Examining Operative Experience with Radical Nephrectomy and IVC Thrombectomy

Renal cell carcinoma invading the inferior vena cava (IVC) is an uncommon condition with high perioperative and long-term morbidity and mortality. Many urologic surgeons are unfamiliar with how to approach these complex cases. Published case series are limited, and extracting practical patient management insights can be challenging.

At the American Urological Association’s (AUA) 2019 annual meeting, Cleveland Clinic researchers presented the results of nearly 30 years of surgical experience with radical nephrectomy and IVC thrombectomy. The substantial case series provides a wealth of information regarding thrombus level, operative technique, outcomes and complications.

“We have extensive experience with this surgery, and we found in our series that level IV thrombus, not unexpectedly, was associated with a higher risk of short-term complications and mortality than level I-III thrombi,” says Molly DeWitt-Foy, MD, the report’s first author and a resident in the Glickman Urological & Kidney Institute’s Department of Urology.

“Most single-center series in the medical literature related to radical nephrectomy and IVC thrombectomy are small, at around 100 cases, and don’t include many level IV thrombi,” Dr. DeWitt-Foy says. The Cleveland Clinic study contains more than four times as many cases as those other series.

“Because this is such a specialized surgery,” she says, “other surgeons want to know what incisions we used, how we managed the vena cava, how many patients were put on cardiac bypass, and other details about our surgical procedures, as well as our outcomes.” The team gave other podium presentations at AUA providing additional perspectives on the case series, Dr. DeWitt-Foy says, and they plan to publish the results.

Methods and outcomes

The team reviewed a prospectively maintained database of all Cleveland Clinic patients who underwent radical nephrectomy and IVC thrombectomy for renal cell carcinoma with associated IVC thrombi between 1990 and 2018. They retrieved demographic information, laboratory results, intra- and postoperative outcomes and overall survival data.

The patient population consisted of 285 men (69%) and 128 women (31%) with an average age of 62 years at the time of surgery. Fifty-nine patients (14.4%) had a level I thrombus, 134 (32.8%) level II, 115 (28.15%) level III and 101 (24.6%) level IV. “Previous series have not included as many level IV cases, which confer a higher risk of intraoperative and postoperative complications and perioperative death,” Dr. DeWitt-Foy says.

The researchers report that 94% of the surgeries were performed with a chevron incision. A thoraco-abdominal approach was used in 10 cases, and a robotic approach in three cases. In the majority of cases, surgeons were able to repair the IVC primarily. Six IVCs were closed with the aid of a bovine pericardial graft, 10 with Gore-Tex, two with native pericardium and 20 with ligation. One hundred thirty-one cases were performed while the patient was on cardiac bypass, with the assistance of cardiothoracic surgeons. Most procedures took four to seven hours to perform.

Mean primary tumor size was 10 cm, with a range of 1.4–30 cm. Three-quarters of tumors (289) were on the right side. Final pathology reports revealed that 97% of tumors were renal cell carcinoma, with the remaining 3% mainly sarcomas and urothelial cell carcinomas.

Complication rates

Short-term complications of radical nephrectomy with IVC thrombectomy typically include bleeding, pulmonary embolism, deep-vein thrombosis, arrhythmias and acute kidney injury, says Dr. DeWitt-Foy. “In this series, post-operative complications occurred in 149 cases (36.7%), with about 12.5% of patients having significant complications.”

The rate of perioperative mortality, which was as high as 12% in the late 1990s, is now about 3%. “Most of the perioperative deaths occur in patients with level IV thrombi, or tumors that grow all the way up to the right atrium,” Dr. DeWitt-Foy says. “One of the things we discovered from this database is that our perioperative mortality rate dropped significantly when our cardiac surgeons changed the kind of cardiopulmonary bypass (CPB) they were doing, from deep hypothermic circulatory arrest to beating-heart CPB. As a result, we’ve been able to make this surgery much safer, even for high-risk patients with high-level thrombi.”

Mortality at 30 days post-surgery was 5.6%, rising to 10.9% at 90 days and 56.6% at 5 years, largely due to the aggressive nature of the malignancy.

The level of thrombus, as expected, was associated with more intraoperative and postoperative complications, and perioperative mortality. Twenty-nine percent of patients with a level IV thrombus experienced significant (Clavien-Dindo grade 3 or higher) postoperative complications, versus less than 10% for levels I to III thrombi (p < 0.0001).

Future plans

The investigators plan to continue studying the database, looking exclusively at patients with metastatic disease to determine if radical nephrectomy and IVC thrombectomy is the appropriate approach, and to evaluate whether patients should receive chemotherapy prior to surgical intervention.

“It is helpful to have data from this large series of patients to confirm previous findings of smaller studies and to give us the ability to refine our surgical approaches to these cases,” says Dr. DeWitt-Foy.