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.