Surgical management of renal cell carcinoma with subhepatic inferior vena cava tumor thrombus: a case report and review of the literature.

BACKGROUND: Renal cell carcinomas are the most common form of kidney cancer in adults. In addition to metastasizing in lungs, soft tissues, bones, and the liver, it also spreads locally. In 2-10% of patients, it causes a thrombus in the renal or inferior vena cava vein; in 1% of patients thrombus reaches the right atrium. Surgery is the only curative option, particularly for locally advanced disease. Despite the advancements in laparoscopic, robotic and endovascular techniques, for this group of patients, open surgery continues to be among the best options. CASE REPORT: Here we present a case of successful tumor thrombectomy from the infrahepatic inferior vena cava combined with renal vein amputation and nephrectomy. Our patient, a 58 year old Albanian woman presented to the doctors office with flank pain, weight loss, fever, high blood pressure, night sweats, and malaise. After a comprehensive assessment, which included urine analysis, complete blood count, electrolytes, renal and hepatic function tests, as well as ultrasonography and computed tomography, she was diagnosed with left kidney renal cell carcinoma involving the left renal vein and subhepatic inferior vena cava. After obtaining informed consent from the patient we scheduled her for surgery, which went well and without complications. She was discharged one week after to continue treatment with radiotherapy, chemotherapy, and immunotherapy. CONCLUSION: Open surgery is a safe and efficient way to treat renal cell carcinoma involving the renal vein and inferior vena cava. It is superior to other therapeutic modalities. When properly done it provides acceptable long time survival and good quality of life to patients.

[A rare malignant tumor of the renal vein]. / Une tumeur maligne rare de la veine rénale.

The renal vein is an exceptional location for leiomyosarcoma, an aggressive malignant tumor of smooth-muscle origin with a poor prognosis. We report the case of a 55-year-old female patient who consulted for left flank pain that had been present for 6 months. A CT scan revealed a 9.4cm left retroperitoneal mass in contact with the psoas muscle, left kidney, stomach, spleen, left colon and extending up to the pancreas, raising the suspicion of a tumour originating in the retroperitoneal tissues. A biopsy revealed a smooth-muscle cell tumour with a degree of malignancy difficult to define. The patient underwent a monobloc left compartmentectomy, which led to the diagnosis of leiomyosarcoma of the left renal vein. A review of the literature on these rare tumours in this location is presented.

Renal vein thrombosis due to metastatic germ cell tumor, report of a case with a very rare clinical scenario.

BACKGROUND: Renal metastasis is a rare manifestation of germ cell tumors. Extension of malignant lesions into the renal vein can complicate the scenario. CASE: This report presents a 35-year-old man with primary stage IS NSGCT. Fourteen months after radical orchiectomy he presented with metastasis in the lung, kidney, and para-aortic lymph nodes. He received multiple lines of salvage treatments including chemotherapy and surgery. Intraoperative exploration during radical nephrectomy and retroperitoneal lymphadenectomy revealed intra-renal vein involvement with a prominent teratomatous component. CONCLUSION: Defining the exact extent of malignant lesions, especially endovascular lesions, is very important to clarify how advanced the malignant lesions are. The surgeons must be aware of the risk factors that predict vascular involvement, and therefore, providing intraoperative access to vascular surgery procedures when needed.

Technical Outcomes of Porto-Mesenteric Venous Reconstruction in Pancreatic Resection Using Autologous Left Renal Vein Graft as Conduit.

BACKGROUND: Portal or superior mesenteric vein (PV-SMV) resection and reconstruction is sometimes required during pancreatic tumor resection. In patients requiring segmental venous resection with interposition grafting, the left renal vein (LRV) is an accessible autologous solution. However, long-term patency outcomes of the LRV as an interposition conduit in this setting have not been analyzed. STUDY DESIGN: We conducted a retrospective analysis of patients undergoing pancreatic resection with PV-SMV reconstruction using LRV between 2002 and 2022. The primary outcome was PV-SMV patency at last follow-up, assessed with postoperative CT scans and analyzed using Kaplan-Meier survival methods that account for variation in follow-up duration. Development of any postoperative acute kidney injury within 7 days of surgery and morbidity were secondary outcomes. RESULTS: The study cohort includes 65 patients who underwent LRV harvest; 60 (92%) ultimately underwent successful reconstruction with harvested LRV graft. Kaplan-Meier 2-year estimated patency rate of the LRV graft was 88%, with no cases of complete occlusion. Six (10%) patients experienced graft stenosis. Nine of 61 (15%) patients experienced grade II or III acute kidney injury, 6 of 9 returning to normal renal function before discharge. No difference in median serum creatinine was observed at baseline, 6 and 12 months from surgery. LRV remnant thrombosis was seen in 7 of 65 (11%) patients. Only 3 of 61 (5%) patients had persistent acute kidney injury caused by complications unrelated to LRV harvesting. CONCLUSIONS: Autologous LRV graft was a reliable conduit for segmental PV-SMV reconstruction, resulting in a high patency rate and marginal impact on renal function. LRV harvest is a safe and potentially ideal surgical option for PV-SMV reconstruction in pancreatic surgery.

Novel Use of Time-Resolved Magnetic Resonance Angiography to Evaluate Retrograde Lumbar Vein Flow and Epidural Venous Plexus Enhancement in Chronic Headache Patients With and Without Nutcracker Physiology.

OBJECTIVE: Compression of the left renal vein by the superior mesenteric artery, known as nutcracker phenomenon (NCP), can cause retrograde flow and congestion in communicating venous systems. It has recently been speculated that NCP can result in retrograde flow and congestion of the lumbar veins and epidural venous plexus (EVP), thereby affecting the central nervous system. This study describes the novel use of time-resolved magnetic resonance angiography (trMRA) to evaluate for retrograde left second lumbar vein (L2LV) flow and early EVP enhancement in patients with chronic daily headache (CDH) with and without NCP. METHODS: A retrospective analysis was performed of 31 patients with CDH (27 females and 4 males; median age, 38 years [range, 18-63 years]) who underwent trMRA centered over the L2LV to evaluate the direction of blood flow and presence of early EVP enhancement from May 2020 to March 2022. Descriptive statistics were performed, and anatomic associations were analyzed in patients with and without retrograde L2LV flow and early EVP enhancement. The accuracy of magnetic resonance imaging findings in detecting these flow patterns was also assessed. RESULTS: Patients with NCP who demonstrated narrowing of the left renal vein, a positive beak sign ( P = 0.052), decreased aortomesenteric distance ( P = 0.038), and decreased SMA angle demonstrated increased rates of retrograde L2LV flow and early EVP enhancement. A positive beak sign was 83% specific, and an aortomesenteric distance of ≤6.5 mm was 61% sensitive and 83% specific for identifying retrograde L2LV flow with early regional EVP enhancement in patients with CDH. CONCLUSIONS: Retrograde L2LV flow with early EVP enhancement in CDH patients can be effectively evaluated using trMRA and was seen with greater propensity in those patients with NCP.

Laparoscopic radical nephroureterectomy in the oblique supine lithotomy integrative position for rare renal malignant perivascular epithelioid cell tumor with renal vein cancerous thrombosis: A case report and literature review.

RATIONALE: Perivascular epithelioid cell tumor (PEComa) is a mesenchymal tumor that arises from perivascular epithelioid cells and can differentiate into melanocytes and smooth muscle cells. Malignant renal perivascular epithelioid cell tumor is extremely rare. Due to the lack of specific clinical manifestations and imaging features, diagnosing PEComa depends on postoperative pathology and immunohistochemistry. Surgery is the primary treatment for malignant PEComa because the efficacy of radiotherapy and chemotherapy is uncertain. There is still a lack of unified diagnostic criteria and treatment guidelines for renal malignant PEComa, especially with vascular invasion. Hence, the treatment experience depends on a small number of cases reported worldwide. PATIENT CONCERNS: A 68-year-old woman was admitted to our hospital due to intermittent hematuria for over 8 months. The color Doppler ultrasound and computed tomography scan revealed a mass in the lower middle part of the left kidney. DIAGNOSIS: Rare renal malignant perivascular epithelioid cell tumor with renal vein cancerous thrombosis. INTERVENTIONS: A laparoscopic radical left nephroureterectomy in the oblique supine lithotomy position was performed. OUTCOMES: The operation process went smoothly, and no pulmonary embolism occurred after the operation. The final pathological diagnosis was a renal malignant perivascular epithelioid cell tumor. After a 12-month follow-up, no recurrence or metastasis was found. LESSONS: Renal malignant PEComa is an extremely rare mesenchymal tumor diagnosed mainly based on pathology. Surgery is currently the effective treatment for malignant PEComa. For the surgical treatment of malignant renal PEComa with vascular invasion, laparoscopic radical nephroureterectomy in the oblique supine lithotomy integrative position has many benefits, as exemplified by our current case.

Associations of left renal vein entrapment with IgA nephropathy and Henoch-Schönlein purpura nephritis.

OBJECTIVES: The aims of the study were to identify whether left renal vein (LRV) entrapment was more prevalent in IgA nephropathy (IgAN) and Henoch-Schönlein purpura nephritis (HSPN) compared with other types of renal diseases, and the association of LRV entrapment with glomerular incidental IgA and galactose-deficient-IgA1 (Gd-IgA1) deposition. METHODS: A total of 797 patients with biopsy-proven kidney diseases have been screened for LRV entrapment by color Doppler ultrasound, and the prevalence of LRV entrapment in different types of renal diseases were then analyzed. Propensity score matching analysis was used to adjust for age, gender, and body mass index. Immunostaining of Gd-IgA1 with KM55 was performed in paraffin-embedded sections of renal biopsy specimens. RESULTS: LRV entrapment was diagnosed in 47 patients (6%) with several kinds of renal diseases in our cohort. A total of 32 (68%) LRV entrapments were combined with expanded IgAN (idiopathic IgAN and HSPN). The prevalence of LRV entrapment in expanded IgAN was significantly higher than that in non-expanded IgAN (17 vs. 2%, p < 0.001), even after adjustment for age, gender, and body mass index by propensity score matching analysis (13 vs. 2%, p < 0.001). Removing expanded IgAN and LN, glomerular incidental IgA deposition was observed to be significantly more common in patients with LRV entrapment compared with patients without it (43 vs. 9%, p < 0.001). Furthermore, in glomerular diseases with incidental IgA deposits, significantly much larger proportion of patients with LRV entrapment were positive for glomerular Gd-IgA1 in contrast to patients without LRV entrapment (5/5 vs. 5/17, p = 0.01). CONCLUSIONS: LRV entrapment coexisted with several kinds of renal diseases, with a significantly higher prevalence in patients with idiopathic IgAN and HSPN. In patients of LN and IgAN-unrelated disease with LRV entrapment, glomerular IgA and Gd-IgA1 deposition was more common compared with patients without LRV entrapment.

A systematic review on nutcracker syndrome and proposed diagnostic algorithm.

OBJECTIVE: Nutcracker syndrome (NCS) is an increasingly recognized venous compressive disease. Although people with NCS can experience debilitating symptoms, making an accurate diagnosis can often be challenging owing to the broad spectrum of clinical presentations and radiologic findings. In the present systematic review, we assessed the most frequent clinical and radiologic criteria used in establishing a diagnosis of NCS and have proposed a comprehensive framework for clinical decision-making. METHODS: We performed a systematic review to identify all observational studies or case series conducted within the previous 10 years that had studied patients with a clinical and radiologic diagnosis of NCS. The extracted data included details related to the study design, participant demographics, presenting clinical features, and radiologic criteria. These details were compared between studies and synthesized to establish a comprehensive diagnostic framework that would be applicable to clinical practice. RESULTS: In the present review, we included 14 studies with a total of 384 patients with NCS. The most common clinical features of NCS were hematuria (69.5%), left flank or abdominal pain (48.4%), pelvic pain (23.1%), and varicocele (15.8%). Computed tomography and ultrasound were the most commonly used imaging modalities, with a threshold for left renal vein stenosis of >80% the most frequently used diagnostic parameter. Eight studies had used venography, with the renocaval pressure gradient the most commonly measured parameter. Two studies had reported using intravascular ultrasound. The findings from our review have shown that a thorough clinical workup of NCS should include critical evaluation of the presenting clinical features and exclusion of alternative diagnoses. All patients should undergo duplex ultrasound with or without the addition of computed tomography or magnetic resonance imaging. Any patient considered for therapeutic intervention should also undergo diagnostic venography with measurement of the renocaval pressure gradient and, if available, intravascular ultrasound with measurement of the left renal vein diameters. CONCLUSIONS: NCS is a challenging condition in terms of the diagnosis and management both. We have proposed a comprehensive diagnostic framework based on the currently available literature to aid in clinical decision-making.

Clinical experience and treatment strategy of leiomyosarcoma originating from the renal vein.

BACKGROUND: Leiomyosarcoma originating from the renal vein (RVLMS) is extremely rare. RVLMS lacks specific clinical manifestations and specific imaging features. This article discusses the epidemiological characteristics and diagnostic difficulties of RVLMS, as well as imaging features, differential diagnosis, treatment strategy, and prognostic factors of this disease. METHOD: A case of RVLMS at our center, and 55 cases from the literature based on the PubMed search. RESULTS: Total operation time was 224 min, and total blood loss during the surgery was 200 ml. Resected tumor was irregular in shape, with negative margins. On the 6th day after the operation, the drainage tube was removed, and the patient was discharged from the hospital. Postoperative pathological results confirmed the renal vein leiomyosarcoma: spindle cell sarcoma, diffuse severe atypia, S-100 (-), SMA ( +), desmin ( +), CD34 (-), CD99 ( +).  Twenty-seven months after the surgery, the patient is alive, and without local recurrence or distant metastases. CONCLUSION: Unspecific clinical manifestations and imaging features make the diagnosis of RVLMS difficult. Most patients are diagnosed intra-operatively or following postoperative pathology. Differential diagnosis with paraganglioma (PG) and retroperitoneal sarcoma (RPS) should be made. Early and complete resection is considered as the first choice of treatment, and whether to preserve the kidney is based on the patient's condition. RVLMS is highly malignant, and may recur locally or metastasize to distant locations; therefore, adjuvant therapy and regular follow-up should be carried out after surgery.

Left renal vein graft and in situ hepatic perfusion in hepatectomy for complete tumor invasion of hepatic veins: hemodynamic optimization and surgical technique.

PURPOSE: Assessing hepatic vein reconstruction using a left renal vein graft and in situ hypothermic liver perfusion in an extended liver resection. METHODS: Patients included in this study were those with liver tumors undergoing curative surgery with resection and reconstruction of hepatic veins. Hepatic vein was reconstructed using a left renal vein graft. We describe the technical aspects of liver resection and vascular reconstruction, the key aspects of hemodynamic management, and the use of in situ hypothermic liver preservations during liver transection (prior to and during vascular clamping). RESULTS: The right hepatic vein was reconstructed with a median left renal venal graft length of 4.5 cm (IQR, 3.1-5.2). Creatinine levels remained within normal limits in the immediate postoperative phase and during follow-up. Median blood loss was 500 ml (IQR, 300-1500) and in situ perfusion with cold ischemia was 67 min (IQR, 60.5-77.5). The grafts remained patent during the follow-up with no signs of thrombosis. No major postoperative complications were observed. CONCLUSION: Left renal vein graft for the reconstruction of a hepatic vein and in situ hypothermic liver perfusion are feasible during extended liver resection.

Severe vaginal bleeding due to vaginal metastasis from renal cell carcinoma with inferior vena cava tumor thrombus: A case report.

RATIONALE: Renal cell carcinoma (RCC) is the most common type of kidney cancer and is the second most common urologic neoplasm. Vaginal metastasis from RCC is extremely rare clinically. PATIENT CONCERNS: A 56-year-old woman presented with intermittent vaginal bleeding that had persisted for 1 month. Enhanced computed tomography examination suggested a vaginal mass (3 × 2 × 2 cm), right kidney tumor (15 × 12 × 10 cm), and an inferior vena cava tumor thrombus. During gynecologic examination, the mass was necrotic and caused uncontrollable vaginal bleeding. DIAGNOSES: Based on clinical and imaging examinations and the pathology, she was diagnosed as vaginal metastasis from RCC. INTERVENTIONS: The patient received percutaneous transcatheter arterial embolization to stop uncontrollable vaginal bleeding, and then treated with targeted therapy. OUTCOMES: Vaginal bleeding disappeared after interventional embotherapy. However, disease progressed, and the patient died 9 months later. LESSONS: In cases of vaginal bleeding, the possibility of metastatic renal cell carcinoma should be considered. Percutaneous transcatheter arterial embolization is an effective and novel treatment for uncontrollable vaginal bleeding caused by vaginal metastasis of RCC.

Nutcracker phenomenon with a daily persistent headache as the primary symptom: Case series and a proposed pathogenesis model based on a novel MRI technique to evaluate for spinal epidural venous congestion.

OBJECTIVE: To determine if a specific population of patients with a daily persistent headache from onset have underlying nutcracker physiology and to propose a pathogenesis model for their headaches utilizing a novel MRI protocol. BACKGROUND: A single case report of a daily persistent headache associated with nutcracker syndrome was recently published. As the left renal vein has a connection to the spinal lumbar veins and secondarily to the spinal epidural venous plexus, one could hypothesize that renal vein compression could lead to persistent headache by altering spinal and cerebral venous pressure with secondary alterations in CSF pressure. The authors have published on a series of patients with a unique subtype of daily persistent headache from onset that appears to be caused by an abnormal reset of CSF pressure to an elevated state. The goal of the present study was to look for the presence of nutcracker physiology in this unique patient subgroup and to propose a pathogenesis model utilizing a novel MRI protocol to evaluate for retrograde lumbar vein flow and regional spinal epidural venous plexus congestion. MATERIALS AND METHODS: Case series of patients with a daily persistent headache from onset, head pressure, and whose headaches worsened in the Trendelenburg position. Patients were imaged with a 3 T MRI in the supine position from the lower diaphragm to the top of the pelvis with a dynamic angiogram centered over the left L2 lumbar vein. RESULTS: 12 patients were studied of which 8 were positive for left renal vein compression, lumbar vein dilation and early spinal epidural venous plexus enhancement. All were women. Mean age of headache onset was 39 years. Six of the 8 patients had a lumbar puncture, and all had a normal opening pressure. All improved with CSF volume removal although pain resolution lasted from hours to 6 months. The patient's headaches were marked by holocranial pressure and the majority displayed migrainous associated symptoms although none had a prior headache history. They did not complain of typical symptoms or signs of nutcracker syndrome. CONCLUSION: We suggest that patients with a daily persistent headache from onset who worsen in the Trendelenburg position may have underlying nutcracker physiology. From our imaging findings, it can be hypothesized that left renal vein compression leads to retrograde flow through the valveless lumbar vein which then leads to spinal epidural venous congestion and subsequently causes congestion of the cerebral venous system leading to an elevation of CSF pressure and to a daily headache. What appears to be unique about these patients is that a daily headache is their only manifestation of nutcracker physiology.

Laparoscopic left nephro-adrenalectomy for renal vein leiomyosarcoma using (ICG) fluorescence and 3D-CT reconstruction: A case report.

INTRODUCTION: Leiomyosarcoma is a rare malignant mesenchymal cancer of smooth muscle and about 50-60 % of cases are from inferior vena cava. Recently, preoperative reconstruction of three-dimensional (3D) images from computed tomography (CT) and intraoperative indocyanine green (ICG) are being developed. We present a case of laparoscopic left nephro-adrenalectomy using ICG fluorescence associated with 3D-CT reconstruction:n. CASE REPORT: A 72-years-old female patient presented pain in left side from two months. Contrast computed tomography and magnetic resonance imaging showed a solid mass between left-adrenal gland and upper renal pole. After multidisciplinary evaluation, a laparoscopic left nephno-adrenalectomy was performed. DISCUSSION: The surgery was without intra and postoperative complications. The patient was discharged in the 3rd postoperative day without complications and with oral steroid replacement therapy. Histology confirmed leiomysarcoma of renal vein. CONCLUSION: In this case, use intraoperative ICG fluorescence associated with preoperative 3D-CT was a valuable support for surgery. KEY WORDS: Endocrine surgery, Indocyanine green fluorescence, Laparoscopic Nephro-Adrenalectomy, Leiomyosarcoma, Three-dimensional computed tomography reconstruction, Video surgery.

Outcomes of renal cell carcinoma with associated venous tumor thrombus: experience from a large cohort and short time span in a single center.

BACKGROUND: The surgical management and outcomes of renal cell carcinoma (RCC) with venous tumor thrombus (VTT) have been reported in limited sample size, and there remain discrepancies over the factors that influence oncologic outcomes after radical nephrectomy with thrombectomy (RNTE). The aim of the study was to analyze the outcomes of the patients with RCC with VTT in our institution and identify the independent prognostic factors. METHODS: Patients with RCC with VTT were enrolled for the study from February 2015 to December 2018. All patients underwent RNTE. Clinical data were compared using Mann-Whitney U test and the chi-square test for continuous and categorical variables respectively. Survival analysis was estimated using the Kaplan-Meier method. Univariable and multivariable survival analyses were performed using Cox regression model. RESULTS: 121 patients (91 men & 30 women) were identified with a median age of 60 years. VTT level was 0 in 25 patients, I in 20, II in 50, III in 12 and IV in 14. The median follow-up time was 24 months. During the follow-up period, 51 (42%) patients died and 69 (57%) patients experienced recurrence or metastasis. The 3-year and 5-year over-all survival (OS) were 58 and 39%. Among the several factors examined, positive lymph node (P = 0.016), metastasis at surgery (P = 0.034), tumor necrosis (P = 0.023) and sarcomatoid differentiation (P < 0.001) were demonstrated as independent significant risk factors on multivariable analysis. CONCLUSION: The OS was poor for patients with RCC with VTT. Rather than VTT level, positive lymph node, metastasis at surgery, tumor necrosis and sarcomatoid differentiation were independent prognostic predictors.

[Criteria for an improved prognostic stratification in category pT renal carcinoma]. / La Categoría Tumor en el carcinoma renal. Criterios morfológicos para una mejor estratificación pronóstica.

Asymptomatic renal carcinomas are usually small and localized and thus, for the assessment of pT, precise criteria are required, able to identify the initial phases of a local extension and correlate them with current prognostic prospects. Various studies and consensus meetings have defined precisely how to measure tumoral nodules (solid, cystic and multiple). Furthermore, they have distinguished tumoral extension to the renal sinus, which has a worse prognosis, from that to the perirenal adipose tissue. They have also analyzed the clinical significance of invasion of the sinus vessels, the hilar veins and parenchymal vascular retroinvasion. Our aim is to revise and update the criteria of the different pT subcategories and consider those morphological aspects which could be clinically significant and that are not currently included in the TNM classification.

Renal vein measurement using ultrasonography in patients with cirrhotic ascites and congestive heart failure.

PURPOSE: Ascites can cause compression of the inferior vena cava (IVC), leading to increased renal venous pressure and renal congestion. Previously, the left renal vein diameter in liver cirrhosis patients with ascites was measured using computed tomography, showing that enlargement of the left renal vein diameter affects the prognosis. Herein, the diameter and flow velocity of the renal veins were measured using ultrasonography. METHODS: Abdominal ultrasonography was performed on 186 patients. The patients were divided into four groups: normal liver (n = 102), liver cirrhosis (LC) without ascites (n = 37), LC with ascites (n = 30), and congestive liver (n = 17). Ultrasonographic measurements for diameter and flow velocity of the IVC, left renal vein main trunk, and segmental renal vein were performed. RESULTS: The left renal vein diameter increased in the following order: normal liver, LC, LC with ascites, and congestive liver groups (P < 0.001). IVC flow velocity was lower and left renal vein diameter was larger in the congestive liver and LC with ascites groups. These results suggest that the two groups have different pathological conditions, but the mechanism of renal congestion is similar. In patients with LC, IVC compression due to ascites might cause blood stagnation and renal congestion. CONCLUSION: The left renal vein and IVC can be measured using ultrasonography. It might help in furthering our understanding of the pathophysiology of renal congestion in these patients.

Treatment of vena cava inferior leiomyosarcoma with cavotomy and right renal vein neoimplantation / Vena cava inferior leiomyosarcoma kezelése cavotomiával és a jobb vena renalis neoimplantatiójával

Leiomyosacroma of the inferior vena cava is an extremely rare malignancy originating from the tunica media of the venous wall. Its symptoms and radiomorphological signs do not always lead to an accurate diagnosis. Histological sampling can be dangerous due to its location. Therefore the diagnosis is often a challenge for clinicians. Its treatment is primarily surgical, supplemented by radiotherapy and chemotherapy applied together or in monotherapy. In our case, an asymptomatic 74-year-old female patient was diagnosed with a tumor of the inferior caval vein located just above the right renal vein and involving the right adrenal gland. As serum cortisol, epinephrine, norepinephrine, adrenocorticotropic hormone (ACTH), total and free testosterone, dehydroepiandrosterone sulfate (DHEA-S), sex hormone binding globulin (SHBG) was at normal level, the tumor showed no hormone secretion. Primary surgical resection was planned. Preoperative biopsy was not performed due to its high risk of complications. During operation, tumor resection was performed by resection of the venous wall, removal of the right adrenal gland and neoimplantation of the right renal vein. For better exposure, cholecystectomy was also performed at the beginning of surgery. There were no postoperative complications. The patient received adjuvant radiation therapy. Thanks to the early diagnosis of the tumor and the complete resection, we significantly increased the patient's chances of total recovery. With the radiotherapy performed, we reduced the likelihood of tumor recurrence.

Current Trends in Management of Renal Cell Carcinoma with Venous Thrombus Extension.

PURPOSE OF REVIEW: To review the evidence regarding the current trends in surgical management of renal cell carcinoma (RCC) with inferior vena cava (IVC) thrombosis. Recent published series have shown the role of minimally invasive surgery in IVC thrombectomy. This review article evaluates the present RCC with venous extent literature to assess the role of open and minimally invasive surgery in this scenario. RECENT FINDINGS: Robotic urological surgery has shown to have known benefits in radical prostatectomy, partial nephrectomy, and pyeloplasty. Recent published series showed feasibility of robotic IVC thrombectomy even for level IV cases. With growing number of robot-assisted and laparoscopic surgeries worldwide, there is a current tendency to treat this complex and challenging pathology with a minimally invasive approach, without compromising oncological outcomes.