Renal Cell Carcinoma (RCC)

IVC tumor thrombus - The single biggest hemodynamic issue. Thrombus in the inferior vena cava cuts venous return and sets the patient up for profound hypotension at induction. Have a phenylephrine drip primed and running before you push induction drugs.

Stage the vascular extension preoperatively - CT of the abdomen shows renal vein and IVC invasion and adjacent organ involvement; MRI is equally good. Chest CT because 10-20% present with lung metastases, and a whole-body bone scan is the test of choice for bone metastases. Know how high the thrombus goes before the case starts.

CVP lies with a thrombus in place - Central venous pressure will not track intravascular volume when tumor blocks the IVC. Use trends, urine output, and the surgical field rather than a single number.

Catastrophic complications to be ready for - Circulatory collapse from complete IVC occlusion, acute intraoperative pulmonary embolization of tumor fragments, and pneumothorax when the tumor sits high (unstable hemodynamics, rising peak inspiratory pressures, falling SpO2).

Lines and blood - Be set up for rapid, massive loss. Two large-bore peripheral IVs with rapid-transfusion tubing, arterial line for beat-to-beat pressure and frequent labs, and a central line based on tumor position — left IJ preferred if the IVC is involved. Send EKG, CBC, CMP, PT/PTT, UA, and type and cross, with about 2 units on standby.

Screen for the paraneoplastic syndrome - Serum calcium (PTH-related peptide, tumor-derived dihydrocholecalciferol, or lytic bone metastases), hemoglobin and hematocrit (anemia from cytokines, or erythrocytosis from tumor erythropoietin), and liver enzymes (Stauffer syndrome, which resolves after the tumor is resected).

Bone metastases change how you move the patient - RCC bone lesions are osteolytic and cause pathologic fractures and spinal cord compression. Band-like back pain from vertebral collapse is a red flag. Log-roll and pad deliberately.

Lateral flexed positioning with the kidney rest - Secure the ETT with extra tape and disconnect the circuit while turning. Keep the head neutral and aligned. Place an axillary roll caudad to the axilla on the rib cage, never in it, and re-check that it hasn't migrated. Pad the fibular head and pillow between knees and ankles.

Avoid nitrous oxide - Bowel distension will cost the surgeon visualization in an already deep field.

Protect the kidney you are leaving behind - Keep the patient well hydrated with a Foley target of urine output above 0.5 mL/kg/hr. Use controlled hypotension only in brief stretches, since sustained low pressure jeopardizes the contralateral kidney. Reflex vasoconstriction in the unaffected kidney can still cause postoperative renal dysfunction, and chronic kidney disease is a known sequela of radical nephrectomy — dose renally cleared drugs with that in mind.

Pain plan for the open case - Postoperative pain is high (7-10). A preoperatively placed epidural is strongly recommended for open nephrectomy, but hold off on dosing local anesthetic until the case is done — the sympathectomy compounds hypotension from blood loss.

Patients may arrive on targeted therapy - Metastatic clear cell RCC is treated with VEGFR tyrosine kinase inhibitors such as sunitinib and pazopanib. Know whether the patient is on one and when it was last taken.

Renal cell carcinoma (RCC) arises from the epithelium of the nephron and makes up over 90% of renal malignancies. Clear cell is the dominant subtype (80-90%), traced to the proximal tubule and driven by loss of the VHL tumor suppressor on chromosome 3p, which lets hypoxia-inducible factors accumulate and switch on angiogenesis. It grows silently — over half are found incidentally, and the classic triad of flank pain, hematuria, and a palpable flank mass shows up in only 10-15%, usually signaling advanced disease.

Two features drive the anesthetic. Clear cell tumors spread hematogenously with direct extension into the renal vein and inferior vena cava, so a tumor thrombus can obstruct venous return. And RCC is a prolific paraneoplastic mimic: hypertension, anemia, hypercalcemia, erythrocytosis from tumor erythropoietin, and Stauffer syndrome (hepatic enzyme elevation without liver metastases).