Real-time transesophageal echocardiography for intraoperative surveillance of patients with renal cell carcinoma and vena caval extension undergoing radical nephrectomy

Purpose: Vena caval tumor thrombus associated with renal cell carcinoma occurs in 4 to 10% of all renal tumors. There is significant operative morbidity and mortality in removing these tumors. We investigate the use of real-time transesophageal echocardiography intraoperatively and to identify tumor thrombus migration and air embolus, which are 2 potentially fatal complications of this procedure. Materials and Methods: A total of 13 consecutive patients with renal masses and vena caval extension underwent extirpative surgery monitored with real-time transesophageal echocardiography. Results: In 11 cases the involved kidney and tumor thrombus were removed without morbidity and no evidence of tumor migration or air embolus. Transesophageal echocardiography revealed a 5 cm. tumor thrombus in the right atrium which was removed by immediate atriotomy in 1 of the remaining 2 cases, and a large volume of air in the right atrium that was percutaneously evacuated in the other. These intraoperative complications were unsuspected and only recognized due to the use of transesophageal echocardiography. Conclusions: Real-time transesophageal echocardiography is a useful adjunct to surgery in patients with renal cell carcinoma and vena caval extension. Transesophageal echocardiography facilitates identification of tumor thrombus migration and air embolization, which are potentially fatal complications, and allows for immediate intraoperative intervention.