Extraction of atrial tumor thrombus in renal cell carcinoma via a complete transabdominal approach

Surgical resection is the mainstay treatment of renal cell carcinoma (RCC) offering a 5-year survival rate of 70-80%. Associated vena cava tumor thrombus adds complexity to surgical planning especially when the thrombus extends above the diaphragm. Those who do not undergo treatment of the primary cancer as well as the associated thrombus have poor mortality outcomes. Cardiopulmonary bypass (CPB) has been the mainstay for level IV thrombectomy since first introduced. While it has advantages, it is also associated with multisystem failure, hypothermia, and coagulopathy. We sought to describe our experience using a completely transabdominal thrombectomy technique in select patients with level IV tumor thrombus. Patient selection depended upon multidisciplinary coordination between urologic oncology, cardiothoracic surgery, and cardiac anesthesiology. Eleven patients at our institution underwent completely transabdominal level IV inferior vena cava (IVC) tumor thrombectomy. All had successful retrieval of thrombus without the use of CPB or need for sternotomy. Intraoperative surgical and anesthetic technique is described. Although two patients were lost to follow up, only three of the remaining patients were found to have recurrence of disease. Further studies are necessary to best elucidate the ideal candidate for this surgical approach as well as evaluate long term outcomes compared with traditional therapies. We propose transabdominal IVC tumor thrombectomy is a safe surgical option in select patients with level IV tumor thrombus.