Pure Retroperitoneal Laparoscopic Radical Nephrectomy for Right Renal Masses with Renal Vein and Inferior Vena Cava Thrombus

Purpose: To describe our pure retroperitoneal laparoscopic radical nephrectomy (LRN) with thrombectomy for right renal masses with renal vein (RV) and inferior vena cava (IVC) thrombus. Patients and Methods: Five patients with right renal masses with RV and IVC thrombus underwent pure retroperitoneal LRN. Three patients had a history of abdominal surgery. In one patient with a RV thrombus, the RV was ligated and dissected with Hem-o-lok clips; in four patients with IVC thrombus, the IVC was partially occluded with a laparoscopic vascular clamp and incised distal to its junction with the right RV, and the thrombus was delivered intact. The IVC was closed with a running 3-0 polypropylene suture. Results: Pure retroperitoneal LRN with thrombectomy was successfully performed for all the patients without hand-assisted or open conversion. The mean tumor size was 6.2 cm, and mean thrombus length was 2.8 cm; four thrombi extended 0.6-1.0 cm into the IVC, and the mean operative time was 127 minutes with the average estimated blood loss at 148 mL. The mean hospital stay was 5 days. Histology revealed two renal-cell carcinomas, one angiomyolipoma, one renal pelvic transitional-cell carcinoma, and one renal infarction. All the surgical margins were negative. With a mean follow-up of 35 months, metastatic diseases did not develop in any patient. Conclusions: Despite the technical challenges, pure retroperitoneal LRN for right renal masses with a RV and IVC thrombus is safe and feasible in appropriately selected patients using a retroperitoneal approach. In patients with minimal caval involvement, our surgical approach provided an alternative treatment option, especially when the patients had a history of abdominal surgery.