european urology 51 (2007)

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1 european urology 51 (2007) available at journal homepage: Kidney Cancer Surgical Management of Renal Cell Carcinoma with Tumor Thrombus in the Renal and Inferior Vena Cava: The University of Miami Experience in Using Liver Transplantation Techniques Gaetano Ciancio a,c, *, Alan S. Livingstone b, Mark Soloway c a Department of Surgery, Division of Transplantation, University of Miami Miller School of Medicine, Miami, Florida, United States b Department of Surgery, Division of Surgical Oncology, University of Miami Miller School of Medicine, Miami, Florida, United States c Department of Urology, University of Miami Miller School of Medicine, Miami, Florida, United States Article info Article history: Accepted November 29, 2006 Published online ahead of print on December 8, 2006 Keywords: Renal cell carcinoma Surgical technique Caval thrombus Tumor thrombus Radical nephrectomy Abstract Objectives: Renal cell carcinoma (RCC) with tumor thrombus in the inferior vena cava (IVC) poses a challenge to the surgeon due to the potential for massive hemorrhage and tumor thromboemboli. We developed a technique for safe resection of these tumors through a transabdominal approach, without recourse to cardiopulmonary bypass (CPB). Materials and methods: From August 1997 to February 2005, 66 patients underwent resection of a RCC with tumor thrombus in the IVC. The extent of the tumor thrombus was renal in 13, infrahepatic in 7; retrohepatic in 38; and intra-atrial in 8 patients. Results: Mean operative time was hours. The estimated blood loss ranged from 200 cc to 16,000 cc, with a mean of transfusions being U. CBP was required in only 3 patients. Three patients (4.5%) died in the immediate postoperative period. Median follow-up among the 56 survivors was 7.1 months. Six patients died due to metastasis and 1 died of a cause unrelated to the cancer. The estimated actuarial survival at 36 months was 66%. Conclusions: An aggressive surgical approach is the only hope for curing patients having RCC with a tumor thrombus in the IVC. The extent of dissection is predicated on the extent and level of tumor thrombus. Our surgical approach uses liver transplant techniques to mobilize the liver off the IVC and to separate the IVC from the posterior abdominal wall. This maneuver provides excellent exposure and enables safe vascular control of the IVC. # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. University of Miami Miller School of Medicine, Department of Surgery, Division of Transplantation, P.O. Box , Miami, FL 33101, United States. Tel ; Fax: address: gciancio@med.miami.edu (G. Ciancio) /$ see back matter # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi: /j.eururo

2 european urology 51 (2007) Introduction Renal cell carcinoma infrequently extends into the inferior vena cava [1]. When it occurs, surgery offers the only potential cure [2]. The approach varies among surgeons yet all agree that the surgery is complex and requires an excellent understanding of the anatomy and, generally, a team approach [3 8]. Some surgeons prefer a thoracoabdominal incision or median sternotomy to provide adequate exposure and vascular control. Both approaches facilitate the use of cardiopulmonary bypass. While CPB provides a measure of safety, postoperative coagulopathy and neurological sequelae from CPB and deep hypothermic circulatory arrest (DHCA) warrant consideration of alternatives. We describe our experience managing 66 patients with RCC and IVC tumor thrombus utilizing a transabdominal approach, usually without recourse to intraoperative bypass maneuvers. Our approach merges surgical principles from the fields of urologic oncology and transplantation and, thus, these patients should be referred to facilities with expertise in dealing with RCC with IVC tumor thrombus. 2. Materials and methods From August 1997 to February 2005, 66 patients, 34 men and 32 women, underwent resection of a RCC with extension of tumor thrombus into the IVC (Stage T3b/c). Their ages ranged from 25 to 84 (mean 62 years). Initial diagnosis was made by computed tomography (CT). Cardiac, renal, and respiratory status were evaluated pre-operatively. The level of the thrombus confirmed in 48 patients with magnetic resonance imaging (MRI). The cranial extent of the tumor was initially defined per Neves and Zincke [3]; however, for a level III thrombus we used our modified definition [8]. Clinical and pathological staging was performed using the TNM classification. Tumor grade was classified according to the Furhman grading system. Thirteen patients had a level I thrombus (renal vein only), 7 had a level II thrombus (infrahepatic IVC), 38 had a level III thrombus (retrohepatic IVC) [8], and 8 had a level IV thrombus (intra-atrial). Sixty three were managed by a transabdominal approach without bypass maneuvers; 3 patients (4.5%) with a level IV tumor thrombus that was adherent to the atrial wall had CPB. The tumor was on the right side in 48 and on the left in 18 patients. Transesophageal echocardiography (TEE) was occasionally used to monitor the tumor thrombi that were above the infrahepatic vena cava. TEE is helpful in delineating the cranial extent of the thrombus. For a level I or level II tumor thrombus, TEE was not used; however, TEE is useful for level III and IV Statistical methods Actuarial patient survival and disease free survival were estimated (along with standard errors of those estimates) using Kaplan-Meier curves. Subgroup differences for a particular hazard rate were tested by the log-rank test. Although the total cohort size and observed number of failures were relatively small, multivariable analysis of both outcome variables was performed using a Cox model stepwise regression approach. Baseline characteristics that were considered for their prognostic value included: patient age at surgery, presentation with distant metastasis, local lymph node involvement, tumor grade, tumor size, and tumor level Operative technique A triradiate incision is made commencing approximately 2 fingerbreadths below the right costal margin, extending out laterally to the mid axillary line. This is extended below the left costal margin as far as necessary, and vertically in the midline to the xiphoid process. A Rochard self-retaining retractor is placed elevating the costal margins and splaying them laterally toward the axillae. We pursue early intraoperative ligation of the involved renal artery. The kidney is mobilized medially until the renal artery is identified and ligated [9]. Arterial ligation results in decompression of collateral circulation and decreasing blood loss. Exposure of the left kidney begins by mobilization of the descending colon. The spleen is dissected off the diaphragm and mobilized en bloc with the pancreas toward the midline. This exposes the entire upper retroperitoneal space from the diaphragm to the inferior border of the kidney Surgical approach based upon degree of thrombus extension Liver mobilization begins with dissection of the ligamentum teres which is divided. The falciform ligament is divided with cautery and this incision is carried around both to the right superior coronary ligament and by passing to the left side, dividing the left triangular ligament. The visceral peritoneum on the right of the hepatic hilum and the infrahepatic vena cava is incised in conjunction with the right inferior coronary and hepato-renal ligaments. The liver is gradually rolled to the left using these techniques as described for liver transplantation [8 13]. Once the liver is mobilized, RCC with a level I tumor thrombus can be resected with minimal vena cava dissection. After vascular control is achieved, a cavotomy is performed and the tumor extracted. The tumor can be milked back into the renal vein and a vascular clamp applied. Level II tumors invade the IVC with the superior extent below the level of the intrahepatic IVC. Complete inferior vena cava obstruction is often present. For better proximal control, the liver may need to be dissected off the IVC in its inferior aspect (see level III). Once vascular control is achieved, the IVC can be clamped partially or totally. The cava is opened along its anterolateral aspect and the tumor thrombus is removed. If the IVC has been completely clamped, the vascular clamps can be repositioned to allow blood return from the legs and the opposite renal vein. For level III and IV an opening in the lesser omentum allows the porta hepatis to be controlled with a Rummel tourniquet; a Pringle maneuver can then be carried out (temporarily occluding the portal venous and arterial inflow

3 990 european urology 51 (2007) Fig. 1 A. The whole abdominal inferior vena cava with tumor thrombus is exposed by mobilizing the liver off of retrohepatic inferior vena cava. B. Inferior vena cava dissected off the posterior abdominal wall. Mobility allows tumor milking below the major hepatic veins by the surgeon s fingers. IVC = inferior vena cava; KT = kidney tumor; L = liver. to the liver) as required. Then we proceed with the piggyback liver transplantation technique [20]. Piggyback liver transplantation is so called because the recipient s vena cava is left in situ and the liver mobilized off the vessel [13]. Small hepatic veins passing from the right and caudate lobe are ligated and divided. The liver is dissected off the inferior vena cava until it lies in a piggyback fashion, attached to the inferior vena cava only by the major hepatic veins (Fig. 1A). In this fashion, the infrahepatic, intrahepatic, and suprahepatic portions of the IVC are completely exposed (Fig. 1A). In addition to mobilizing the liver off the cava, a plane between the IVC and the posterior abdominal wall is important because it permits circumferential vascular control of the cava [15 18] (Fig. 1B). Small tributaries can become engorged to look like lumbar vessels, and they need to be identified and ligated. A useful technique, which we have applied for a thrombus located above the hepatic veins, is to milk the thrombus below the major hepatic veins and then apply a vascular clamp just below the major hepatic veins (Fig. 2). This technique is often feasible since ligation of the renal artery reduces the blood Fig. 2 Abdominal removal of renal cell carcinoma with level III supradiaphragmatic, suprahepatic, infra-atrial tumor thrombus. A. The entire abdominal inferior vena cava is exposed by mobilization of the liver off the retrohepatic inferior vena cava. Diaphragm is dissected off of the suprahepatic inferior vena cava. A plane is created between the inferior vena cava and the posterior abdominal wall () )))). B. Mobility of the inferior vena cava allows milking the tumor below the hepatic veins. Clamp is placed below the hepatic veins and continual hepatic venous drainage is permitted during the closure or reconstruction of the inferior vena cava.

4 european urology 51 (2007) Fig. 3 A. Central tendon of the diaphragm and the posterior wall of the IVC are dissected. Right atrium, IVC, porta hepatis, left renal vein, and distal IVC are clamped. B. The tumor thrombus is milked down or dissected off the atrium wall and suprahepatic IVC, then the vascular clamp is repositioned below the major hepatic veins and the porta hepatis clamp is released. supply to the tumor thrombus. It serves a dual function. First, it allows the liver to drain into the IVC avoiding hypotension from decreased venous return. Second, by not clamping the major hepatic veins or porta hepatis, liver congestion and postoperative hepatic dysfunction are avoided. The surgeon must be careful when touching the thrombus so as to avoid dislodging it. For level IV and some level III thrombi [8], the central tendon of the diaphragm is dissected until the supradiaphragmatic, intrapericardial IVC is identified (Fig. 3A). This dissection is carried out circumferentially so that the intrapericardial IVC can be encircled at its confluence with the right atrium. The right atrium is gently pulled beneath the diaphragm (Fig. 3). The Pringle maneuver is then performed to temporarily occlude the vascular inflow to the liver. The infrarenal cava and left or right renal vein are controlled, and a Satinsky clamp is placed across the right atrium. For a level III tumor thrombus a vascular clamp is placed across the intrapericardial or suprahepatic IVC [8]. The IVC is incised from the diaphragm to the renal vein, and the tumor is sharply dissected off the atrial wall and/or IVC. The three major hepatic veins can be directly visualized, their orifices inspected, and tumor removed if it is invading them. Following removal of the tumor thrombus and closure of the upper cava, the clamp is repositioned below the hepatic veins, the Pringle is released, and normal liver blood flow is reestablished (Fig. 3). The remaining IVC below the hepatic veins is sutured closed [14,15] Budd-Chiari Syndrome (BCS) associated with RCC with tumor thrombus In 5 patients, the tumor invaded the major hepatic veins causing a BCS. In 4 of them, the tumor also extended into the right atrium (level IV), and in 1 the tumor extended above the diaphragm but below the atrium. One patient with severe BCS had to go on cardiopulmonary bypass. This, in conjunction with cirrhosis, discovered only at surgery, resulted in a coagulopathy requiring 47 units of blood, 98 units of platelets, and component therapy. Hemostasis was achieved, but she developed liver failure and died 2 weeks postoperatively due to multiorgan dysfunction. Another patient with BCS also had large transfusion requirements of 20 units of blood during tumor removal. His convalescence was uneventful, but he died 6 months after surgery from metastatic renal cancer [10] Resection of the IVC during tumor thrombus removal Four patients underwent radical nephrectomy with resection of the abdominal IVC. The first patient had a left RCC with a tumor thrombus, as well as a thrombosed infrarenal cava containing an IVC filter that had been placed at another hospital. The infrarenal and juxtarenal cava were resected along with the tumor thrombus, left renal vein, and left kidney. The IVC was oversewn distally above the confluence of the iliac veins, and the suprarenal cava was repaired restoring antegrade flow through the right renal vein. Two patients had a right nephrectomy and removal of most of the abdominal IVC. The left renal vein, the distal IVC, and the cava just below the hepatic veins were oversewn (Fig. 4). The left renal vein was not reimplanted as there were extensive collaterals draining the kidney. The fourth patient had a similar resection but in his case a large segment of the left renal vein had to be removed. The remaining left renal vein was anastomosed endto-end to the proximal IVC to avoid renal dysfunction [11]. 3. Results Sixty six patients underwent radical nephrectomy with resection of tumor thrombus from the IVC. Serum creatinine values ranged from 0.6 mg/dl to 4.6 mg/dl (mean 1.28 mg/dl, normal mg/dl). Two patients were on hemodialysis preoperatively. Clinical staging revealed T3b with level I thrombus in 13 (19.7%), level II thrombus in 7 (10.6%), level III thrombus in 38 (57.6%), and T3c with level IV thrombus in 8 (12.1%) (Table 1). The level of thrombus

5 992 european urology 51 (2007) Fig. 4 The surgical specimen includes en-block resection of the inferior vena cava (A), tumor thrombus (B) and kidney tumor (C). on CT/MRI correlated well with the intraoperative findings. All patients had complete extraction of tumor from the IVC. Mean operative time was h (range h). Estimated blood loss ranged from 200 cc to 16,000 cc (mean 1, cc). The number of transfusions ranged from 0 to 47 (mean U). Four patients received cell saver blood only, 34 received allogeneic blood, and 28 did not require a transfusion (Table 1). Three patients required CPB. Veno-venous bypass was not used. Ten patients had known metastatic RCC. Sixty three of the patients had an uneventful postoperative course. One patient with a level III thrombus died on the first postoperative day from a cardiac arrhythmia. Another patient had severe BCS and needed to go on CPB. She developed a coagulopathy and liver failure, and died 2 weeks postoperatively of multiorgan dysfunction. The third patient died of sepsis 2 weeks after surgery. Pathological examination revealed RCC of the clear cell variety in 53 patients, sarcomatoid in 2, granular in 3, clear/granular in 3, and papillary in 5. There were lymph node metastases in 12 patients (18%) 1 with a level I, 9 with level III and 1 with a level IV tumor thrombus. The median Furhman grade was 3 and the mean tumor size was 10 cm (range cm). The median follow-up among the 56 survivors was 7.1 months (range months). Ten deaths have been observed so far, with 3 occurring in the immediate postoperative period, 6 due to metastasis and 1 due to complication of a pelvic fracture. Actuarial survival for the whole cohort at 36 months was 66% 13%. A multivariable analysis of survival identified 2 factors that were unfavorable: distant metastasis at the time of surgery (P = 0.003) and a level IV thrombus (P = 0.004). Ten patients had distant metastasis at the time of surgery, and 8 patients had a level IV tumor (1 patient had both of these characteristics). Among the 49 patients having a more favorable prognosis, i.e., presentation without metastasis and a level I-III tumor, only 3 deaths were observed (actuarial survival at 3 years post-surgery was 82% 10%). Conversely, among the 17 patients at high risk of death, i.e. presentation with distant metastasis or a level IV tumor, 7 have died (actuarial survival estimate at 3 years postsurgery was 0%) (P = by the log-rank test). Among the 56 patients who were free of distant metastasis at the time of surgery, 14 patients developed a distant metastasis. The actuarial probability of developing metastasis by 2 years post-surgery was 47% 11%. One factor was found to be associated with a significantly higher rate of developing metastasis: patients having a level IV tumor (P = 0.005). The observed proportion of patients who developed a distant metastasis post-surgery was 10/49 among those having a level I-III tumor in comparison with 4/7 among those with a level IV tumor. 4. Discussion Patients with a thrombus from RCC which extends into the IVC, without lymph node metastasis, have a reasonable prognosis [16]. Five-year survival rates of 32% 64% with surgery have been reported [3,5,17 19]. Table 1 Patients with renal cell carcinoma and level tumor thrombus Level N Operative time (hours) * Transfusion (n) * Blood loss (ml) * I II III , IV , Total , * Standard error; N, number of patients; (n), number of units of blood.

6 european urology 51 (2007) The critical factor is successful surgery, mainly management of the IVC [17], and the important goals are to minimize bleeding and prevent embolism from the thrombus during surgery. Either event often leads to fatal consequences. While the oncological prognostic value of this series was obviously limited by the small numbers and presence of many subgroups in terms of level, presence or not of nodes and metastasis, our overall results were quite expected: (i) a very small percentage (3/66) of our patients died of a post-operative complication, (ii) presence of metastasis at the time of surgery was significantly associated with a poorer survival, and (iii) level IV tumors were associated with a significantly higher risk of the development of metastatic spread. Over the years, several approaches have been developed to aid in the safe removal of these tumors. The improvement in surgical technique has often been due to the application of surgical principles from different disciplines. Cardiopulmonary bypass, with or without deep hypothermic circulatory arrest, is an example of using cardiac surgery tools in an oncologic operation [20,21]. We propose blending lessons learned in the fields of liver transplantation surgery and urologic oncology to deal with a tumor thrombus of the IVC. The concept of resorting to an entirely intra-abdominal approach without cardiopulmonary or veno-venous bypass is the byproduct of this approach [12]. Cardiopulmonary bypass, with or without deep hypothermic circulatory arrest [6,21,22], can produce platelet dysfunction and coagulopathy, resulting in bleeding from the extensive raw retroperitoneal surfaces [5]. Cardiopulmonary bypass in patients with a bulky, intra-atrial thrombus may be required. However those with a minimal, non-adherent atrial thrombus, or level III tumor extension, may not require cardiopulmonary bypass. Advocates of preoperative renal artery embolization claim it makes the operation easier because (a) it reduces blood loss by collapsing the many collaterals on the surface of the kidney and the hilum, (b) it allows ligation of the renal vein without first ligating the artery and (c) if 24 to 48 hours are allowed to elapse after infarction, considerable edema develops around the tumor facilitating dissection from contiguous structures. We have never preoperatively embolized any of our patients, but an important principle of our surgical approach includes mobilization of the kidney with resection early ligation of the renal artery. With the posterior approach, fewer varices are encountered as opposed to dissection anterior to the kidney. Once the kidney is mobilized medially, the renal artery is identified, ligated and divided. The collateral circulation quickly collapses making the rest of the dissection easier, and has the same effect as preoperative embolization without the morbidity [9]. Budd-Chiari syndrome (BCS) is a rare disorder resulting from the occlusion of the major hepatic veins or the suprahepatic inferior vena cava. It classically presents with the triad of hepatomegaly, right-sided abdominal pain, and ascites [23]. A variety of underlying conditions predispose to the development of BCS, but hepatocellular, adrenal, and renal cell carcinomas are the most common malignant causes [24,25]. The presence of hepatic vein obstruction causing a BCS is an adverse feature. Portosystemic varices add to the problem of enlarged caval collaterals and meticulous attention to homeostasis is essential. Liver congestion makes mobilization more difficult and poor liver function and increased third space losses due to the portal hypertension further complicate the post-operative management and can be associated with imminently life-threatening sequelae like hepatic failure seen in one of our patient. Our five patients with hepatic vein occlusion and secondary BCS had collateral circulation and varices of sufficient magnitude that partially compensated for the greatly reduced outflow from the hepatic veins. These extensive collaterals, caused by both the cava and hepatic vein occlusion, make the surgery especially challenging. Our technique allows complete removal of all gross tumor extending into the hepatic veins, and can be used in conjunction with cardiopulmonary bypass when necessary. Fortunately in the present series it was not associated with mortality. Our experience affirms the possibility of resection of the IVC en-bloc with RCC and tumor thrombi without the need for IVC reconstruction. Complete piggyback liver mobilization [8 12] facilitates thrombectomy because cavotomy may be extended cranially to remove any adherent tumor thrombus, and makes removal of the IVC easier when necessary. Although prosthetic grafts can be placed in this setting, we have successfully avoided them. 5. Conclusions A strict abdominal approach to RCC with tumor thrombus in the IVC can provide the surgeon with exposure similar to the thoracoabdominal incision without the pain and chest tube associated with a thoracotomy. The use of liver and IVC mobilization techniques helps in achieving additional exposure and enables the surgeon to have excellent control of the IVC for safe resection of these tumors.

7 994 european urology 51 (2007) Conflicts of interest The authors have no disclosure to make. We have no commercial relationship such as: consultancies, stock ownership or other equity interests, patents received and/or pending, or any commercial relationship which might be in any way considered related to a submitted article. Acknowledgments The authors thank the illustration expertise of Claudia Gutierrez. References [1] Williams RD. Renal, perirenal and ureteral neoplasms. In: Adult and Pediatric Urology. Gillenwater JY, Grayhack JT, Howards SS, Duckett JW, editors. 1st ed. Chicago, Vol 1, Chapt 16; p [2] Tribble CG, Gerkin TM, Flanagan TL, et al. Vena caval involvement with renal tumors: surgical considerations. Ann Thorac Surg 1988;46:36 9. [3] Neves RJ, Zincke H. Surgical treatment of renal cancer with vena cava extension. Br J Urol 1987;59: [4] Marshall FF, Dietrick DD, Baumgartner WA, et al. Surgical management of renal cell carcinoma with intracaval neoplastic extension above the hepatic veins. J Urol 1988; 139: [5] Skinner DG, Pritchett TR, Lieskovsky G, et al. Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 1989;210: [6] Novick AC, Kaye MC, Cosgrove DM, et al. Experience with cardiopulmonary bypass and deep hypothermic circulatory arrest in the management of retro-peritoneal tumors with large vena caval thrombi. Ann Surg 1990;212: [7] Nesbit JC, Soltero ER, Dinney CP, et al. Surgical management of renal cell carcinoma with inferior vena cava tumor thrombus. Ann Thorac Surg 1997;63: [8] Ciancio G, Vaidya A, Savoie M, et al. Management of renal cell carcinoma with level III thrombus in the inferior vena cava. J Urol 2002;168: [9] Ciancio G, Vaidya A, Soloway M. Early ligation of the renal artery using the posterior approach: a basic surgical concept reinforced during resection of large hypervascular renal cell carcinoma with or without inferior vena cava thrombus. BJU Int 2003;92: [10] Ciancio G, Soloway M. Renal cell carcinoma invading the hepatic veins. Cancer 2001;92: [11] Ciancio G, Soloway M. Resection of the abdominal inferior vena cava for complicated renal cell carcinoma with tumor thrombus. Br J Urol Int 2005;96: [12] Ciancio G, Hawke C, Soloway M. The use of liver transplant techniques to aid in the surgical management of urological tumors. J Urol 2000;164: [13] Tzakis A, Todo S, Starzl TE. Orthotopic liver transplantation with preservation of the inferior vena cava. Ann Surg 1989;210: [14] Ciancio G, Soloway M. Renal cell carcinoma with tumor thrombus extending above the diaphragm: avoiding cardiopulmonary bypass. Urology 2005;66: [15] Cerwicka WH, Ciancio G, Salerno TA, Soloway M. Renal cell cancer with invasive atrial tumor thrombus excised off-pump. Urol 2005;66:1319.e e11. [16] Patard JJ. Renal cell carcinoma with inferior vena cava invasion: An orphan disease? Eur Urol 2006;50: [17] Swierzewski DJ, Swierzewski MJ, Libertino JA. Radical nephrectomy in patients with renal cell carcinoma with venous, vena caval and atrial extension. Am J Surg 1994;168: [18] Glazer AA, Novick AC. Long-term followup after surgical treatment for renal cell carcinoma extending into the right atrium. J Urol 1996;155: [19] Montie JE, el Ammar R, Pontes JE, et al. Renal carcinoma with inferior vena cava thrombi. Surg Gynecol Obstet 1991;173: [20] Vaislic C, Puel P, Grondin P, et al. Surgical resection of neoplastic thrombus in the inferior vena cava by neoplasms of renal-adrenal tract. Vasc Surg 1983;17: [21] Marshall FF, Reitz BA, Diamond DA. A new technique for management of renal cell carcinoma involving the right atrium. Hypothermia and cardiac arrest. J Urol 1984;131: [22] Vaislic C, Puel P, Grondin P, et al. Cancer of the kidney invading the vena cava and heart. Results after 11 years of treatment. J Thorac Cardiovasc Surg 1986;91: [23] Mahmoud AEA, Elias E. New approaches to the Budd- Chiari syndrome. J Gastroenterol Hepatol 1996;11: [24] Kume H, Kameyama S, Kasuya Y, Tajima A, Kawabe K. Surgical treatment of renal cell carcinoma associated with Budd-Chiari syndrome: report of four cases and review of the literature. Eur J Sur Oncol 1999;25:71 5. [25] Mitchell MC, Boitnott JK, Kaufman S, Cameron JL, Maddrey WC. Budd-Chiari syndrome: etiology, diagnosis and management. Medicine 1982;61: Editorial Comment Peter F.A. Mulders, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands P.Mulders@uro.umcn.nl This article deals with a technique that can make the removal of tumour thrombus in the caval vena more accessible. Real prognostication for these patients and standardised procedures for indication and surgical approaches are lacking because of the limited numbers of patients and the variety of staging systems. Several issues are addressed in the article and can be discussed.

8 european urology 51 (2007) Extension of tumour thrombus in the vena cava is divided into different levels. The study has a substantial number of patients who have only limited vena caval extension. The question is whether the procedure with liver mobilisation and retrograde ligation of the artery should always be used. The procedure can be especially beneficial in tumour thrombi with extension below the atrium but above the hepatic vein to avoid cardiac arrest and reduce morbidity. Therefore, it is important to use adequate diagnostic tools to determine the exact extension. The use of magnetic resonance imaging, multislice computer tomography scanning, and colour flow ultrasound can be used with reasonable accuracy, with ultrasound giving information on blood flow and attachment of the thrombus to the caval wall [1,2]. It can individualise the necessary extent of preparation for the procedure, especially for the indication of cardiac arrest. The low prevalence of patients with extensive vena caval involvement of thrombus and the higher morbidity and even mortality risks also indicate the need for experience with performing the procedure. Guidelines advise that these patients be referred to experienced centres with all equipment available. The manoeuvre with mobilising the liver and the possibility for cardiac arrest explain the need for a multidisciplinary surgical team to obtain optimal oncology outcome with acceptable morbidity. Indications for surgery should be discussed with oncology teams because of the prognostic differences based on the extent of the thrombus [3]. References [1] Lawrentschuk N, Gani J, Riordan R, Esler S, Bolton DM. Multidetector computed tomography vs magnetic resonance imaging for defining the upper limit of tumour thrombus in renal cell carcinoma: a study and review. BJU Int 2005;96: [2] Gupta NP, Ansari MS, Khaitan A, et al. Impact of imaging and thrombus level in management of renal cell carcinoma extending to veins. Urol Int 2004;72: [3] Kim HL, Zisman A, Han KR, Figlin RA, Belldegrun AS. Prognostic significance of venous thrombus in renal cell carcinoma. Are renal vein and inferior vena cava involvement different? J Urol 2004;171(2 pt 1):