Editing Open Kidney Surgery (section)

==== Pre-operative considerations ====
* '''<span style="color:#ff0000">Anticoagulation</span>'''
** Patients with kidney cancer are at increased risk of pulmonary embolism as a result of malignancy-associated hypercoagulability and venous thrombus embolization.
**'''<span style="color:#ff0000">Intravenous or low-molecular-weight heparin should be started as soon as tumor thrombus is detected</span>'''
***Potential benefits (3):
***#Reduce risk of pulmonary embolism
***#Tumour thrombus shrinkage
***#Bland thrombus shrinkage and/or prevention
***Evidence supporting the use of preoperative anticoagulation is limited
***Temporary suprarenal IVC filters are also an option for patients with level 0, I, and II tumor thrombi. However, suprarenal IVC filters are not recommended because of the risk of contralateral renal and hepatic vein thrombosis, the risk of provoking embolization, and the impediment that these devices can pose to future IVC thrombectomy.
*'''<span style="color:#ff0000">Preoperative angioembolization'''
**'''<span style="color:#ff0000">Can be considered to attempt to shrink the thrombus and facilitate surgery''' 
**Indications (4):
**#Caval thrombi appears to invade the IVC
**#Thrombus is associated with a bleeding kidney
**#When deep hypothermic arrest is planned since the patency of the coronary arteries can be simultaneously assessed with angiography
**#Thrombus invades the intrahepatic or suprahepatic veins and cannot be excised
**#*Angiographic infarction of the blood supply to the tumor thrombus can help shrink a large thrombus to a more manageable size, potentially avoiding the need for bypass or extensive mobilization of the liver.
**In ≈1/3 of cases, tumour thrombi have an independent blood supply arising from the renal artery and/or aorta.
**Timing
***Optimal timing for angioembolization is unknown but at most centers, when undertaken, it is usually performed 1 day prior to surgery.
** Complications
*** Iatrogenic pulmonary embolization of the tumor thrombus when angiography is performed; however, this risk appears to be minimal.
*** Ischemia-related flank pain
*** Tumor lysis syndrome
*'''Multidisciplinary Approach'''
**Urologists who do not routinely handle the IVC and aorta should consult a vascular surgeon for level II and III thrombi to aid in vena caval control and reconstruction.
**Consultation with a cardiothoracic surgeon preoperatively for all level III and IV thrombi is essential, since access to the mediastinal compartment for vascular bypass and thrombus removal may be required.
**Involvement of a cardiologist or cardiac anesthesiologist is essential for level II to IV thrombi to allow for intraoperative TEE.
***'''<span style="color:#ff0000">Intraoperative use of transesophageal echocardiography (TEE) for level II to IV thrombi is recommended given the risk of intraoperative thrombus detachment and the possibility of interval thrombus growth in the period immediately preceding surgery.'''

* '''Surgical approach'''
**'''Tailored to the level of IVC thrombus. In general:'''
*** '''Level I thrombi are isolated by a Satinsky clamp''' and are thus readily addressed
*** '''Level II thrombi require sequential clamping''' of the caudal IVC, contralateral renal vasculature, and cephalad IVC along with mobilization of the relevant segment of the IVC and occlusion of lumbar veins. The renal ostium is then opened and the thrombus is removed, all in a bloodless field.
*** '''Level III thrombi may require mobilization of the liver and exposure of the intrahepatic IVC''' to allow the thrombus to be mobilized caudad to the hepatic veins, and venous isolation can then proceed as for a level II thrombus.
*** '''Level IV thrombi have traditionally been managed with cardiopulmonary bypass and hypothermic circulatory arrest'''
**** '''A hypocoagulable state follows when coming off the pump following hypothermic circulatory arrest. This is associated with increased risks of cerebrovascular accident and myocardial infarction'''
**** Hypothermic circulatory arrest is still the preferred approach in complex cases but some centers are now trying to avoid it
*** When tumor thrombus invades the wall of the vena cava, aggressive resection of the involved cava and attainment of negative surgical margins are required to minimize the risk of recurrence. IVC grafting or reconstitution is required in some instances.