Real-time transesophageal echocardiography for intraoperative surveillanceof patients with renal cell carcinoma and vena caval extension undergoing radical nephrectomy

Purpose: Vena caval tumor thrombus associated with renal cell carcinoma occ urs in 4 to 10% of all renal tumors. There is significant operative morbidi ty and mortality in removing these tumors. We investigate the use of real-t ime transesophageal echocardiography intraoperatively and to identify tumor thrombus migration and air embolus, which are 2 potentially fatal complica tions of this procedure. Materials and Methods: A total of 13 consecutive patients with renal masses and vena caval extension underwent extirpative surgery monitored with real -time transesophageal echocardiography. Results: In 11 cases the involved kidney and tumor thrombus were removed wi thout morbidity and no evidence of tumor migration or air embolus. Transeso phageal echocardiography revealed a 5 cm. tumor thrombus in the right atriu m which was removed by immediate atriotomy in 1 of the remaining 2 cases, a nd a large volume of air in the right atrium that was percutaneously evacua ted in the other. These intraoperative complications were unsuspected and o nly recognized due to the use of transesophageal echocardiography. Conclusions: Real-time transesophageal echocardiography is a useful adjunct to surgery in patients with renal cell carcinoma and vena caval extension. Transesophageal echocardiography facilitates identification of tumor throm bus migration and air embolization, which are potentially fatal complicatio ns, and allows for immediate intraoperative intervention.