Koichi Ueno

Preoperative Computerized Tomography Detection of Extensive Invasion of the Inferior Vena Cava by Renal Cell Carcinoma: Possible Indication for Resection with Partial Cardiopulmonary Bypass and Patch Grafting

The relationship of the diameter of the inferior vena cava as measured by computerized tomography (CT) and tumor invasion of the inferior vena caval wall was determined in patients with renal cell carcinoma. In addition, the indications and usefulness of surgery using partial cardiopulmonary bypass and a polytetrafluoroethylene (Gore-Tex) patch graft are discussed. In all 7 patients with an inferior vena caval diameter of 40 mm. or larger on CT tumor had extensively invaded the vessel wall macroscopically and microscopically. Therefore, resection of the inferior vena caval wall and repair with a patch graft were necessary. Partial cardiopulmonary bypass was used in 6 of these 7 patients. On the other hand, of 11 patients with an inferior vena cava less than 40 mm. in diameter only 2 with extensive tumor invasion of the vessel wall underwent a patch graft procedure without partial cardiopulmonary bypass. One patient who had massive hemorrhage before bypass was started died while in a coma. The survival of the remaining patients ranged from 6 to 131 months (median 19 months). Blood loss in patients who underwent surgery with partial cardiopulmonary bypass was much less than that in patients without bypass. In our series, there were no complications related to the graft itself and graft patency was excellent. Our results indicate that an inferior vena caval diameter of 40 mm. or more on CT probably indicates extensive tumor invasion. Although further experience and observation are necessary to evaluate whether partial cardiopulmonary bypass and/or a patch graft improves the prognosis of patients with extensive inferior vena caval invasion by renal cell carcinoma, this method was relatively safe and decreased blood loss.

Novel bladder sparing surgery for select patients with advanced rectal carcinoma.

Advanced rectal carcinoma sometimes invades the posterior bladder wall or the base of the prostate. Radical surgical treatment may involve resection of part or all of the bladder, prostate or ureters since it is essential to create clear margins if the procedure is to be curative. As a result, patients sometimes require 1 stoma for the urinary and another stoma for fecal stream diversion. Segmental resection is rarely performed, although it would significantly improve the quality of life for these patients by obviating the need for 2 stomas. To achieve this end, we performed en bloc removal of the rectum with the prostate in highly selected patients who had advanced rectal carcinoma with macroscopic invasion of the prostate but without invasion of the bladder or membranous urethra. This procedure could preclude urinary diversion and be useful for select patients.

Bladder reconstruction with autotransplanted ileum in the dog: better functional results than standard enterocystoplasty

Objective To compare, in a dog model, the properties of a reconstructed bladder (peristalsis, histological changes and absorption) using an autotransplanted ileal segment with standard enterocystoplasty.

Surgical treatment of renal cell carcinoma with tumor thrombi in the inferior vena cava

BackgroundWe evaluated the results of surgical treatment for renal cell carcinoma with tumor thrombi in the inferior vena cava.MethodsBetween March 1984 and July 1996, 25 patients were surgically treated for renal cell carcinoma with extension to the inferior vena cava. Inferior vena caval thrombosis was classified as supradiaphragmatic in 3 patients and infradiaphragmatic in 14 patients. Thrombi were also detected around the renal vein in 8 patients. Twenty-three patients underwent transperitoneal radical nephrectomy, and thrombectomy. One patient with bilateral renal cancer underwent right nephrectomy, left partial nephrectomy, and thrombectomy. The remaining patient underwent nephrectomy and an incomplete thrombectomy due to massive hemorrhage during surgery. In 10 patients with an inferior vena caval diameter of >40 mm, a partial cardiopulmonary bypass was used during surgery. After removal of tumor thrombi, simple closure of the caval wall was performed in 14 patients, Gore-Tex™ (W.L. Gore & Associates, Elkton, MD, USA) patch grafting, in 10 patients, and inferior vena caval replacement with Gore-Tex, in 1 patient.ResultsThe 1-, 3- and 5-year cause-specific survival in all patients was (72%, 50%, and 23%), respectively. The mortality rate was (8%). There was no significant difference in cause-specific survival according to tumor thrombi level. However, the cause-specific survival of patients with metastasis to either regional lymph node or distant organs, or both (n=10), was significantly lower compared to that of patients without metastasis (n=15); the 3-year cause-specific survival was (17%) and (59%) in the metastasis group and the non-metastatic group, respectively (P=0.042).)ConclusionThese results indicate that removal of tumor thrombi in the inferior vena cava is a safe and useful treatment for renal cell carcinoma with no metastasis.