Background. The only effective treatment for renal cell carcinoma with tumor inferior vena cava (IVC) thrombosis is surgery. Nephrectomy with thrombectomy (NETE) is usually associated with clinically significant blood loss. The role of blood-sparing methods using autoerythrocyte reinfusion device (ARD) or replacement of blood loss with donor erythrocytes (DE) on the outcomes of NETE has not been well studied. Aim. To study the rate of hemostasis disorders with intraoperative ARD use, as well as the effect of ARD and DE transfusions on specific (SS), relapse-free (RFS), and progression-free (PFS) survival of patients with renal cell carcinoma (RCC) after NETE. Materials and methods. The observational study included medical data of 507 patients with RCC and tumor IVC thrombosis operated after NETE. The median volume of blood loss was 4000 [20006500] mL. In 312 (61.5%) patients, ARD without a leukocyte filter was used to compensate for blood loss (median volume of reinfused autoerythrocytes AE was 1140 [700; 1900] mL). Transfusion of DE was required in 387 (76.3%) cases; the median number of DE transfused doses was 3 [1; 5]; 475 (93.7%) patients were discharged from the hospital. The median follow-up of all surviving patients was 24 (1189) months. Results. Indications for blood transfusions (DE and AE) were directly correlated to the pN (r=0.101; p=0.024) and pT (r=0.091; p=0.040) categories, respectively. The use of AE had no significant effect on the rate of hemostasis disorders and coagulopathic complications compared to other methods of blood loss replacement: 6.8% (21/311) vs 4.7% (9/193), p=0.227; 5.1% (16/311) vs 4.1% (8/193), p=0.394, respectively. ARD had no effect on SS, RFS (after radical surgery), and PFS (after cytoreductive surgery) after NETE. There was a reduction of SS in patients who received DE transfusions compared with those who did not (hazard ratio 0.4; 95% confidence interval 0.10.9; p=0.048). The effects of DE transfusions on RFS and PFS were not identified. Conclusion. Intraoperative ARD use is an effective and safe method of correcting anemia, which does not increase the risk of coagulopathic complications or decrease survival rates. The non-use of the leukocyte filter during AE preparation does not worsen the medium-term oncological results of RCC surgical treatment with tumor IVC thrombosis. The effect of DE transfusion on the survival of RCC patients after NETE requires further research.

Objective : to evaluate the outcomes of thrombectomy performed using different surgical techniques in renal cell carcinoma (RCC) patients with extensive tumor venous thrombosis. Materials and methods . This study included 345 RCC patients with extensive tumor venous thrombosis who underwent surgical treatment. The median age was 57 years (range: 16—79 years); the male-to-female ratio was 1:1.9. Two hundred and sixty patients (75.4 %) had their tumor thrombus originating from the right renal vein, 85 patients (24.6 %) — from the left renal vein. In 169 patients (49.0 %), the thrombus spread to the retrohepatic inferior vena cava (IVC), while in 176 patients (51.0 %), it spread above the diaphragm (to the intrapericardial IVC in 59 patients (17.1 %) and to the right heart cameras in 117 patients (33.9 %)). Regional metastases were found in 90 individuals (26.1 %), while distant metastases were observed in 124 patients (35.9 %). All patients underwent surgical treatment (radical in 251 patients (72.8 %) and cytoreductive — in 94patients (27.2 %)); the technique of vascular control and circulatory support was chosen individually. In 97 patients (28.1 %), the control over the cranial thrombus boarder did not require opening of the chest cavity; eleven patients (3.2 %) were operated on with cardiopulmonary bypass. Results . The median surgery time was 215 minutes; the median blood loss was 4500 mL. Intraoperative complications were registered in 209 patients (60.6 %) and postoperative complications were observed in 118 patients (35.1 %) (including those of grade I—II in 43 individuals (12.8 %) and grade III—V in 75 individual (22.3 %)). The in-hospital mortality rate was 10.7 % (37/345). At a median follow-up of 32.3 months, overall and diseasespecific survival rates among all patients were 51.9 % and 68.3 %, respectively; relapse-free survival rate in 226patients who have undergone radical surgeries and discharged from the hospital was 61.5 %; progression-free survival rate in 82 patients who have undergone cytoreductive surgery was 33.0 %. The method ofIVC control and circulatory support had no effect on both short-term and long-term treatment outcomes (p >0.05 for both). Conclusion . The use of minimally invasive techniques of vascular control and avoidance of cardiopulmonary bypass in carefully selected RCC patients with extensive tumor venous thrombosis do not worsen the outcomes of nephrectomy and thrombectomy.

Objective: to assess safety of left renal vein (LRV) ligation during circular resection of the inferior vena cava in right-side kidney carcinoma with tumor venous thrombosis.Materials and methods. We selected medical data of 63 renal cell carcinoma patients with tumor venous invasion undergone nephrectomy, thrombectomy, IVC resection with LRV ligation (Group 1; n = 29 (46.0 %)) or preservation of venous outflow from the contralateral kidney (Group 2; n = 34 (54.0 %)). Median age of study participants was 56.0 + 8.8 years (range: 32—72 years); a male to female ratio was 1:1.9. Such parameters as age, gender, median glomerular filtration rate (GFR), stages of chronic kidney disease (CKD), blood loss, and duration of surgery were comparable across the two groups (р >0.05 for all parameters). Median follow-up was 32.8 months (range: 1—226 months). Results. We observed no significant changes in median GFR in the late postoperative period compared to baseline among patients with ligated LRV (65.7 vs 71.2 mL/min/1.73 m2; р >0.05) and patients with preserved venous outflow from the contralateral kidney (60.6 vs 68.4 mL/min/1.73 m2; р>0.5). Patients that underwent LRV ligation were less likely to have reduced GFR compared to those with normal contralateral renal venous outflow (34.5 % vs 44.1 %; p >0.05). However, participants with ligated LRV had CKD upstaging (from stage 0—I to stage I—II) more frequently than participants with preserved venous outflow (27.6 % vs 5.9 %; р = 0.022). None of the patients developed stage III CKD after LRV ligation.Conclusion. LRV ligation during circular resection of the IVC in right-side renal cell carcinoma patients with tumor venous thrombosis does not lead to a clinically significant decrease in long-term deterioration of renal function.

Objective : to assess safety of left renal vein (LRV) ligation during circular resection of the inferior vena cava in right-side kidney carcinoma with tumor venous thrombosis. Materials and methods . We selected medical data of 63 renal cell carcinoma patients with tumor venous invasion undergone nephrectomy, thrombectomy, IVC resection with LRV ligation (Group 1; n = 29 (46.0 %)) or preservation of venous outflow from the contralateral kidney (Group 2; n = 34 (54.0 %)). Median age of study participants was 56.0 + 8.8 years (range: 32—72 years); a male to female ratio was 1:1.9. Such parameters as age, gender, median glomerular filtration rate (GFR), stages of chronic kidney disease (CKD), blood loss, and duration of surgery were comparable across the two groups ( р >0.05 for all parameters). Median follow-up was 32.8 months (range: 1—226 months). Results. We observed no significant changes in median GFR in the late postoperative period compared to baseline among patients with ligated LRV (65.7 vs 71.2 mL/min/1.73 m2; р >0.05) and patients with preserved venous outflow from the contralateral kidney (60.6 vs 68.4 mL/min/1.73 m2; р >0.5). Patients that underwent LRV ligation were less likely to have reduced GFR compared to those with normal contralateral renal venous outflow (34.5 % vs 44.1 %; p >0.05). However, participants with ligated LRV had CKD upstaging (from stage 0—I to stage I—II) more frequently than participants with preserved venous outflow (27.6 % vs 5.9 %; р = 0.022). None of the patients developed stage III CKD after LRV ligation. Conclusion . LRV ligation during circular resection of the IVC in right-side renal cell carcinoma patients with tumor venous thrombosis does not lead to a clinically significant decrease in long-term deterioration of renal function.

Objective: to develop an effective and safe surgical technique for the treatment of patients with renal cell carcinoma with invasive tumor venous thrombosis of the inferior vena cava (IVC). Materials and methods. The study included 75 patients underwent surgical treatment at the N.N. Blokhin Russian Cancer Research Center between 1995 and 2017. The median age of patients was 57 years (range: 32–72 years). All patients were diagnosed with RCC with invasive tumor venous thrombosis levels II–IV; of them, 55 patients (73.3 %) had complete IVC obstruction and mature venous collaterals. Twenty- seven patients (26.0 %) were diagnosed with regional, 37 (49.3 %) – with distant metastases. Prior nephrectomy was performed in 5 (6.7 %) cases. Surgical treatment included nephrectomy (n = 70; 93.3 %), thrombectomy with IVC resection (n = 75; 100 %), and metastasectomy in solitary distant lesions (n = 11; 14.7 %). Partial IVC resection was demanded in 18 patients (24.0 %): with infrarenal IVC plication – 14 (18.7 %), with reconstruction of IVC with synthetic patch – 4 (5.3 %). Fifty-seven patients (76.0 %) underwent circular IVC resection (with left renal vein (LRV) ligation – 35 (46.7 %)). The IVC was replaced with ePTFE grafts in 4 (5.3 %) patients, IVC reconstruction was not required in 53 (70.7 %) patients. IVC grafting was considered to be justified in patients without mature venous collaterals. Twenty-two patients (29.3 %) received systemic antitumor therapy. Median follow-up was 32.3 months (range: 1–226 months). Results. Median operative time was 237.5 min (range: 135–580 min); median blood loss – 7000 mL (range: 1200–27 000 mL). The post- operative complications rate was 52.1 % (grades III–V – 31.5 %). Hospital mortality was 13.3 % (10 of 75 patients). Thirty-two months overall, cancer-specific, and recurrence-free survival were 42.4 %, 49.5 %, and 61.2 % respectively. At 19 months all prosthesis were patent. None of the patients had glomerular filtration rate <60 ml/min/1.73 m2 after LRV ligation. No patients developed disabling chronic venous insufficiency of the lower limbs after IVC ligation/resection without grafting. Conclusion. Nephrectomy, thrombectomy, and IVC resection is the only effective method of treatment for RCC with invasive tumor venous thrombosis. The development of IVC and LRV venous collaterals allows performing circular IVC resection with LRV ligation without graft replacement.

Objective. To evaluate short-term and long-term results of nephrectomy, thrombectomy, circular inferior vena cava (IVC) resection in patients with renal cell carcinoma (RCC) and advanced IVC tumor invasion. Materials and methods . Medical data of 49 patients with RCC and level II–IV tumor venous thrombus with advanced IVC wall tumor invasion were analyzed. All the patients underwent nephrectomy, thrombectomy, circular IVC resection (radical – 35 (71.0 %), cytoreductive, in M+ cases – 14 (28.6 %)). Circular resection of the infrarenal IVC segment was performed in 25 (51.0 %) patients; resection of the infrarenal, perirenal and retrohepatic IVC segments with a ligation of the left renal vein (RV) – in 24 (49.0 %) patients. Perirenal IVC prosthesis was used in 2 (4.1 %) patients with initially preserved IVC blood flow, in other cases replacement of the removed IVC segment wasn’t performed due to presence of a network of venous collaterals duplicating the IVC. Patients with metastases received systemic antitumor treatment after nephrectomy, thrombectomy. Results . Median operative time was 260 (135–580) minutes, median blood loss was 8750 (3000–27 000) ml. Severe intraoperative complications were observed in 2 (4.0 %) patients, 1 (2.0 %) patient died on the operating table due to hypovolemic shock. Postoperative complications were observed in 26 (53.2 %) cases (grade III–V in 22 (45.8 %) patients). Five-year overall and cancer-specific survival of all patients was 54.6 and 67.8 %, respectively, relapse-free survival of 35 patients with M0 category was 49.4 %. Both IVC prostheses were patent 12 months after the surgery. Function of the left kidney after ligation of the left RV was preserved at the preoperative level in all 24 patients in a median of 12 (2–120) months. Conclusion. Nephrectomy, segmental/subtotal cavectomy with preservation of the main renal venous entries is an effective treatment method in RCC patients with advanced tumor IVC invasion. The method allows to achieve satisfactory long-term survival rates and functional results.

Objective. To evaluate short-term and long-term results of nephrectomy, thrombectomy, circular inferior vena cava (IVC) resection in patients with renal cell carcinoma (RCC) and advanced IVC tumor invasion.Materials and methods. Medical data of 49 patients with RCC and level II–IV tumor venous thrombus with advanced IVC wall tumor invasion were analyzed. All the patients underwent nephrectomy, thrombectomy, circular IVC resection (radical – 35 (71.0 %), cytoreductive, in M+ cases – 14 (28.6 %)). Circular resection of the infrarenal IVC segment was performed in 25 (51.0 %) patients; resection of the infrarenal, perirenal and retrohepatic IVC segments with a ligation of the left renal vein (RV) – in 24 (49.0 %) patients. Perirenal IVC prosthesis was used in 2 (4.1 %) patients with initially preserved IVC blood flow, in other cases replacement of the removed IVC segment wasn’t performed due to presence of a network of venous collaterals duplicating the IVC. Patients with metastases received systemic antitumor treatment after nephrectomy, thrombectomy.Results. Median operative time was 260 (135–580) minutes, median blood loss was 8750 (3000–27 000) ml. Severe intraoperative complications were observed in 2 (4.0 %) patients, 1 (2.0 %) patient died on the operating table due to hypovolemic shock. Postoperative complications were observed in 26 (53.2 %) cases (grade III–V in 22 (45.8 %) patients). Five-year overall and cancer-specific survival of all patients was 54.6 and 67.8 %, respectively, relapse-free survival of 35 patients with M0 category was 49.4 %. Both IVC prostheses were patent 12 months after the surgery. Function of the left kidney after ligation of the left RV was preserved at the preoperative level in all 24 patients in a median of 12 (2–120) months.Conclusion. Nephrectomy, segmental/subtotal cavectomy with preservation of the main renal venous entries is an effective treatment method in RCC patients with advanced tumor IVC invasion. The method allows to achieve satisfactory long-term survival rates and functional results.