locally advance rcc with its classification and management

1. Treatment of Locally
Advanced RCC
Prepared by: Rojan Adhikari
FCPS II Urology Resident

2. References

4. Definition of radical nephrectomy
• Classically Robson describe Radical nephrectomy as
complete removal of the kidney outside the Gerota’s fascia
together with the ipsilateral adrenal gland and complete
regional lymphadenectomy from the crus of the diaphragm
to the aortic bifurcation. 1
• Nowadays the definition has changed , adrenalectomy and
lymphadenectomy is not performed until it is involved 2
1. Robson et al. (1969)
2. Shah et al., 2017b

5. Indication
• tumors in nonfunctional kidneys,
• large tumors replacing the majority of renal parenchyma,
• tumors associated with detectable regional lymphadenopathy,
• tumors associated with renal vein thrombus.
• Tumors invading collecting system
Campbell-Walsh- Wein Urology, 12th edi

6. Surgical Procedure
Position : modified lateral decubitus position
incisions : subcostal flank
Campbell-Walsh- Wein Urology, 12th edit

7. On right
• The posterior parietal peritoneum on the white line of Toldt is incised from
the pelvis (region of the iliac artery) to the right upper quadrant (region of
hepatic flexure).
• anterior pararenal space is developed by dissecting in the plane between
the anterior renal fascia and the mesentery of the ascending colon.
• After mobilizing the hepatic flexure of the colon using sharp and blunt
dissection, the second part of the duodenum is mobilized medially using
the Kocher maneuver .
• With medially located tumors, mobilization of the duodenum should be
performed with extreme care to avoid injury.
Campbell-Walsh- Wein Urology, 12th editi

8. Campbell-Walsh- Wein Urology, 12th ed

9. • After mobilization of the duodenum, the IVC is identified posteriorly.
• Dissection anterior to the IVC will enable identification of the renal
vein and gonadal vein. Placement of a vessel loop will enable gentle
traction of the renal vein
• The renal vein is palpated for any tumor thrombus.
Campbell-Walsh- Wein Urology, 12th edi

10. • Next the renal artery is
identified posterior to the
renal vein.
• If identification of the
renal artery is difficult,
attention is turned to the
lower pole of the kidney
to identify the ureter and
gonadal vein.

11. • If technically feasible, the gonadal vein is spared. However, often
because of the large size of the renal tumor, the gonadal vein cannot
be safely left intact without the risk for avulsion from the IVC
• With ligation of the ureter, the kidney is lifted from a posterior to an
anterior position to aid in identification of the renal artery posterior
to the kidney.
Campbell-Walsh- Wein Urology, 12th ed

12. • With the renal artery controlled, the right kidney and tumor will
decrease in size and engorgement, easing the dissection of the kidney
at the hilum and the remaining sites.
• The right renal vein, which should now be flaccid, is examined for any
tumor thrombus
Campbell-Walsh- Wein Urology, 12th ed

13. On left
• Incision of the white line of Toldt from the splenic flexure to the common
iliac artery, the descending colon is reflected medially.
• The renocolic ligament is divided, and extreme care is taken to avoid injury
to the tail of the pancreas.
• The left renal vein is identified using the anterior surface of the aorta as a
guide.
• The left renal artery is usually located cranial and posterior to the left renal
vein.
Campbell-Walsh- Wein Urology, 12th edit

14. • After further mobilization of the lower pole of the kidney, the left ureter
and the left gonadal vein are identified.
• The left gonadal vein can be traced to its insertion to help identify the left
renal vein.
• The ureter is divided, and the inferior and posterior surface of the kidney is
mobilized to identify the left renal artery.
• Once the renal artery and vein are identified, the renal artery is ligated and
divided first then follows the vein.
Campbell-Walsh- Wein Urology, 12th edit

15. • Sometimes renal artery and vein cannot be separated individually
because of significant hilar lymphadenopathy or adhesion.
• Then, a whole pedicle clamp technique may be utilized to control the
hilar vessels. Although the risk for arteriovenous fistula may be
associated with en bloc ligation of the whole renal pedicle.
Campbell-Walsh- Wein Urology, 12th edition

16. Complications
Intra-operative Bleeding
Trauma to adjacent organs
Tumor seeding
Pneumothorax
Post-operative Bleeding
Infection
AKI
late HTN
Tumor recurrance
Aneurysm, Pseudoaneurysm
AV fistula

17. Adrenalectomy
• overall incidence of adrenal metastasis is less than 5% 1
• Indications 2
diffuse involvement by tumor,
large tumor size of upper pole (>10 cm),
extrarenal tumor extension,
tumor thrombus,
lymphadenopathy and regional metastasis, or an adrenal mass on
imaging.
1. Siemer et al., 2004
2. Campbell-Walsh- Wein Urology, 12th ed

18. Regional lymphadenectomy
• incidence of lymph node disease is about 5% 1
• The role of regional lymphadenectomy on RCC has remained controversial 2
• Indications 3
enlarged lymph nodes on imaging,
cytoreductive surgery for metastatic disease,
tumor size greater than 10 cm, nuclear grade 3 or greater,
sarcomatoid histology,
presence of tumor necrosis on imaging,
extrarenal tumor extension, and
tumor thrombus 1. Capitanio et al., 2013;
2. Sun et al., 2014
3. Campbell-Walsh- Wein Urology, 12th edition

20. Sample size: 772
RCC with N0M0 and
resectable, patients were
randomly into two group
Conclusion: The incidence of
unsuspected lymph-node metastases
is 4.0% and no survival advantage of
a complete lymph-node dissection in
conjunction with a radical
nephrectomy alone .

21. Conclusion:
• The existing literature does not support a survival benefit with LND in either
M0 or M1 RCC
• A small subset of patients with isolated nodal metastases experience long-
term survival after surgical resection.

22. Inferior Vena Cava Involvement
• 4% to 10% of patients with RCC 1
• 45-70 % of patients with venous tumor thrombus can be cured with
nephrectomy and thrombectomy 1
• two components associated with IVC thrombi are tumor thrombus (tumor
cells contained within bland thrombus) and bland thrombus (blood
coagulum without tumor cells) 2
• In RCC with venous thrombus, 10% have associated positive regional lymph
nodes, 25% have associated metastases, and 50% have perirenal fat
invasion 2
1. Blute et al., 2004b;
2. Martinez-Salamanca et al., 2011

23. • MRI, CECT, and echocardiography are useful adjuncts in the pre- and
perioperative planning
• MRI is the preferred diagnostic study at many centers , however,
recent literature indicates that an appropriately performed CT can
provide essentially equivalent information
• venacavography, is rarely used and reserved for patients whom MRI
and CT are contraindicated
Pouliot et al., 2010
Campbell-Walsh- Wein Urology, 12th edition

24. Preoperative Considerations
• Anticoagulation with intravenous or low-molecular-weight heparin to
be started
• Temporary suprarenal IVC filters are also an option for patients with
level I, and II tumor thrombi but controversial as provoke
embolization to contralateral renal vein and hepatic vein
• Preoperative angioembolization can be considered because tumor
thrombi have an independent blood supply arising from the renal
artery and/or aorta in one-third of cases
Campbell-Walsh- Wein Urology, 12th edition

25. Mayo classification of macroscopic venous invasion

29. Patching, Replacing, and Interrupting the
Inferior Vena Cava
• If the IVC is expected to be less than 50%
of its original size, a patch cavoplasty is
necessary to prevent IVC stenosis and
thrombosis-related events.
• Autologous and bovine pericardium,
polytetrafluoroethylene (PTFE), collagen-
impregnated Dacron , or autologous
saphenous vein are materials that can be
used for patch cavoplasty.

30. Conclusion,
• In patients with non-metastatic RCC with thrombus, independent predictors of
recurrence include: BMI ≤20 kg/m2, preoperative haemoglobin , perinephric fat
invasion, IVC thrombus height, tumour diameter, nuclear grade and non-clear-cell
histology. Patients with >2 risk factors are at highest risk of recurrence and should
be considered for adjuvant therapy trials or increased surveillance.

31. • Conclusions
• Survival in patients with pT4 remains poor. pT4 is associated with a
locally and regionally invasive biology that requires specific attention
and warrants careful study

32. Complications
Intra-operative Air Embolism
Acute Pulmonary Embolism
Massive Hemorrhage
Hepatic dysfunction
Organ Ischemia
Trauma to adjacent organs
Post-op Hemorrhage
Infection
late Tumor recurrance
Aneurysm,
Pseudoaneurysm
AV fistula

36. Conclusions
The addition of adjuvant
therapy provided no survival
benefit but increased the rates
of adverse events for locally
advanced RCC patients.
• Twelve studies (5,936
patients)
• compared to placebo or
observation
• targeted therapy, and
immune therapy

37. Double-blind, phase 3
trial, randomization with
1:1 ratio, patients after
nephrectomy, with or
without metastasectomy,
to receive either adjuvant
pembrolizumab
total of 496 patients
were randomly
assigned to receive
pembrolizumab, and
498 to receive placebo
Conclusion:
Pembrolizumab treatment
led to a significant
improvement in disease-
free survival as compared
with placebo after surgery
among patients with
kidney cancer

38. THANK YOU