Stapled Renal Vein With In Situ Tumor Thrombus: A Useful Intraoperative Maneuver to Facilitate Radical Nephrectomy and Inferior Vena Cava Thrombectomy

ObjectivesPatients with genitourinary tumors and inferior vena cava thrombus often have large lesions and significant neovascularity. Early division of the renal vein with the in situ thrombus is desirable; however, concerns have been raised regarding tumor spillage and thrombus migration. We describe a novel technique using a stapling device to secure the renal vein during resection of renal tumors associated with an inferior vena cava thrombus.MethodsSince 2005, 38 patients have undergone surgery for genitourinary tumors and inferior vena cava tumor thrombus by a single surgeon. We examined the utility of an endovascular stapler (Endo-GIA) to transect the renal vein and the in situ thrombus. The renal vein containing the tumor thrombus was divided with an endovascular stapler in 14 of 38 patients. The outcomes of this technique were assessed.ResultsThe stapled group included more level III-IV thrombi than the nonstapled group. The tumors removed in the stapled group were larger (median 11.5 versus 9 cm), and the median intraoperative transfusion requirements were greater (9.5 versus 3 U). One patient developed an intraoperative pulmonary embolus, and another experienced hemodynamic changes suggestive of an embolus. Local recurrence developed in 1 and 2 patients in the stapled and conventional groups, respectively, during a median follow-up period of 3 months.ConclusionsThe Endo-GIA stapler is a safe and effective instrument for division of the in situ renal vein component of the tumor thrombus, allowing the surgeon to complete the nephrectomy, achieve hemostasis, and, subsequently, concentrate on the vena cava and tumor thrombus aspects of the procedure.