Deep hypothermia and circulatory arrest in the surgical management of renal tumors with cavoatrial extension.

BACKGROUND: The inferior vena cava (IVC) is involved in almost 5% to 10% of renal tumors. Their intraluminar extension to the cardiac cavities occurs with a tumor-thrombus formation at a percentage of 1%. The aim of this study is to present the principles of "radical" management that should be targeted to excision of the kidney together with the cavoatrial tumor-thrombus. MATERIAL: From 2003 through 2008, we treated six patients with renal-cell carcinoma involving the IVC and/or the right cardiac chambers. The main symptoms leading to the diagnosis were hematuria, dyspnea, or lower limb edema. The extension of the tumor was type IV in three cases, type III in two, and type II in one case. METHOD: Extracorporeal circulation combined with a short period of hypothermic circulatory arrest was the method used. Radical nephrectomy combined with cavotomy and atriotomy was performed to an "en-block" extirpation of the tumor-thrombus and allowed oncologic surgical clearance of the disease. RESULTS: There was no operative death. The mean postoperative course duration was 11 days, apart from one obese patient who presented postoperative pancreatitis and died on the 44th postoperative day due to respiratory failure. During the cumulative postoperative follow-up of 171 months the patients remain free of recurrence. CONCLUSIONS: The use of extracorporeal circulation and deep hypothermic circulatory arrest provides a good method for radical excision of renal carcinomas involving the IVC with satisfactory morbidity and long-term survival results. Cooperation of urologists and cardiac surgeons is necessary for this type of operation.

Fournier's gangrene due to perioperative iatrogenic colon perforation in a renal transplant recipient.

Fournier's gangrene is not a common cause of morbidity in renal transplant recipients, but, if it occurs, it is difficult to treat because of the immunosuppression and associated increased mortality rate. We describe the case of a male patient who underwent renal transplantation with complicated post-operative course, resulting in cecum perforation (thermal injury due to cautery use during transplantation) requiring exploratory laparotomy and cecostomy. A few days later, he developed Fournier's gangrene and urgent radical surgical debridement of the scrotum was performed, along with aggressive antibiotic regimen and the immunosuppressive treatment was modified. Subsequently, the patient underwent scheduled cecostomy closure (right hemicolectomy), while the scrotum trauma healed with tertiary intention. Epidemiologic characteristics, clinical presentation, diagnostic workup, therapeutic options and morbidity-mortality rates of Fournier's gangrene are reviewed, emphasizing the role of immunosuppression in renal transplant recipients to disease development.