Radical Nephrocapsulectomy and Caval Thrombectomy with Extracorporeal Circulation and Deep Hypothermic Circulatory Arrest in Right Anterior Minithoracotomy: A Minimally Invasive Approach

Abstract 

Objectives

Radical nephrocapsulectomy and cavoatrial thrombectomy with median sternotomy and abdominal access, using extracorporeal circulation (ECC) and deep hypothermic circulatory arrest (DHCA), has become the gold standard treatment for renal cell carcinoma (RCC) with neoplastic thrombosis of the suprahepatic and intrapericardial inferior vena cava (IVC) and right atrium (RA). Any modification of surgical techniques should be compared with this therapeutic strategy.

Methods

In our quest to identify a minimally invasive approach and to apply available technology to ensure patient safety, even in cases of RCC with suprahepatic IVC and RA thrombosis, we identified a therapeutic approach that foresees en bloc radical nephrocapsulectomy, with ECC and DHCA in right anterior minithoracotomy. Furthermore, to make surgery even safer, we made some modifications and used auxiliary maneuvers. We present the case of a 39-year-old man with a neoplasm that involved the right kidney and suprahepatic IVC thrombosis, undergoing radical nephrocapsulectomy and thrombectomy with ECC and DHCA in right anterior minithoracotomy.

Conclusions

Radical nephrocapsulectomy and thrombectomy of the suprahepatic and intrapericardial IVC and/or of the RA with ECC and DHCA in right anterior minithoracotomy for RCC is a valid minimally invasive alternative to standard surgical techniques. Compared with standard median sternotomy access, right anterior minithoracotomy allows a more rapid functional recovery, a reduction in risk of infection of the wound, and a reduction in pain during postoperative convalescence, and has considerable esthetic advantages, without limiting surgical therapeutic chances, regardless of the cranial extension of the thrombus.