The "301 classification" system and surgical strategies for treatment of renal tumor and venous thrombus: report of 100 cases
Huang Qingbo1, Peng Cheng1, Gu Liangyou1, Wang Baojun1, Liu Kan1, Du Songliang1, Fan Yang1, Lyu Xiangjun1, Shen Dan1, Tang Lu1, Li Xintao1, Shi Taoping1, Li Hongzhao1, Zhu Jie1, Guo Gang1, Chen Guangfu1, Xu Axiang1, Song Tao1, Fu Weijun1, Dong Jun1, Zhang Lei1, Hu Minggen2, Xiao Cangsong3, Wang Haiyi4, Liu Fengyong5, Ma Xin1, Zhang Xu1
1 Department of Urology, State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital, Beijing, 100853, China; 2 Department of Hepatology, Chinese PLA General Hospital; 3 Department of Cardiovascular Surgery, Chinese PLA General Hospital; 4 Department of Radiology, Chinese PLA General Hospital; 5 Department of Interventional Radiology, Chinese PLA General Hospital
Abstract：Objective: To describe and evaluate the safety and feasibilityof a novel classification named “301 classification” and its corresponding surgical technique in the treatment of renal tumor and venous extension. Methods: From June 2013 to August 2017, a total of 100 cases of renal neoplasm and venous tumor thrombus underwent surgical treatment in Chinese PLA General Hospital. A novel classification named "301 classification" was established to make decision of surgical strategy. Renal vein tumor thrombus on the right side was classified as level 0, and renal vein tumor thrombus on the left side as level 0a or 0b depending on whether the thrombus exceeds the superior mesenteric artery or not. The IVC thrombi were classified into 4 levels: Level Ⅰ referred to the thrombus in the IVC but below the first porta hepatis; Level Ⅱ referred to the retrohepatic thrombus between the first and the second porta hepatis; Level Ⅲ referred to the suprahepatic thrombus at the level or above the hepatic vein but below the diaphragm; Level Ⅳ referred to the thrombus exceeding the diaphragm. Surgical strategies include the necessity of angioembolization of renal artery, position changing, liver mobilization, liver hilum vessels clamp, and veno-venous or cardiopulmonary bypass, which depend on the level of venous tumor thrombus. The perioperative data such as operation time, estimated blood loss, hospital stay and complications were retrospectively analyzed. Results: A total of 100 patients were analyzed, including 77 males and 23 females. The median age was 56 years (23-81 years). Grouped by the noval classification, 6 cases were classified as level 0b, 40 cases as levels 0 or 0a, 32 cases as Level Ⅰ, 15 cases as Level Ⅱ, 6 cases as Level Ⅲ, and only one case of Level Ⅳ. One hundred operations were successfully performed using the strategies divided by "301 classification", which included 68 cases given robotic surgery, 19 cases given laparoscopic surgery and 13 cases given open surgery. There was no intraoperative pulmonary embolism, however, there was one case of intestinal injury and 2 cases of spleen injury. The median operation time was 164 min (range, 43 to 465 min) for all patients, 109.5 min (range, 43-324 min) for level 0/0a, 196 min (range, 120-348 min) for level 0b, 170 min (range, 76-422 min) for level Ⅰ, 240 min (range, 130-360 min) for level Ⅱ, 337 min (range, 255-465 min) for level Ⅲ, and 336 min for level Ⅳ, respectively. The median estimated blood loss was 400 mL (range, 20-7 000 mL), 100 mL (range, 20-2 000 mL) for 0a, 450 mL (range, 100-3 000 mL) for level 0b, 425 mL (range, 20-4 500 mL) for level Ⅰ, 1 200 mL (range, 100-4 000 mL) for level Ⅱ, 2 600 mL (range, 500-7 000 mL) for level Ⅲ, 3 000 mL for level Ⅳ, respectively. There was significant difference in operation time and estimated blood loss among levels (P<0.001). All the patients recovered well after discharge, and the median postoperative hospital stay was 7 days (range, 3-30 days). The common tumor type was clear cell renal cell carcinoma (79 cases), followed by papillary renal cell carcinoma (9 cases) and others (12 cases). Conclusions: The "301 classification" and its corresponding strategies were established based on the experience of Chinese PLA General Hospital and it is feasible and safe for surgical treatment of renal neoplasm and venous tumor thrombus. However, more cases from multicenters are needed to confirm the conclusion.
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