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| Contemporary techniques and outcomes of surgery for locally advanced renal cell carcinoma with focus on inferior vena cava thrombectomy: The value of a multidisciplinary team |
Riccardo Campia,b,*( ),Paolo Barzaghia,a,Alessio Pecoraroa,Maria Lucia Galloa,Damiano Straccia,Alberto Mariottia,Saverio Giancanea,Simone Agostinic,Vincenzo Li Marzia,Arcangelo Sebastianellia,Pietro Spataforaa,Mauro Gaccia,Graziano Vignolinia,Francesco Sessaa,b,Paolo Muiesand,e,Sergio Sernia,b
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aUnit of Urological Robotic Surgery and Renal Transplantation, University of Florence, Careggi Hospital, Florence, Italy
bDepartment of Experimental and Clinical Medicine, University of Florence, Florence, Italy
cDepartment of Radiology, Unit of Urogenital, Nephrological and Kidney Transplantation Imaging, Careggi Hospital, University of Florence, Florence, Italy
dHepatobiliary Unit, Department of Clinical and Experimental Medicine, University of Florence, AOU Careggi, Florence, Italy
eLiver Unit, Queen Elizabeth Hospital, Birmingham, UK |
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Abstract Objective: To report the outcomes of surgery for a contemporary series of patients with locally advanced non-metastatic renal cell carcinoma (RCC) treated at a referral academic centre, focusing on technical nuances and on the value of a multidisciplinary team.
Methods: We queried our prospective institutional database to identify patients undergoing surgical treatment for locally advanced (cT3-T4 N0-1 M0) renal masses suspected of RCC at our centre between January 2017 and December 2020.
Results: Overall, 32 patients were included in the analytic cohort. Of these, 12 (37.5%) tumours were staged as cT3a, 8 (25.0%) as cT3b, 5 (15.6%) as cT3c, and 7 (21.9%) as cT4; 6 (18.8%) patients had preoperative evidence of lymph node involvement. Nine (28.1%) patients underwent nephron-sparing surgery while 23 (71.9%) received radical nephrectomy. A template-based lymphadenectomy was performed in 12 cases, with evidence of disease in 3 (25.0%) at definitive histopathological analysis. Four cases of RCC with level IV inferior vena cava thrombosis were successfully treated using liver transplant techniques without the need for extracorporeal circulation. While intraoperative complications were recorded in 3 (9.4%) patients, no postoperative major complications (Clavien-Dindo ≥3) were observed. At histopathological analysis, 2 (6.2%) patients who underwent partial nephrectomy harboured oncocytoma, while the most common malignant histotype was clear cell RCC (62.5%), with a median Leibovich score of 6 (interquartile range 5-7).
Conclusion: Locally advanced RCC is a complex and heterogenous disease posing several challenges to surgical teams. Our experience confirms that provided careful patient selection, surgery in experienced hands can achieve favourable perioperative, oncological, and functional outcomes.
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Received: 03 February 2022
Available online: 20 July 2022
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Corresponding Authors:
Riccardo Campi
E-mail: riccardo.campi@gmail.com
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Overview of preoperative imaging techniques to diagnose, characterise, and stage locally-advanced RCC. (A and B) Coronal and axial magnetic resonance images showing a case of RCC with level IV IVC thrombosis; (C) Axial contrast-enhanced computed tomography images showing a right-sided RCC with level II IVC thrombosis; (D and E) Selected snapshots from preoperative trans-oesophageal echocardiography showing a case of RCC with level III IVC thrombosis; (F) Coronal contrast-enhanced computed tomography images showing a right-sided RCC with level II IVC thrombosis. RCC, renal cell carcinoma; IVC, inferior vena cava. T, tumour. Arrow, level III IVC thrombosis showed during trans-oesophageal echocardiography.? Thrombus.
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Intraoperative snapshots showing the main steps of open surgery for locally advanced RCC. (A) Skin incision (modified Makuuchi incision) routinely performed at our institution for cases of RCC with suspected IVC thrombosis/infiltration, and/or suspected involvement of adjacent organs; (B) Overview of the operative field after placement of the Rochard retractor; (C) Intraoperative snapshot showing the final surgical result after radical nephrectomy with IVC thrombectomy and placement of a Gore-Tex prosthesis; (D) Exposure of a right-sided large RCC; (E) Exposure of the IVC and right renal loggia after retroperitoneal lymph node dissection; (F) Intraoperative snapshot showing the Pringle manoeuvre; (G) Intraoperative snapshot showing the operative field after left radical nephrectomy plus retroperitoneal lymph node dissection involving paraaortic and inter-aorto-caval templates. RCC, renal cell carcinoma; IVC, inferior vena cava.
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Technical nuances of radical nephrectomy and IVC thrombectomy for locally-advanced RCC. (A) Exposure and complete mobilisation of the IVC and left or right renal veins; (B) Intraoperative snapshot showing the early ligation of the right renal artery in the inter-aorto-caval space; (C, D and E) Step-by-step overview of IVC thrombectomy for a RCC with level III thrombus; (C) Cavotomy with cold knife; (D) Caudal extension of the cavotomy to progressively remove the tumour thrombus; (E) Closure of the IVC with running Prolene sutures. RCC, renal cell carcinoma; IVC, inferior vena cava; LRV, left renal vein; RRV, right renal vein; RRA, right renal artery; T, tumour. Arrow, the incision direction on inferior cava vein (venotomy). Circle, the renal hilum.
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Postoperative pictures showing a variety of specimens after radical nephrectomy for locally-advanced RCC. (A and B) RCC with level II IVC thrombosis; (C) pT4 RCC infiltrating the liver (in this case, en-bloc radical nephrectomy plus liver segmentectomy was needed); (D) RCC with level III IVC thrombosis (in this case, radical nephrectomy plus adrenalectomy was performed for suspected metastasis of the right adrenal at preoperative imaging; final stage pT3c pM1); (E and F) RCC with level II IVC thrombosis. RCC, renal cell carcinoma; IVC, inferior vena cava.
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| Characteristic | Value (n=32) | | Age, median (IQR), year | 68 (55-75) | | BMI, median (IQR), kg/m2 | 25.0 (23.5-26.0) | | Male, n (%) | 20 (62.5) | | Symptomatic patient at diagnosis, n (%) | 18 (56.2) | | Smoking exposure, n (%) | | No smoker | 15 (46.9) | | Current smoker | 10 (31.2) | | Former smoker | 7 (21.9) | | Diabetes mellitus, n (%) | 4 (12.5) | | ASA physical status classification, median (IQR) | 2 (2-3) | | CCI (age-adjusted), median (IQR) | 2 (1-3) | | Previous abdominal surgery, n (%) | 17 (53.1) | | Preoperative hemoglobin, median (IQR), g/dL | 13.4 (11.5-14.7) | | Preoperative creatinine, median (IQR), mg/dL | 1.0 (0.9-1.1) | | Preoperative eGFR (CKD-EPI), median (IQR), mL/min/1.73 m2 | 72.0 (58.0-89.0) | | Kidney side, n (%) | | Right | 18 (56.3) | | Left | 13 (40.6) | | Bilateral | 1 (3.1) | | Tumour diameter at preoperative imaging, median (IQR), cm | 8 (5-10) | | PADUA score | | Overall score, median (IQR) | 11 (9-12) | | Risk groups, n (%) | | Low (6-7) | 1 (3.1) | | Intermediate (8-9) | 11 (34.4) | | High (≥10) | 20 (62.5) | | SPARE score | | Overall score, media (IQR) | 7 (4-8) | | Risk groups, n (%) | | Low (0-3) | 4 (12.5) | | Intermediate (4-7) | 19 (59.4) | | High (≥8) | 9 (28.1) | | Clinical T stage, n (%) | | T3a | 12 (37.5) | | T3b | 8 (25.0) | | T3c | 5 (15.6) | | T4 | 7 (21.9) | | Clinical N stage, n (%) | | N0 | 26 (81.2) | | N1 | 6 (18.8) |
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Preoperative baseline patients' and tumours' characteristics.
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| Characteristic | Value | | Operative time, median (IQR), min | 185 (150-210) | | Type of surgery, n (%) | | Partial nephrectomy | 9 (28.1) | | Radical nephrectomy | 23 (71.9) | | Surgical approach, n (%) | | Open | 13 (40.6) | | Robot-assisted | 19 (59.4) | | Warm ischaemia timea, median (IQR), min | 18 (14-22) | | Lymph nodes dissection, n (%) | 12 (37.5) | | Hilar dissection | 2 (6.2) | | Periaortic dissection | 2 (6.2) | | Hilar, pericaval and periaortic dissection | 6 (18.8) | | Iliac and pericaval dissection | 1 (3.1) | | Iliac and hilar dissection | 1 (3.1) | | Ipsilateral adrenalectomy, n (%) | 4 (12.5) | | Metastasis dissection, n (%) | 1 (3.1) | | Intraoperative adverse incident classification, n (%) | | Grade 0 | 0 (0) | | Grade 1b | 3 (9.4) | | Grade 2 | 0 (0) | | Grade 3 | 0 (0) | | Grade 4 | 0 (0) | | Grade 5 | 0 (0) |
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Intraoperative outcomes in patients undergoing surgery for locally-advanced renal cell carcinoma in our series.
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| Characteristic | Value | | Early postoperative outcome | | Overall length of hospitalization, median (IQR), day | 4 (4-6) | | Length of stay in ICU, median (IQR), day | 0 (0-1) | | Patients with postoperative complications, n (%) | 14 (43.8) | | Hemoglobin, median (IQR), g/dL | | POD 1 | 11.6 (10.3-13.2) | | POD 3 | 10.9 (9.8-12.0) | | eGFR (CKD-EPI), median (IQR), mL/min/1.73 m2 | | POD 1 | 55.8 (41.5-74.5) | | POD 3 | 52.3 (42.3-68.7) | | At discharge | 55.8 (42.3-82.5) | | Highest grade postoperative surgical complicationa, n (%) | | Grade 0 | 18 (56.2) | | Grade 1 | 3 (9.4) | | Grade 2 | | Overall | 11 (34.4) | | Transfusions | 5 (15.6) | | Grade 3a | 0 (0) | | Grade 3b | 0 (0) | | Grade 4a | 0 (0) | | Grade 4b | 0 (0) | | Grade 5 | 0 (0) | | Comprehensive complication index, median (IQR) | 0.0 (0.0-20.9) | | Histopathology outcome | | Benign histology, n (%) | 2 (6.2) | | Histological subtypes, n (%) | | Clear RCC | 20 (62.5) | | Papillary RCC | 5 (15.6) | | Chromophobe RCC | 3 (9.4) | | Other malignant tumour | 2 (6.2) | | Benign tumour | 2 (6.2) | | ISUP grade ≥3 (n=26)b, n (%) | 21 (80.8) | | Pathological T stage (n=28)b, n (%) | | T1a | 0 (0) | | T1b | 2 (7.1) | | T2a | 3 (10.7) | | T2b | 0 (0) | | T3a | 14 (50.0) | | T3b | 8 (28.6) | | T3c | 1 (3.6) | | T4 | 0 (0) | | pN stage (n=12)b, n (%) | | N0 | 9 (75.0) | | N1 | 3 (25.0) | | pM1 stage (n=30)b,c, n (%) | 1 (3.3) | | Diameter of the tumour at pathologic evaluation, median (IQR), cm | 7 (5-10) | | Leibovich score (n=20 clear cell RCC)d | | Overall score, median (IQR) | 6 (5-7) | | Risk groupsc | | Low (0-2) | 3 (15.0) | | Intermediate (3-5) | 5 (25.0) | | High (≥6) | 12 (60.0) |
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Postoperative outcomes and histopathologic results in patients undergoing surgery for locally-advanced RCC in our series.
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| Characteristic | Value | | Follow-up, median (IQR), month | 24 (18-37) | | Cancer related death at last follow-up, n (%) | 2 (6.2) | | Hospital re-admission (at least one episode) after renal surgery, n (%)a | | Surgery for another urologic tumour | 1 (3.3) | | Surgery for RCC recurrence | 1 (3.3) | | Other causes not related to surgery/recurrence | 6 (20.0) | | Patients with recurrence at last follow-up, n (%)a | | Recurrence in the ipsilateral remanent kidney after partial nephrectomy | 1 (3.3) | | Recurrence in ipsilateral renal fossa and lymph nodes | 1 (3.3) | | Multiple recurrence in intra-abdominal soft tissues or organs | 4 (13.3) | | Distant recurrence | 2 (6.7) | | Treatment of recurrence (n=8), n (%) | | Palliative treatment | 1 (12.5) | | Surgery | 1 (12.5) | | Systemic therapy | 4 (50.0) | | Multiple treatment | 2 (25.0) | | eGFR at last follow-up (CKD-EPI), median (IQR), mL/min/1.73 m2 | 57.0 (46.0-69.0) |
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Follow-up data in patients undergoing surgery for locally-advanced RCC in our series.
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