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Nephrectomy with Vein/Vena Cava Involvement

X-ray film of a patient showing a kidney tumor

Kidney Tumor with Vena Cava Invasion

Larger tumors may extend into the veins draining the kidney. These tumors can then extend into the vena cava (the largest vein in the body) and even all the way up to the heart. If you have a large tumor, it is important to verify that the tumor has not extended into these areas.

Illustration of a kidney

Classically, an MRI scan could reliably give us this information. More recently, Johns Hopkins urologists teamed with Johns Hopkins radiologist Elliott Fishman and showed that a special CT scan could also show this reliably (multidetector computed tomography).* It is imperative that your scan is of good quality to reliably delineate this area.

*(Guzzo TJ, Pierorazio PM, Schaeffer EM, Fishman EK, Allaf ME. The accuracy of multidetector computerized tomography for evaluating tumor thrombus in patients with renal cell carcinoma.  J Urol. 2009 Feb;181(2):486-90; discussion 491. Epub 2008 Dec 19.)

For select patients with vena cava involvement, surgery could be life-saving. This type of surgery is very rare and is best approached at centers of excellence. At Johns Hopkins we take a multi-disciplinary approach to these cases.

Depending on the extent of the tumor, a team is assembled that may consist of a general surgeon, vascular surgeon, cardiothoracic surgeon, and a specialized anesthesiologist. The anesthesia team is critical during these operations and routinely perform intraoperative transesophageal echocardiogram (TEE) to monitor the tumor during the operation. TEE is a special ultrasound that is placed in the patient’s esophagus and monitors the tumor that sits within the vena cava. This is important as part of the tumor or a blood clot on it could dislodge and result in a pulmonary embolus (clot in the lung) which can be deadly. Keeping an eye on this area allows the surgical team to be updated on the status of the tumor much like a GPS machine in your car.

Illustration of a kidney

Occasionally venous bypass or even full cardiopulmonary bypass is required to perform these procedures safely. Our multidisciplinary team has recently described a novel approach to difficult recurrent tumors in the vena cava.*  Sometimes part of the vena cava wall has to be removed because it is involved with tumor and a graft is placed to allow closure of this delicate blood vessel.  Our team has also recently described our favorable results with these graft procedures.**

*(Alejo JL, George TJ, Beaty CA, Allaf ME, Black JH 3rd, Shah AS. Novel approach to recurrent cavoatrial renal cell carcinoma. Ann Thorac Surg. 2012 May;93(5):e119-21.)
**( Hyams ES, Pierorazio PM, Shah A, Lum YW, Black J, Allaf ME. Graft reconstruction of inferior vena cava for renal cell carcinoma stage pT3b or greater. Urology. 2011 Oct;78(4):838-43. Epub 2011 Aug 6.)

In general, for these operations the kidney is dissected and the renal artery (artery feeding the tumor) is promptly controlled. Now that there is no new blood coming into the tumor, we assess how "high" it goes-- is it just in the vena cava, or into the liver veins, or all the way into the heart? This is usually performed by the surgeon but our anesthesia team uses a specialized ultrasound that monitors the tumor and can evaluate the extent of the tumor accurately. This real-time intraoperative transesophageal ultrasound can confirm that the tumor has been removed and can also alert the surgeon of additional tumor that the surgeon may not be able to see or feel.

Illustration of a kidney

After the extent of the tumor is define, the blood flow to the area is interrupted and the vena cava is opened. The tumor is extracted and the vena cava is then reconstructed. In rare situations the vena cava is grafted (see above) or in even rarer situations it can be tied off completely. Blood flow through the vena cava is then resumed and the procedure is terminated.

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