Abstract
OBJECTIVE To investigate the outcome and indications for radical nephrectomy with a Chevron incision to treat complicated renal carcinoma.
METHODS Large renal carcinomas were found in 15 patients during a preoperative CT and/or MRI examination. A tumor thrombus in the renal vein or inferior vena cava was found in 5 cases, and a complication of metastasis in the contralateral adrenal gland was found in 2 patients. All of the 15 patients underwent a radical nephrectomy by a chevron incision and the postoperative pathological results noted.
RESULTS Of the 15 patients who underwent a radical nephrectomy and lymphadenectomy, 5 also received a thrombectomy, and 2 a contralateral adrenalectomy. All surgical operations were safe and successful. The mean operation time was (4.45 ± 0.83) h, and the intraoperative blood loss was (785 ± 910) ml. All patients recovered well after the surgery. Multimodal therapy was conducted in these cases, with rigorous follow-up.
CONCLUSION In determining the type of incision for surgery of renal carcinoma, a chevron incision is suitable for cases with a large tumor, local nodal metastasis, thrombus of the renal vein or inferior vena cava and complicated metastasis to the contralateral adrenal gland. The incision produces a clear operating field with less intra- and post-operative complications.
keywords
Introduction
From August 2004 through July 2006, radical nephrectomy and lymphadenectomy with an abdominal chevron incision were conducted in 15 patients with renal carcinoma. Of the total patients, a embolectomy was conducted at the same time in 5 who suffered from a complication of a venous tumor embolism (VTE). Two patients underwent a contralateral adrenalectomy because of complicating contralateral adrenal metastasis (CLAM). The surgical results were satisfactory.
Materials and Methods
General data
There were 15 patients in our group, with 11 males and 4 females. The age of the patients ranged from 40 to 73 years, with an average of 56. Final diagnosis of renal carcinoma was based on results of the first visit for 8 of the 15 patients who had a painless gross hematuria. The primary symptom for 3 of the patients was a complaint of lumbar pain, and for the other 4 the tumor was found during a medical examination.
Image analysis
Preoperative B-ultrasound, CT and isotope (nuclide) bone scan examinations were conducted in all 15 cases. Of all these cases, a MRI examination was performed in 4, and preoperative inferior vena cavography in 2. In our group, there were 11 cases with carcinoma of the right kidney, and 4 with carcinoma of the left kidney. A complication of inferior cava vena VTE was found in 5 cases, with carcinoma of the right kidney in 4 and carcinoma of the left kidney in 1. According to the staging standard for VTE of renal carcinoma, put forward by Neves and Zincke, Stages I, II and III VTE were respectively found in 1, 3 and 1 case. Based on the AJICC 2002 standards used for TNM staging, 2 of the 15 cases were identified as Stage-T2N0M0, and all of the other 13 the cases were in Stage-T3bN0M0 and above. Lymph node metastasis occurred in 4 cases, with individual regional nodal metastasis (RNM) in 2 and multiple RNM in the other 2. Preoperative CLAM was found in 2 cases. Before surgery a B-ultrasound and CT scan were conducted in all 15 cases. An MRI examination was performed in 4 of the 15 cases, finding a renal spaceoccupying lesion in all of the 4 cases. The inferior vena cavography was conducted in 2 of the 15 cases, in order to finalize the stages of the tumor embolus. Of the total cases, 4 cases with VTE were diagnosed by B-ultrasound and the other 5 VTE cases were ascertained by a CT scan. Inferior vena cavography was conducted in 2 cases, showing that the tumor embolus staging was in conformity with the postoperative pathological findings. Location of the vena caval VTE was determined using an intra-operative intervention of vascular ultrasound within the operating field in the 5 cases with the dubious vena caval VTE before surgery. The technique could macroscopically ascertain the specific position of a distal tumor embolus to confirm the scope of the blood vessel blockage. The embolectomy was conducted smoothly in all of the 5 cases, with integral dislodgement of the inferior vena caval tumor embolus.
By use of B-ultrasound, no retroperitoneal lymph node metastases were found in all 15 cases. The CT report indicated that lymph node metastasis had occurred in 5 of the 15 cases. In 4 of these 5 cases with nodal metastasis, a solitary RNM was confirmed in 2, and multiple RNM in the other 2 by postoperative pathologic findings.
A renal carcinoma complicated with CLAM was seen in 2 of the 15 cases, with a carcinoma of the left or right kidney. The postoperative pathological result was in conformity with the preoperative diagnosis.
Operation methods
A supine position and abdominal chevron incision were used in the surgery, with the patient’s waist and back elevated. The incision began from the pointed part of the eleventh rib on one side to the superior inner part, and went downwards to the infra-xyphoid site along the costal margin. It then went both outwards and downwards to the pointed part of the eleventh rib on the other side. An Omni retractor was used to thoroughly expose the superior and middle parts of the abdomen, as well as the renal region undergoing the surgery. The intestinal canal was pushed to the opposite side, and the posterior peritoneum was cut open, with its superior extremity to the right hepatic flexure of the colon or left colonic splenic area, and its inferior extremity to the crotch of the abdominal aorta. The ascending or the descending colon was dissociated towards the midline, in order to thoroughly reveal the abdominal aorta and inferior vena cava (IVC). The tumor was separated and renal pedicle dissected outside of the retroperitoneal perirenal fascia, then the renal artery and vein were respectively ligated. The perirenal fascia, perirenal adipose capsule, diseased kidney, and subterminal renal duct, as well as homolateral adrenal gland, were excised en bloc outside of the perirenal fascia. Intra-operative vascular ultrasound was conducted in the operating field for the patients with preoperatively doubtful caval VTE, in order to localize the renal vein and caval VTE, and to ascertain the scope of blood vessel blockage. The IVC was blocked separately at the superior and the inferior part of the embolus. If there was an encroachment of the tumor embolus on IVC, the postcaval embolectomy was conducted. At the same time, reniportal, para-caval, abdominal aortic and retroperitoneal lymphadenectomies were conducted, and a homochronous contralateral adrenalectomy was completed in the patients with CLAM. Based on the postoperative pathologic results, the preoperative tumor staging was revised, and further treatment plan was determined.
Follow-up
All patients received regular visits and follow-up to monitor their hepatic and renal functions. Chest X-rays, abdominal B-ultrasound, nuclide bone scan examinations, and if necessary, CT rechecks, were conducted, so as to monitor the possibility of relapse or distant metastasis.
Results
The time of surgery ranged from 2.5 h to 5.25 h in the 15 cases of our group, with an average of (4.45 ± 0.83)h. The intra-operative blood loss ranged from 50 ml to 2,500 ml. Of the total cases, the mean blood loss was 1,400 ml in 4 complicated with caval VTE. So the blood loss during surgery was significantly higher in these 4 cases compared to cases without VTE. The surgical procedure was smooth and there were no severe complications, such as tumor exfoliation which could have resulted in pulmonary embolism and embolic residues. Postoperative recovery of the patients was quick. After surgery, the patients were discharged from the hospital in 8 days at the least and 24 days at the most, without wound infections. Of the 15 cases postoperative complicating bronchitis was found in 2 and slight anemia in 1. All the 15 cases received interferon treatment after surgery.
Pathological findings
Of the 15 cases, 14 were identified as clear-cell carcinoma and 1 as a mixed renal cell carcinoma. Lymph node metastasis was found in 4 cases. Preoperative CLAM was found in 2 of the 15 cases, and a radical nephrectomy plus a contralateral adrenalectomy was conducted. The CLAM was confirmed by postoperative pathological findings, suggesting a suprarenal epithelioma. In the 5 cases with complicating inferior vena cava renal VTE, 1 was diagnosed with a tumor of the left kidney and 4 with a tumor of the right kidney. The staging of the tumor VTE was Stage-II, and the staging of VTE for the other 4 cases with the tumor of the right kidney was as follows: there was 1 case of Stage I, 2 of Stage II and 1 of Stage III.
Postoperative follow-up was conducted in all 15 patients, with a mean of 16 months (6~29 months). One patient died of renal cancer metastasis 6 months after surgery. Two patients received chemotherapy because of pulmonary metastasis respectively at 13 and 16 months after surgery. The postoperative 1-year survival rate reached 93.4%. At present 14 of the patients are carefully being followed-up.
Discussion
In 1965, Robson put forward the concept of a “Radical” nephrectomy, which was of great significance in altering surgical treatment of renal carcinoma[1]. The basic principles include the following, i.e. the renal artery and vein are first ligated, and the kidney is excised outside of the perirenal fascia. Afterwards the homolateral adrenal gland is excised and the lymph nodes, ranging from the foot of the diaphragm to the region of the aortic bifurcation, are cleared. Owing to the biological features of renal carcinoma, and its insensitivity to radio-chemotherapy, surgical excision of the primary focus of the tumor remains the treatment of choice [2]. The report of Skinner et al.[3] showed that a vena caval VTE complication will not affect the 5-year survival rate of renal carcinoma patients, so active therapeutic measures should be conducted.
The selection of the incision for radical nephrectomy is mainly based on the extension for surgical excision and exploration, and the principle of diminishing the injury as far as possible. Based on related reports from China and overseas, the incision at the eleventh rib of the waist, epigastric subcostal and linear incisions, and chevron incisions were frequently used[4]. For the cases complicated with a tumor embolus at a superior position, an abdominothoracic incision can be used to completely expose the IVC. In our group a chevron incision was used in all 15 cases. The Omni retractor was employed in the operation, producing a good operating field. A chevron incision can effectively expose the abdominal great vessels and the blood vessel of the renal pedicle in order to ligate the renal artery and vein, and to decrease blood loss. At the same time, the outward extension of the operative procedure can allow treatment of the extrarenal tumor.
Renal cell carcinomas have abundant blood supplies, with frequently-seen encroachment of the intrarenal veins. The incidence rate of tumorous invasion into the renal vein is 30%, and the incidence of the involvement of the inferior vena cava ranges from 4% to 10%[5]. The study of Bastian et al.[6] showed that complication of the renal vein or caval VTE does not decrease the 5-year survivals, so active surgical treatment of the renal carcinoma patients with a tumor embolus complication should be conducted. Since a complete removal of the tumor embolus is needed in order to thoroughly dissociate the renal vein and the inferior vena cava, the scope of the operating field to be exposed has to be enlarged. However, the incision at the eleventh rib of the waist, and the epigastric subcostal and linear incisions fail to satisfy the procedures.
In the 5 cases with a complication of caval VTE, a chevron incision was used for a thoroughly upward and downward exposure and complete dissociation of the inferior caval vein, so as to deal with a vascular accident and variance with ease. An intra-operative blockade of the contralateral renal vein, and the inferior vena cava above and below the embolus was successfully conducted following the preliminary ligation of the bilateral lumbar veins within the scope of the blockade. The inferior vena cava was cut open and the tumor embolus was taken out, in order to effectively diminish the blood loss. The exposure of the operating field was satisfactory in the 5 cases, with a smooth surgical procedure. In our group, 1 case was identified as a carcinoma of the left kidney complicated with a caval VTE. Since an abdominal linear incision or subcostal incisions apparently failed to meet the needs of synchronously treating the tumor of the left kidney as well as the tumor embolus inside the IVC, a chevron incision was used to effectively solve the problem, resulting in an improvement over other surgical methods.
A surgical resection is the sole available method to treat local and adrenal metastasis from renal carcinoma[7]. The incidence of the renal carcinoma complicated with homolateral adrenal metastasis is 3%, and the incidence of CLAM is 0.7%[8]. The study of Plawner et al.[9] indicated that after surgical treatment of the patients for renal carcinoma and CLAM, the 5-year survival rate of the patients was significantly higher than that of the patients with CLAM after surgery of the renal carcinoma, and the 5-year survival rate was 40% and 20% respectively in the two groups. Active surgical treatment should be conducted with patients that have renal carcinoma along with contralateral adrenal metastasis. The difficulty of surgery would be significantly increased when a monolateral radical nephrectomy and contralateral adrenalectomy are performed. It would be difficult to synchronously treat the lesions at both places using other operative incisions. With our patients a chevron incision was used in 2 renal carcinoma cases with CLAM, thus avoiding an increase in excessive injury brought about by the incision. At the same time the period of surgery was shortened, the level of anesthesia less and the incidence of complications diminished.
Among our cases, lymph node metastasis occurred in 4 cases, of which 3 had nodal metastasis of the renal pedicle, and 1 had multiple lymph node metastases in the renal pedicle and beside the aorta. A chevron incision was used producing a thorough exposure of the retroperitoneal lacuna for convenient lymphadenectomy. Postoperative recovery was smooth in the 15 cases, with only a complication of bronchitis in 2, and anemia in 1. These 3 patients recovered after symptomatic treatment, without an incision infection, and with a good healing. Parekh et al.[10] reported that an abdomen incision is good for a safe and effective surgical excision of a larger renal carcinoma complicated with inferior vena caval VTE, thus avoiding problems associated with an abdominothoracic incision. In comparison with an abdominothoracic incision, a chevron incision produces only minor injury, avoiding splitting thoracic bones, as well as complications such as pleural effusion and thoracic infection etc. No postoperative chest drainage is needed. Therefore the opportunity for infections and the patient’s discomfort are both minimized, and the length of stay is shortened.
- Received November 7, 2007.
- Accepted June 8, 2008.
- Copyright © 2008 by Tianjin Medical University Cancer Institute & Hospital and Springer