In patients with renal cell carcinoma and IVC tumor thrombus, radical nephrectomy with inferior vena cava (IVC) thrombectomy is still the most effective treatment option. Up to 35% of patients with renal cell carcinoma have been reported to have involvement of the inferior vena cava (IVC). It is distinguished by its strong tendency for vascular invasion, which extends through the renal vein and inferior vena cava (IVC). The prognosis of patients is unaffected by complete removal of the tumor thrombus's extension into the IVC, but non-removal has been linked to a lower survival rate. Even in patients with distant metastases, aggressive surgical resection, such as radical nephrectomy with IVC thrombectomy, is the most beneficial therapeutic option for patients with RCC and IVC tumor thrombus.

The surgical approach varies depending on the surgeon and level of the thrombus, but it is generally agreed that these cases are complex, call for a thorough understanding of abdominal anatomy, and benefit from a surgical team approach.

Purpose: 

About 3% of all new cancer cases are renal cell carcinomas (RCC). A thrombus in the inferior vena cava (IVC) develops in 4–10% of RCC patients. A radical nephrectomy combined with an IVC thrombectomy is done to treat these patients. Reports have shown a 50–65% survival rate after patients have undergone this surgery. 

Procedure:

Finding the level of the tumor thrombus is the most important aspect of the preoperative workup. In addition to being useful for prognosis, it will be crucial for surgical planning. Computed tomography (CT) and magnetic resonance imaging (MRI) are the most frequently used tests.

To ensure proper access to both subdiaphragmatic spaces, the patient is placed in a supine position with the lumbar lordosis extended. The surgeons make a bilateral subcostal incision to provide the best possible surgical exposure.

opening the parietal peritoneum, moving the kidney tumor laterally until it reaches the renal artery outside the Zuckerkandl fascia. Once there, the artery is connected and divided.

If it is a level I or some IIIb/IIIc levels of thrombus, they can be treated manually by pulling the thrombus below the suprahepatic veins and placing a clamp below them. 

TEE control should help with this step by evaluating the clamp level and the possibility of the thrombus dislodging and causing a pulmonary embolism as a result.

The Pringle maneuver, the IVC below the thrombus, the contralateral renal vein, the right adrenal vein if necessary, and the IVC above the thrombus are performed prior to the correct sequential vascular clamping of the vessels once the IVC has been dissected. 

Cavotomy begins in the affected renal vein and extends as far proximally as necessary. Sharp dissection is used to completely remove the tumor thrombus, including any adherent thrombus to the IVC wall. Direct visualization of the IVC wall and major hepatic veins makes it possible to completely remove thrombi from their ostia. The IVC is then ligated. 

After the thrombus is removed, a vascular clamp is placed immediately above the proximal segment of the cavotomy, allowing the suprahepatic clamp and hepatic hilium clamp to be safely removed and hepatic circulation to be restored.

Recovery: 

Depending on the procedure, you might need to recover from surgery for two to three weeks or longer. Do not immediately resume your previous activities at your previous pace, even if you begin to feel better. For however long you need to rest easy, follow the recommendations of your medical team.

In order to avoid infection or injury, make sure to thoroughly wash your hands before touching your incision, whether it be to change bandages or clean them.

Contact a friend or family member to arrange a ride home after surgery. After surgery, you might also require help with daily chores like cooking, laundry, and pet care.

The best person to turn to for advice on any post-surgery issues is your doctor, so schedule regular follow-up appointments. If you experience complications like a temperature of 101.5 degrees or higher, increased pain, problems with your incisions, abnormal swelling, redness, or drainage, call your doctor even if it's not yet time for your follow-up appointment.

Risk:

Even with advances in preoperative diagnostic techniques, anesthesia, and postoperative care, this type of surgery is still associated with significant morbidity and mortality, ranging from 2.7% to 40% (3, 8, 12), primarily due to massive pulmonary embolism and hemorrhage (7, 13). These complications are closely related to the IVC tumor thrombus's cephalic extension, indicating that patients whose tumor thrombi extend above the level of the diaphragm should only undergo radical surgery.

Conclusion:

Radical nephrectomy with thrombectomy has improved the prognosis for RCC patients with IVC thrombus in comparison to nonaggressive surgical treatment. Therefore, if surgery is considered technically possible, radical nephrectomy with thrombectomy should be taken into consideration for patients with high-level thrombus. Additionally, there is currently a growing amount of discussion and interest surrounding the use of robotic surgery and laparoscopic surgery in the management of RCC with IVC thrombosis. Long-term survival is possible in some patients after radical nephrectomy with vena caval thrombectomy, which is associated with acceptable postoperative morbidity and mortality. No matter the surgical strategy, treatment planning for these patients needs to be coordinated by a multidisciplinary team and include options for immunotherapy during the perioperative period.