A Decade of Robotic-Assisted Radical Nephrectomy with Inferior Vena Cava Thrombectomy: A Systematic Review and Meta-Analysis of Perioperative Outcomes

Abstract

Purpose:Open radical nephrectomy with inferior vena cava thrombectomy (O-CT) is standard management for renal cell carcinoma with inferior vena cava thrombus. First reported a decade ago, robotic-assisted radical nephrectomy with inferior vena cava thrombectomy (R-CT) is a minimally invasive option for this disease. We aimed to perform a systematic review to assess the safety and feasibility of R-CT in terms of perioperative outcomes and compare the outcomes between R-CT and O-CT.Materials and Methods:The PubMed®, Scopus®, Cochrane Central Register of Controlled Trials and Web of ScienceTM databases were searched using the free-text and MeSH terms “renal cell carcinoma,” “inferior vena cava,” “thrombosis” or “thrombus,” “robot” and “thrombectomy.” Studies reporting perioperative outcomes of R-CT and studies comparing R-CT with O-CT were included. The review was done in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.Results:The search retrieved 28 articles describing R-CT, including 7 comparative studies. This systematic review included 1,375 patients, out of which 329 patients were in single-arm studies and 1,046 patients were in comparative studies. Of the 329 patients who underwent R-CT, 14.7% were level I, 60.9% level II, 20.4% level III and 2.5% level IV thrombus. Operative time ranged from 150 to 530 minutes; blood transfusion was administered in 38.2% (126). The overall complication rate was 30.3% (99). R-CT, in comparison to O-CT, was associated with a lower blood transfusion rate (18.4% vs 64.3%, p=0.002) and a lower complication rate (14.5% vs 36.7%, p=0.005). Major complication and 30-day mortality rates were similar in both groups.Conclusions:R-CT has acceptable perioperative outcomes in carefully selected patients. Compared with O-CT, R-CT is associated with a lower blood transfusion rate and fewer overall complications. In experienced hands with carefully selected patients, R-CT is feasible and safe, with acceptable outcomes; however, selection bias limits definitive inference of these results, and optimal patient selection criteria remain to be described.

Inferior vena cava thrombectomy for renal cell carcinoma: perioperative systemic therapy, cytoreductive nephrectomy, and complex cases

“…Selected IVC thrombectomy cases are now being regularly performed with robotic assistance. Robotic renal surgery has a number of potential benefits over the open approach including reduced blood loss, less pain, and faster convalescence ( 23 ). Robotic assistance is most relevant to level 0–II IVC thrombus cases where mortality is low and these perioperative benefits are most relevant.…”

Les complications de la néphrectomie totale et de la néphrectomie partielle : quelles sont-elles, comment les prévenir et les prendre en charge ?

“…La morbidité de la NT est considérablement augmentée en cas de thrombus cave surtout lorsqu'il dépasse les veines hépatiques (niveau III ou IV). Une méta-analyse récente évalue le taux de complications globales à 30 % [9].…”

“…Ce sont souvent des tumeurs volumineuses avec une importante circulation collatérale ce qui augmente les pertes sanguines et la fréquence des transfusions (environ 40 %) [9].…”

“…La voie robotique a été rapportée par des équipes expertes depuis 10 ans et pourrait être associée à un saignement et des complications moins importants chez des patients très sélectionnés et dans des équipes entraînées [9].…”

Editorial Comment to Robot‐assisted radical nephrectomy and inferior vena cava tumor thrombectomy using the hinotori: Initial experience with two cases

“…demonstrated in a systematic review and meta‐analysis of perioperative outcomes that if well‐experienced urologists perform RARN with IVCTT in carefully selected patients, favorable outcomes could be obtained. Particularly, RARN with IVCTT was associated with lower blood transfusion rate, fewer overall complications, and shorter hospital stays compared with ORN 1 . However, RARN with IVCTT remains challenging.…”