Shchukin D. The rationale of the surgical strategy in the treatment of renal cell carcinoma with macroscopic intravenous extension.

The dissertation is devoted to improving the quality of treatment in patients with intravenous extension of renal cell carcinoma through development of optimal surgical tactics and formation of effective algorithms of care of patients with this pathology. The high efficacy and safety of surgical strategy of the implementation of thrombectomy before the renal artery ligation was demonstrated. It's results did not depend on the tumors spread, were not accompanied by deterioration of oncological parameters, and significantly exceeded the effectiveness of standard procedures in terms of feasibility and safety. The study presented feasibility of a new surgical maneuver - creation of a cross-tunnel under the major hepatic veins in 80% and 50% (p> 0,087) patients according to the anatomical and clinical researches. The highest efficiency of T-shaped diaphragmotomy among other approaches to the supradiaphragmatic IVC through the abdominal cavity was demonstrated. Analysis of bleeding from the isolated IVC segment during thrombectomy showed that they are found in 56.5% of cases and their main source are the upper right lumbar veins. The results of nephron sparing surgery in 25 patients with RCC and neoplastic venous thrombosis demonstrated feasibility of this method. The overall level of the perioperative complications of that surgical approach did not differ from the frequency of complications after nephrectomy, and oncological parameters exceeded the results in patients from nephrectomy group. Immunohistochemical profile of the renal cell carcinoma with macroscopic intravenous invasion demonstrated high levels of MMP-9 (100%) and VEGF (92,2%). Multivariate analysis has demonstrated the statistical significance of only one parameter - the level of IVC tumor thrombus.