These authors from a large kidney surgery center report their experience with preoperative renal artery embolization before radical nephrectomy and inferior vena cava (IVC) tumor thrombectomy during a 17-year period. Although not done using a prospective protocol, it appears these surgeons systematically used preoperative arterial embolization for advanced level 3-4 kidney cancers in 58% (135/231) of patients with IVC tumor thrombus, making this a large and unique data set. In brief, this retrospective analysis found patients with preoperative embolization did worse or no better than those with upfront radical nephrectomy in perioperative mortality, transfusion, and morbidity, and the authors have recommended abandoning its use. It is not surprising that preoperative arterial embolization did not lessen the need for transfusion, as bleeding from advanced kidney cancer with IVC tumor thrombus is from the venous collaterals and, depending on the degree of IVC occlusion, the flow in these collaterals is physiologically reversed. Therefore, mobilization of the kidney and ligation of these collaterals before thrombectomy is associated with tremendous venous bleeding, given that significant venous hypertension is present. When approaching a patient with advanced kidney cancer and an IVC tumor thrombus, the surgeon must consider it an operation of the IVC first and radical nephrectomy second. Therefore, our approach is typically in 3 steps after exposure of the IVC and renal hilum: (a) ligate the renal artery, (b) perform dissection of IVC and the thrombectomy, and (c) radical nephrectomy.
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