primary transitional cell carcinoma of the renal pelvis or ureter is a relatively rare condition . it accounts for less than 1% of genitourinary neoplasms and 5 to 7% of all urinary tract tumors . extension of transitional cell carcinomas into the vena cava is rarely reported in the literature . most data available are derived from retrospective studies , and surgery is the mainstay of treatment . aggressive surgery to remove an inferior vena cava ( ivc ) thrombus is reported to be effective in prolonging survival in patients with renal cell carcinoma ( rcc ) . however , the value of aggressive surgery in the treatment of transitional cell carcinoma of the renal pelvis remains unclear owing to limited evidence and the aggressive course of the condition . in the case of ivc invasion , complete resection is necessary , but ivc resection presents a technical challenge . in cases requiring surgical reconstruction , human cadaveric aortic grafts , or cryopreserved aorta , could be an option , but their use has not yet been reported for the restoration of caval continuity . we herein report a case of radical nephroureterectomy with ivc replacement with a human cadaveric aortic graft for a patient with renal pelvis transitional cell carcinoma with ivc invasion . a 67-year - old man presented to our clinic with a 3-month history of dull pain in the right flank . urine analysis , complete blood count , and routine blood chemistry results were unremarkable and urine cytology showed atypical cells . abdominal computed tomography ( ct ) demonstrated that most of the right kidney was occupied by a huge irregular tumor measuring 8 cm  6.5 cm  6.5 cm in size ( fig . the right perirenal space exhibited strand - like infiltration and the right renal fascia was thickened . multiple , enlarged , para - aortic lymph nodes were seen . under the impression of a renal pelvis tumor , we subsequently performed a right radical nephroureterectomy with replacement of the ivc with a human cadaveric aortic graft . the tumor was mobilized en bloc with the right kidney , adrenal gland , ureter , and regional lymph node . the right renal artery was divided and clamped on the left side of the ivc . the ivc was then clamped proximally , contralaterally , and distally and was resected for an extension of 12 cm in length . grossly , a huge , grayish , solid tumor measuring 8.1 cm  6.5 cm in dimension was seen involving the whole renal pelvis and calyces . microscopically , the renal tumor was classified as grade iii transitional cell carcinoma ( world health organization classification ) and comprised neoplastic cells arranged in irregular solid nests associated with marked tumor necrosis . the patient was discharged on the eighth postoperative day and anticoagulant therapy was initiated , which was continued for 9 months . however , venous infiltration by transitional cell carcinoma of the renal pelvis remains rarely reported [ 1 - 3 ] . few renal pelvic tumors extend into the ivc , and it is very rare that they invade the wall of the ivc . earlier presentation of many of these transitional cell lesions due to hematuria may be partly responsible . when a patient presents with signs and symptoms such as lower - extremity edema , varicocele , albuminuria , pulmonary embolism , or urographic dysfunction of the involved kidney , tumor extension into the ivc should be suspected before removing the renal tumor [ 1 - 5 ] . nevertheless , the majority of patients with extension of tumor into the renal vein and ivc are asymptomatic , and the diagnosis is usually made radiologically [ 1 - 3,7 ] . in the case of tumor invasion of the caval wall , medial venotomy carries a higher risk of narrowing after caval wall excision and renal vein repair and often requires caval wall reconstruction . if collateral circulation is not present , ivc resection can be associated with severe edema of the lower extremities . in this setting , reconstructing the ivc should be considered and can be performed with a ptfe graft , but the main concern with prosthetic grafts for vein replacement is higher risks of thrombosis and infection . therefore , autologous venous and pericardial grafts are preferred . urine cytology and brushings from the involved renal pelvis may aid in correct diagnosis , although a frozen section of the tumor upon removal of the specimen may be necessary to exclude transitional cell carcinoma . similarly to the case of rcc , aggressive surgical treatment is indicated in all patients with renal tumors associated with ivc invasion , because nephrectomy alone is associated with dismal prognosis . cardiopulmonary bypass may minimize bleeding from the operation field and achieve stable hemodynamic status during ivc clamping and thus provides a bloodless operative field to facilitate tumor resection and venous reconstruction in patients with ivc invasion . however , cardiopulmonary bypass is the main cause of the complex systemic inflammatory response , which leads to adverse postoperative outcomes , including renal , pulmonary , and neurological complications . postoperative bleeding and coagulation disturbances are the most frequently reported complications in patients who undergo ivc thrombectomy with nephrectomy . another technique that may achieve hemodynamic stability is aortic cross - clamping during ivc reconstruction . even patients without venous occlusion tolerate this procedure without experiencing significant hemodynamic instability , and transient hypotension can be managed by fluid and blood replacement . however , the limits of this well - established technique include the risk of prosthetic occlusion or infection . aortic graft availability is scant because harvesting from multi - organ donors is not a standard procedure . however , an aortic graft has the advantages of being a good size - match to the vascular defect with resistance to infection . the long - term patency of ivc reconstruction is still in question , because no cases have previously been reported . however , we elected to initiate post - operative anticoagulation , which continued for 9 months , to ensure patency of the aortic graft . long - term follow - up will be necessary to monitor graft survival . in this report , if safety , efficacy , and long - term patency were to be validated , a regular collection of large vessels by donor surgical teams should be encouraged to facilitate the conduct of prospective studies .
we herein report a case of radical nephroureterectomy and replacement of the inferior vena cava ( ivc ) with ahuman cadaveric aortic graft for a patient with renal pelvis transitional cell carcinoma associated with ivc infiltration . 
 in advanced disease , radical surgery is essential to achieve long - term survival . 
 this case entails the use of another treatment option among the numerous options currently available for the management of patients with advanced renal cancer associated with ivc invasion .