Operative technique
No preoperative arterial embolization was performed. The surgical
approach was tailored according to the size and location of the tumor,
its relationship with the surrounding tissue, and the level of a tumor
thrombus. All patients underwent open or laparoscopic nephrectomy and
thrombectomy. Retroperitoneal lymph node dissection was performed in
cases that were node-positive based on radiology or those with
perioperative suspicion of lymph node involvement. Surgical access
consisted of full midline, anterior subcostal (8), L- shaped (16),
reversed L-shaped (5), and combined incision (4). The incision was
extended in selected cases (Figure 1 ).
The procedure was started as in standard radical nephrectomy. Then the
vena cava inferior (VCI), lumbar veins, and the renal vein on the
opposite side were isolated by careful dissection from the surrounding
tissues. The general surgeon undertook liver mobilization. After
achieving complete vascular control, longitudinal cavatomy was performed
from the renal vein ostium. Digital milking or balloon catheter
retraction was used to remove the thrombus. Sternotomy was added to the
surgery of cases of advanced supradiaphragmatic thrombus excision,
intracardiac tumor excision, or additional cardiac intervention by the
thoracic and cardiovascular surgeon. After the control of bleeding,
surgical plans were closed anatomically. Perioperative blood loss,
operation time, and transfusion rates were noted.