incision for radical nephrectomy provides adequate exposure to the renal hilum and infra-hepatic vena cava for Neves-Zincke I and II caval thrombi. Thus flank incision is a safe and effective option in selected cases.