Radical Nephrectomy with Inferior Vena Cava (IVC) Thrombectomy: Implications for Post-operative Nursing Care

Implications for Post-operative Nursing Care

Janee Klipfel, BSN, RN, CURN; Therese M. Jacobson, MSN, APRN-BC, CWOCN; Michelle Havel, BSN, RN, CURN

Disclosures

Urol Nurs. 2010;30(6):347-352. 

In This Article

Overview of the Surgical Procedure

Peri-operative mortality for radical nephrectomy with IVC thrombectomy has decreased from 3.9% between 1970 and 1989 to 1.5% between 1990 and 2005, with a corresponding de crease in length of hospitalization from a median of eight days to six days (Karnes & Blute, 2008). However, it is well documented that early surgical complications (less than 30 days post-procedure) increase with the level of tumor thrombus (Blute, Leibovich, Lohse, Cheville, & Zincke, 2004; Boorjian, Sengupta, & Blute, 2007). This fact has implications for the multidisciplinary team, including nurses, who must manage this increasingly complex patient in the hospital setting.

Surgical resection is the accepted standard of treatment for localized renal cell carcinoma. Radical nephrectomy has been defined as the removal of the kidney outside of Gerota's fascia, the adrenal gland on the affected side, the proximal half of the ureter, and lymph nodes up to the area of the renal vessels (Tanagho & McAninch, 2008).

In a radical nephrectomy with IVC thrombectomy, the removal of the blood clot/thrombus from the vena cava occurs first, followed by removal of the kidney. Thrombi are classified as Levels 0 to IV, with Level IV being the most complicated. Thrombus removal associated with renal cell carcinoma is planned prior to surgery based on the extension of thrombus and whether clamping of the IVC or cardiopulmonary bypass is needed to remove the tumor thrombus (Boorjian et al., 2007; Karnes & Blute, 2008). A cardiovascular surgeon must be in volved when a bypass procedure is needed.

Level 0 or Level I tumor thrombi are contained in the renal vein or extend minimally into the IVC and can often be manipulated back into the renal vein by the surgeon. The tumor is contained within a vascular clamp on the vena cava around the renal vein ostium, and thus, avoids complete occlusion of the IVC. The renal ostium, the orifice between renal vein and vena cava, is cut circumferentially. The thrombus is then removed with the kidney and renal vein. The cavotomy is closed with sutures (Boorjian et al., 2007; Karnes & Blute, 2008).

Level II tumors extend more than two centimeters above the renal vein but below the hepatic veins. This level of tumor thrombi requires gaining vascular control of the IVC proximally and distally to the thrombus. The IVC is first clamped above the thrombus, then on the contralateral renal vein, and finally, on the IVC below the thrombus. An incision is made into the IVC, the thrombus is dissected, and the renal vein is removed with the kidney. The IVC is flushed and examined for residual tumor; resection or biopsy may be necessary to achieve margins negative for cancer (Boorjian et al., 2007; Karnes & Blute, 2008). The cava is then closed with sutures.

Level III tumors have extended proximally to the level of the hepatic vein or above it, but remain below the diaphragm. Intra-abdominal management using liver mobilization may be utilized to expose the IVC and to allow clamping above the head of the tumor thrombus (Boorjian et al., 2007; Karnes & Blute, 2008). Level IV tumors extend above the diaphragm and require abdominal and thoracic management with both an abdominal incision and a sternotomy (Boorjian et al., 2007; Karnes & Blute, 2008).

In the presence of a bland thrombus, a non-cancerous tumor thrombus that extends toward the legs, more extensive surgery on the vena cava is needed. Surgical techniques to prevent fatal emboli and extension of the thrombus may include placement of an IVC filter, IVC ligation, or IVC resection to prevent the growth of bland thrombus (Blute et al., 2007). If the tumor invades the wall, this requires removing a portion of the vena cava and IVC reconstruction with a synthetic patch or graft (Boorjian et al., 2007; Karnes & Blute, 2008). Careful planning of peri-operative care by the health care team is crucial for a successful patient outcome. Nurses need to understand the surgical procedure and its inherent risks to proactively and successfully manage the patient's post-operative care and discharge education.

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