Surgery in Motion Liver Transplantation Techniques for the Surgical Management of Renal Cell Carcinoma with Tumor Thrombus in the Inferior Vena Cava: Step-by-Step Description Gaetano Ciancio a,b , Javier Gonzalez c, *, Samir P. Shirodkar b , Javier C. Angulo c , Mark S. Soloway b a Department of Surgery, Division of Transplantation, University of Miami Miller School of Medicine, Miami, Florida, USA b Department of Urology, University of Miami Miller School of Medicine, Miami, Florida, USA c Servicio de Urologı´a, Hospital Universitario de Getafe, Getafe (Madrid), Spain EUROPEAN UROLOGY 59 (2011) 401–406 available at www.sciencedirect.com journal homepage: www.europeanurology.com Article info Article history: Accepted July 20, 2010 Published online ahead of print on August 3, 2010 Keywords: Renal cell carcinoma Surgical technique Caval thrombus Tumor thrombus Radical nephrectomy Please visit www.europeanurology.com and www.urosource.com to view the accompanying video. Abstract Background: Renal cell carcinoma (RCC) with tumor thrombus in the inferior vena cava (IVC) poses a challenge to the surgeon given the operative difficulty, potential for massive hemorrhage, and possibility of tumor thromboemboli. Objective: To determine the applicability of a self-developed technique based on orthotopic liver transplantation procedures for safe resection of these tumors. Design, setting, and participants: From August 1997 to February 2008, 68 consecutive patients underwent resection of RCC with suprahepatic and/or retrohepatic (level 3 and 4) tumor thrombus in a single referral institution. Surgical procedure: A triradiate incision over the upper abdomen permits the place- ment of a Rochard retractor. Early vascular control of the renal artery is achieved by creating a posterior plane of dissection. Venous collateral decompression permits development of a bloodless anterior plane by mobilizing the liver in a ‘‘piggy-back’’ fashion and the spleen–pancreas en bloc to the midline. Thrombus extraction requires circumferential control at the renal veins, hepatic hilum, and IVC before cavotomy. The central tendon of the diaphragm may be opened for cranial control and gentle traction over the right atrium performed. Repositioning of the proximal clamp and Pringle release avoid veno-venous bypass and cardiopulmonary bypass (CPB) in most cases. Measurements: The extent of the tumor thrombus was retrohepatic in 56 patients and suprahepatic/intra-atrial in 12 patients. Results and limitations: Mean operative time was 5 h 32 min. Mean estimated blood loss (EBL) was 2112 Æ 3834 ml (range: 100–25 000), with a mean transfusion being 4.2 Æ 4.1 U (range: 0–30). Five patients (7.3%) required CPB. Three patients (4.4%) died in the immediate postoperative period. All had complete tumor resection. No patient developed intraoperative thromboembolism. Conclusions: This surgical approach provides excellent exposure and control of the IVC in cases with level 3 and 4 tumor thrombus, avoiding CPB except in rare circumstances. # 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. Servicio de Urologı ´a, Hospital Universitario de Getafe, Ctra. De Toledo Km 12,500, 28905 Getafe (Madrid), Spain. Tel. +34 916839360 ext. 6381; Fax: +34 916247309. E-mail address: fjgg1975@yahoo.com (J. Gonzalez). 0302-2838/$ – see back matter # 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2010.07.028