Robot-assisted laparoscopic retroperitoneal lymph node dissection with concomitant inferior vena cava thrombectomy for metastatic mixed testicular germ cell cancer: a case report

Abstract

Background The robot-assisted laparoscopic management of post-chemotherapy retroperitoneal metastasis and inferior vena cava tumor thrombus secondary to testicular cancer is a challenging task for urologists. Case presentation A pathological examination of a 36-year-old Caucasian man who had undergone a right radical orchiectomy showed mixed testicular germ cell cancer (70% embryonal cancer and 30% seminoma); he had undergone four prior courses of cisplatin, etoposide, and bleomycin chemotherapy and was found to have residual retroperitoneal enlarged lymph nodes close to the right renal hilum and a 9.8 cm inferior vena cava tumor thrombus (pT1, N2, M1, S2). Pre-surgical three-dimensional image reconstruction was performed based on contrast computed tomography data. The inferior vena cava tumor thrombus was found in the vena cava at the level of the celiac trunk and the inferior mesenteric artery. Our patient accepted treatment with robot-assisted laparoscopic retroperitoneal lymph node dissection with concomitant inferior vena cava thrombectomy and cava reconstruction on September 12, 2018. During the procedure, a drop-in robotic ultrasound probe was used to define the thrombus. Vena cavoscopy using a flexible ureteroscope found that the tumor thrombus adhered to the cava wall in all directions. The tumor thrombus was dissected free from the inferior vena cava lumen, and vena cava reconstruction was achieved using the da Vinci™ Si HD surgical system. The operative time was 550 minutes. The intraoperative estimated blood loss was 2300 ml. Intraoperative blood transfusions consisted of 10 units of red blood cells (Clavien-Dindo grade II). No Clavien-Dindo grade III or above perioperative complications occurred. The length of hospital stay was 7 days. Pathology revealed no viable cancer cells in any of the residual lymph node tissues or in the vena cava tumor thrombus. Conclusion This is the first case of robot-assisted laparoscopic retroperitoneal lymph node dissection with concomitant inferior vena cava thrombectomy and reconstruction for metastatic mixed testicular germ cell cancer published to date. This complicated surgical procedure was facilitated by the innovative usage of three-dimensional image reconstruction for defining the vena cava tumor thrombus, a robotic ultrasound probe for intraoperatively defining the vena cava tumor thrombus, and vena cavoscopy using a flexible ureteroscope.

Robot-assisted retroperitoneal lymphadenectomy: The state of art

“…Of note, oncologic outcomes do not seem to be compromised by the minimally invasive technique. Also, the node yield, which usually reflects the effectiveness of oncologic surgery, presented a weighted mean of 22.15 nodes in our review and was comparable with recent publications on the O-RPLND series that reported a median 28 [ [19] , [20] , [21] , [22] , [23] , [24] , [25] , [26] , [27] , [28] , [29] , [30] , [31] , [32] , [33] , [34] , [35] , [36] , [37] , [38] ] nodes removed [ 41 , 44 ].…”

“…As a result, multiple series of R-RPLND have been successfully reported recently in multiple experienced centers around the world, showing the potential of this surgical approach to increase the number of well-trained surgeons performing minimally invasive RPLND [ 10 , 11 , [13] , [14] , [15] , [16] , [17] , [18] ]. Even challenging cases as bulky CS III disease with concomitant inferior vena cava thrombectomy for metastatic GCT have already been managed successfully with a robotic approach by high-volume surgeons [ [23] , [24] , [25] , [26] , [27] ]. With regards to patient positioning, the initial series described the R-RPLND approach with the patient in flank position and trocar placement and docking similar to a partial nephrectomy [ 4 ].…”

Robotic renal and adrenal oncologic surgery: A contemporary review

“…It is also useful to assess renal vasculature and collaterals, and the hepatic anatomy, especially the number and location of hepatic veins. Three-dimensional (3D) reconstruction of the renal anatomy and thrombus might be useful in the management [ 36 ]. The CT has a sensitivity of 93% and specificity of 80% in determining the extent of tumor thrombus [ [37] , [38] , [39] ].…”

“…The cavatomy is then performed to complete the thrombectomy, and following reconstruction of the IVC the right kidney is revascularized [ 40 ]. Since then, many series with level II and level III thrombus have been described, reiterating the safety and feasibility of robotic surgery in this condition [ 36 , [47] , [48] , [49] , [50] ]. In a series by Wang et al.…”

“…This is usually followed by retroperitoneal lymph node dissection. The use of a flexible cystoscope/ureteroscope to visualize the interior of IVC has been described [ 36 , 49 ]. Rarely, if the tumor thrombus infiltrates the IVC wall, the excision of the IVC wall and the use of venous grafts are necessary if re-suturing occludes the lumen more than 50% [ 49 ].…”