Robot assisted radical nephrectomy and inferior vena cava thrombectomy: surgical technique, perioperative and mid-term oncologic outcomes
Objective
Radical nephrectomy with Inferior vena cava (IVC) thrombectomy for renal cancer is one of the most challenging urologic surgical procedures. We describe surgical technique and present perioperative and oncologic outcomes of 23 consecutive cases of completely intracorporeal robot-assisted radical nephrectomy with IVC level I (17,9%) II (30%) and III (52,1%) tumor thrombectomy.
Materials and Methods
Twenty-three consecutive patients with renal tumor and IVC thrombus were treated between July 2011 and September 2017. Baseline, perioperative and follow-up data were collected into prospectively maintained IRB approved databases. Surgical technique has been previously described. We report perioperative and oncologic outcomes of 23 consecutive patients treated in a tertiary referral center.
Results
All procedures were successfully completed; open conversion wasn’t necessary. Median operative time was 300 minutes. Eleven patients (47.8%) did not experience any complication. Ten patients (43,4%) required blood transfusion (Clavien grade 2); one patient (4,3%) had a Clavien grade 3a complication (gastroscopy); one patients (4,3%) had Clavien grade 3b complication (reintervention due to bleeding from adrenal gland); Two patients (8,6%) required ICU admission (Clavien 4a), for PRESS syndrome and atrial fibrillation, respectively. Out of 8 patients who underwent cytoreductive nephrectomy and IVC thrombectomy, at a median follow-up of 19 months (IQR 6-31), 2-yr cancer specific and overall survival rates were 50%. Fifteen patients received surgery with curative intent and 7 of these experienced disease recurrence. three patients died of disease progression; 2-yr disease-free and cancer specific survival rates were 42.1% and 71.5%, respectively.
Discussions
Robotic IVC tumor thrombectomy is feasible for level II-III thrombi [1]. To maximize intraoperative safety and chances of success, a thorough understanding of applied anatomy and altered vascular collateral flow channels, careful patient selection, meticulous cross-sectional imaging, and a highly experienced robotic team are essential.
Conclusion
Robotic IVC tumor thrombectomy has demonstrated to be a feasible and safe surgical procedure in tertiary referral centers. Favorable perioperative outcomes represent a rational base to expand indications also in the cytoreductive setting.
Reference
1. Robot-assisted Level II-III Inferior Vena Cava Tumor Thrombectomy: Step-by-Step Technique and 1-Year Outcomes.
Chopra S, Simone G, Metcalfe C, de Castro Abreu AL, Nabhani J, Ferriero M, Bove AM, Sotelo R, Aron M, Desai MM, Gallucci M, Gill IS.
Eur Urol. 2017 Aug;72(2):267-274. doi: 10.1016/j.eururo.2016.08.066. Epub 2016 Sep 20.