Piggy-back Hepatic Transplant Technique and Veno-venous Bypass Without Cardiac Arrest: A Multidisciplinary Approach in Borderline T3b/T3c Renal Tumors

Open access


Surgery for renal cell carcinomas with tumor thrombus extending in the Inferior Vena Cava (IVC) can be particularly challenging, especially in the retrohepatic and intraatrial situations (T3b and T3c). Classically, these tumors require the intraoperative use of cardio-pulmonary by-pass (CPB) and deep hypothermic circulatory arrest (DHCA), that can result in specific complications (stroke, platelet dysfunction), with increased postoperative morbidity rates.

In urological practice, a particular IVC preparation method is currently in use, allowing full control both upon the IVC and its tributaries. It is derived from the “piggy-back” liver transplantation technique and implies the resection of all hepatic ligaments, leaving the hepatic vascular connections intact. This procedure is joined by a form of veno-venous bypass (between the right atrium and the infrarenal IVC) that allows a constant central venous pressure (by assuring blood return), with less bleeding and without the need for CPB and DHCA (avoiding, in this way, their inherent complications). All in all, these recently-introduced procedures can offer better thrombus control, improved oncologic outcomes and smaller complication rates. We aim to present a case of borderline T3b/T3c renal tumor that was successfully treated in our university center using these techniques.

1. Wotkowicz C, Wszolek MF, Libertino JA. Resection of renal tumors invading the vena cava. Urol Clin North Am, 2008;35:657-671.

2. Kim HL, Zisman A, Han KR, Figlin RA, Belldegrun AS. Prognostic significance of venous thrombus in renal cell carcinoma. Are renal vein and inferior vena cava involvement different? J Urol, 2004; 171:588-591.

3. Whitson JM, Reese AC, Meng MV. Population based analysis of survival in patients with renal cell carcinoma and venous tumor thrombus. Urol Oncol, 2013;31:259-263.

4. Neves RJ, Zincke H. Surgical treatment of renal cancer with vena cava extension. Br J Urol, 1987;59:390-395.

5. Moinzadeh A, Libertino JA. Prognostic significance of tumor thrombus level in patients with renal cell carcinoma and venous tumor thrombus extension. Is all T3b the same? J Urol, 2004;171:598-601.

6. Ljungberg B, Bensalah K, Bex A. Guidelines on Renal Cell Carcinoma, European Association of Urology, Available from: http://www.uroweb.org/gls/pdf/10%20Renal%20Cell%20Carcinoma_LR.pdf

7. Ciancio G, Gonzalez J, Shirodkar SP, Angulo JC, Soloway MS. Liver transplantation techniques for the surgical management of renal cell carcinoma with tumor thrombus in the inferior vena cava: step-by-step description. Eur Urol, 2011;59:401-406.

8. Ciancio G, Shirodkar SP, Soloway MS, et al. Renal carcinoma with supradiaphragmatic tumor thrombus: avoiding sternotomy and cardiopulmonary bypass. Ann Thorac Surg, 2010;89:505-510.

9. Gorin MA, Gonzalez J, Garcia-Roig M, Ciancio G - Transplantation techniques for the resection of renal cell carcinoma with tumor thrombus: A technical description and review. Urol Oncol, 2013;31:1780-1787.

10. Botea F, Brasoveanu V, Constantinescu Aet al. - Living donor liver transplantation with dual grafts -- a case report. Chirurgia (Bucur), 2013;108:547-552.

11. Borz C, Marian D, Bara TJret al. - Anatomical and Surgical Basis for Adult Living Donor Liver Transplantation with the Right Liver Lobe. Acta Medica Marisiensis, 2014;60:129-132.

12. Popescu I, Ionescu M, Tulbure D, Ciurea S, Băilă S, Braşoveanu V, Hrehoreţ D, Sârbu-Boeţi P, Pietrăreanu D, Alexandrescu S, Dorobanţu B, Gheorghe L, Gheorghe C, Mihăilă M, Boroş M, Croitoru M, Herlea V. Orthotopic liver transplantation in adult patients with cadaveric grafts. Experience of the Fundeni Center of General Surgery and Liver Transplantation. Chirurgia (Bucur), 2005;100:13-26.

13. Gorin MA, Garcia-Roig M, Shirodkar SP, Gonzalez J, Ciancio G - Modified surgical technique for the management of renal cell carcinoma with level I or II tumor thrombus. Urology, 2012;79:478-481.

14. Wotkowicz C, Libertino JA, Sorcini A, Mourtzinos A - Management of renal cell carcinoma with vena cava and atrial thrombus: minimal access vs median sternotomy with circulatory arrest. BJU Int, 2006;98:289-297.

15. Pouliot F, Shuch B, Larochelle JC, Pantuck A, Belldegrun AS. Contemporary management of renal tumors with venous tumor thrombus. J Urol, 2010;184:833-841.

Acta Medica Marisiensis

The Journal of The University of Medicine and Pharmacy of Targu-Mures

Journal Information


All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 158 117 3
PDF Downloads 64 56 6