Robotic assisted radical nephrectomy with Inferior vena cava tumor thrombus

Abstract

Purpose: Surgery for renal cell carcinoma (RCC) with an inferior vena cava (IVC) tumor thrombus can be done via a robotic approach. While this approach is thought to minimize blood loss, it may still result in significant losses ( 1 ) and current publications indicate that it can require upwards of 3-day hospital stays ( 1 , 2 ). However, innovative surgical techniques, such as the split and roll, may curtail this. The purpose of this video is to present the case and surgical technique of robotic assisted radical nephrectomy with IVC thrombectomy. Materials and Methods: The patient was a 77-year-old male found to have a right upper pole renal mass on CT urogram. On MRI ( Figure 1 ), a renal mass and level II thrombus was seen. For this case, the Da Vinci Xi Intuitive robotic system was used, with four robotic 8-millimeter (mm) metallic trocars, two 5 mm assistant trocars, and one 12 mm air seal port. The split and roll technique were utilized to access the IVC and lumbar veins. This surgical method uses the adventitia of the IVC as a plane of dissection and safely identifies all branches/tributaries of the IVC to minimize the chance of vascular injury ( 3 ). Results: Robotic console time was 150 minutes. The patient had an excellent outcome, with all tumor thrombus removed, less than 50cc of blood loss, and was discharged within 24 hours of the operation. The tumor pathology came back as papillary, high grade, and was stage pT3bN1. Conclusions: The robotic approach with split and roll technique is a great surgical option for urologists to consider in patients with RCC and a level I or II thrombus, which can minimize blood loss and expedite discharge.

Selection of best videos of the year for 2023

“…I would encourage our readers to share this resource with their colleagues as it highlights how this reconstructive technique can be used to address challenging proximal ureteral defects/resections, ideally in the setting of a dilated renal pelvis/upper urinary system. The third prize for best videos of the year is awarded to Sandberg, et al from Wake Forest University in North Carolina (USA) for their submission entitled “Robotic assisted radical nephrectomy with inferior vena cava tumor thrombus” published in volume 49, number 5 of our journal ( 3 ). Although the minimally invasive approach to complex urologic oncology cases such as kidney cancer with intravascular venous thrombus has been well reported in the recent peer reviewed scientific literature, the present video details very elegantly how even high level IVC thrombi can be tackled using meticulous technique and adherence to key principles of vascular surgery including proximal/distal control, lumbar vessel ligation, and ensuring the entire tumor thrombi is resected (understanding that if vascular wall invasion is in fact seen at time of surgery it will necessitate resection and possible vascular patching, grafting, or in certain select circumstances ligation (if collateral flow can be established over time).…”