Renal Cell Carcinoma with Supradiaphragmatic Tumor Thrombus: Avoiding Sternotomy and Cardiopulmonary Bypass

Main Article Content

Marina M. Tabbara Javier González Gaetano Ciancio


Renal cell carcinoma (RCC) accounts for 2-3% of all malignant disease in adults and has a propensity to infiltrate the surrounding adjacent structures with a biologic predisposition for vascular invasion. This tropism for the venous system facilitates propagation into the renal vein and inferior vena cava (IVC) in up to 25% of patients with RCC. Surgical resection remains the mainstay treatment for RCC with venous tumor thrombus (TT) extension and the only hope for a potential cure. Higher thrombus levels correlate with more advanced stages of disease and thus poorer survival rates. Although CPB with circulatory arrest has been successfully performed during resection of these tumors, its use remains controversial due to the risk of coagulopathy, platelet dysfunction, and central nervous system complications. Complete intraabdominal surgical excision of level III thrombi can be achieved without sternotomy and CPB by utilizing hepatic mobilization maneuvers. The purpose of this review is to provide an update on the surgical management of these difficult cases of RCC with supradiaphragmatic tumor thrombi, including a description of transplant-based techniques that avoid sternotomy and cardiopulmonary bypass (CPB), minimizing intra- and post-operative complications.

Keywords: renal cell carcinoma, tumor thrombus, nephrectomy, thrombectomy, cardiopulmonary bypass, sternotomy, surgical technique

Article Details

How to Cite
TABBARA, Marina M.; GONZÁLEZ, Javier; CIANCIO, Gaetano. Renal Cell Carcinoma with Supradiaphragmatic Tumor Thrombus: Avoiding Sternotomy and Cardiopulmonary Bypass. Medical Research Archives, [S.l.], v. 10, n. 7, july 2022. ISSN 2375-1924. Available at: <>. Date accessed: 19 june 2024. doi:
Research Articles


1. Haidar GM, Hicks TD, El-Sayed HF, Davies MG. Treatment options and outcomes for caval thrombectomy and resection for renal cell carcinoma. J Vasc Surg Venous Lymphat Disord. May 2017;5(3):430-436. doi:10.1016/j.jvsv.2016.12.011
2. Gonzalez J. Update on surgical management of renal cell carcinoma with venous extension. Curr Urol Rep. Feb 2012;13(1):8-15. doi:10.1007/s11934-011-0222-0
3. Lardas M, Stewart F, Scrimgeour D, et al. Systematic Review of Surgical Management of Nonmetastatic Renal Cell Carcinoma with Vena Caval Thrombus. Eur Urol. Aug 2016;70(2):265-80. doi:10.1016/j.eururo.2015.11.034
4. Calero A, Armstrong PA. Renal cell carcinoma accompanied by venous invasion and inferior vena cava thrombus: classification and operative strategies for the vascular surgeon. Semin Vasc Surg. Dec 2013;26(4):219-25. doi:10.1053/j.semvascsurg.2014.06.015
5. Psutka SP, Leibovich BC. Management of inferior vena cava tumor thrombus in locally advanced renal cell carcinoma. Ther Adv Urol. Aug 2015;7(4):216-29. doi:10.1177/1756287215576443
6. Marshall VF, Middleton RG, Holswade GR, Goldsmith EI. Surgery for renal cell carcinoma in the vena cava. J Urol. Apr 1970;103(4):414-20. doi:10.1016/s0022-5347(17)61970-0
7. Karnes RJ, Blute ML. Surgery insight: management of renal cell carcinoma with associated inferior vena cava thrombus. Nat Clin Pract Urol. Jun 2008;5(6):329-39. doi:10.1038/ncpuro1122
8. Shiff B, Breau RH, Mallick R, et al. Prognostic significance of extent of venous tumor thrombus in patients with non-metastatic renal cell carcinoma: Results from a Canadian multi-institutional collaborative. Urol Oncol. Dec 2021;39(12):836 e19-836 e27. doi:10.1016/j.urolonc.2021.08.016
9. Haddad AQ, Wood CG, Abel EJ, et al. Oncologic outcomes following surgical resection of renal cell carcinoma with inferior vena caval thrombus extending above the hepatic veins: a contemporary multicenter cohort. J Urol. Oct 2014;192(4):1050-6. doi:10.1016/j.juro.2014.03.111
10. Padala SA, Barsouk A, Thandra KC, et al. Epidemiology of Renal Cell Carcinoma. World J Oncol. Jun 2020;11(3):79-87. doi:10.14740/wjon1279
11. Neves RJ, Zincke H. Surgical treatment of renal cancer with vena cava extension. Br J Urol. May 1987;59(5):390-5. doi:10.1111/j.1464-410x.1987.tb04832.x
12. Ciancio G, Vaidya A, Savoie M, Soloway M. Management of renal cell carcinoma with level III thrombus in the inferior vena cava. J Urol. Oct 2002;168(4 Pt 1):1374-7. doi:10.1097/01.ju.0000023441.00587.02
13. Shah PH, Thompson RH, Boorjian SA, et al. Symptomatic Venous Thromboembolism is Associated with Inferior Survival among Patients Undergoing Nephrectomy with Inferior Vena Cava Tumor Thrombectomy for Renal Cell Carcinoma. J Urol. Sep 2018;200(3):520-527. doi:10.1016/j.juro.2018.04.069
14. Gonzalez J, Gaynor JJ, Martinez-Salamanca JI, et al. Association of an organ transplant-based approach with a dramatic reduction in postoperative complications following radical nephrectomy and tumor thrombectomy in renal cell carcinoma. Eur J Surg Oncol. Oct 2019;45(10):1983-1992. doi:10.1016/j.ejso.2019.05.009
15. Boorjian SA, Sengupta S, Blute ML. Renal cell carcinoma: vena caval involvement. BJU Int. May 2007;99(5 Pt B):1239-44. doi:10.1111/j.1464-410X.2007.06826.x
16. Lambert EH, Pierorazio PM, Shabsigh A, Olsson CA, Benson MC, McKiernan JM. Prognostic risk stratification and clinical outcomes in patients undergoing surgical treatment for renal cell carcinoma with vascular tumor thrombus. Urology. Jun 2007;69(6):1054-8. doi:10.1016/j.urology.2007.02.052
17. Kaag MG, Toyen C, Russo P, et al. Radical nephrectomy with vena caval thrombectomy: a contemporary experience. BJU Int. May 2011;107(9):1386-93. doi:10.1111/j.1464-410X.2010.09661.x
18. Wotkowicz C, Wszolek MF, Libertino JA. Resection of renal tumors invading the vena cava. Urol Clin North Am. Nov 2008;35(4):657-71; viii. doi:10.1016/j.ucl.2008.07.013
19. Chen YH, Wu XR, Hu ZL, et al. Treatment of renal cell carcinoma with a level III or level IV inferior vena cava thrombus using cardiopulmonary bypass and deep hypothermic circulatory arrest. World J Surg Oncol. Apr 22 2015;13:159. doi:10.1186/s12957-015-0584-8
20. Taweemonkongsap T, Nualyong C, Leewansangtong S, et al. Surgical treatment of renal cell carcinoma with inferior vena cava thrombus: using liver mobilization technique to avoid cardiopulmonary bypass. Asian J Surg. Apr 2008;31(2):75-82. doi:10.1016/S1015-9584(08)60062-7
21. Hevia V, Ciancio G, Gomez V, Alvarez S, Diez-Nicolas V, Burgos FJ. Surgical technique for the treatment of renal cell carcinoma with inferior vena cava tumor thrombus: tips, tricks and oncological results. Springerplus. 2016;5:132. doi:10.1186/s40064-016-1825-1
22. Ciancio G, Hawke C, Soloway M. The use of liver transplant techniques to aid in the surgical management of urological tumors. J Urol. Sep 2000;164(3 Pt 1):665-72. doi:10.1097/00005392-200009010-00012
23. Zhang JP, Zhu Y, Liu YJ, et al. Temporary filters and liver mobilization technique improve the safety and prognosis of radical nephrectomy and inferior vena cava thrombectomy in renal cell carcinoma with subdiaphragmatic thrombosis. Urol Int. 2013;91(3):279-84. doi:10.1159/000350521
24. Blute ML, Leibovich BC, Lohse CM, Cheville JC, Zincke H. The Mayo Clinic experience with surgical management, complications and outcome for patients with renal cell carcinoma and venous tumour thrombus. BJU Int. Jul 2004;94(1):33-41. doi:10.1111/j.1464-410X.2004.04897.x
25. Ciancio G, Gonzalez J, Shirodkar SP, Angulo JC, Soloway MS. Liver transplantation techniques for the surgical management of renal cell carcinoma with tumor thrombus in the inferior vena cava: step-by-step description. Eur Urol. Mar 2011;59(3):401-6. doi:10.1016/j.eururo.2010.07.028
26. Tzakis A, Todo S, Starzl TE. Orthotopic liver transplantation with preservation of the inferior vena cava. Ann Surg. Nov 1989;210(5):649-52. doi:10.1097/00000658-198911000-00013
27. Parekh DJ, Cookson MS, Chapman W, et al. Renal cell carcinoma with renal vein and inferior vena caval involvement: clinicopathological features, surgical techniques and outcomes. J Urol. Jun 2005;173(6):1897-902. doi:10.1097/01.ju.0000158459.42658.95
28. Ciancio G, Shirodkar SP, Soloway MS, Livingstone AS, Barron M, Salerno TA. Renal carcinoma with supradiaphragmatic tumor thrombus: avoiding sternotomy and cardiopulmonary bypass. Ann Thorac Surg. Feb 2010;89(2):505-10. doi:10.1016/j.athoracsur.2009.11.025
29. Abaza R, Eun DD, Gallucci M, et al. Robotic Surgery for Renal Cell Carcinoma with Vena Caval Tumor Thrombus. Eur Urol Focus. Dec 15 2016;2(6):601-607. doi:10.1016/j.euf.2017.01.001
30. Masic S, Smaldone MC. Robotic renal surgery for renal cell carcinoma with inferior vena cava thrombus. Transl Androl Urol. May 2021;10(5):2195-2198. doi:10.21037/tau.2019.06.15
31. Sun Y, de Castro Abreu AL, Gill IS. Robotic inferior vena cava thrombus surgery: novel strategies. Curr Opin Urol. Mar 2014;24(2):140-7. doi:10.1097/MOU.0000000000000033
32. Campi R, Tellini R, Sessa F, et al. Techniques and outcomes of minimally-invasive surgery for nonmetastatic renal cell carcinoma with inferior vena cava thrombosis: a systematic review of the literature. Minerva Urol Nefrol. Aug 2019;71(4):339-358. doi:10.23736/S0393-2249.19.03396-4
33. Murphy C, Abaza R. Complex robotic nephrectomy and inferior vena cava tumor thrombectomy: an evolving landscape. Curr Opin Urol. Jan 2020;30(1):83-89. doi:10.1097/MOU.0000000000000690
34. Abaza R. Robotic surgery and minimally invasive management of renal tumors with vena caval extension. Curr Opin Urol. Mar 2011;21(2):104-9. doi:10.1097/MOU.0b013e32834350ff
35. Wang B, Li H, Huang Q, et al. Robot-assisted Retrohepatic Inferior Vena Cava Thrombectomy: First or Second Porta Hepatis as an Important Boundary Landmark. Eur Urol. Oct 2018;74(4):512-520. doi:10.1016/j.eururo.2017.11.017
36. Wang B, Huang Q, Liu K, et al. Robot-assisted Level III-IV Inferior Vena Cava Thrombectomy: Initial Series with Step-by-step Procedures and 1-yr Outcomes. Eur Urol. Jul 2020;78(1):77-86. doi:10.1016/j.eururo.2019.04.019