Indocyanine green guided Robot assisted radical nephrectomy and level III Inferior Vena Cava tumor thrombectomy

Giuseppe Simone1, Leonardo Misuraca1, Gabriele Tuderti1, Mariaconsiglia Ferriero1, Francesco Minisola1, Salvatore Guaglianone1, Michele Gallucci1
  • 1 Istituto Nazionale Tumori "Regina Elena" (Roma)


INTRODUCTION: Radical nephrectomy with IVC thrombectomy is a challenging procedure. A crucial step is the control of the cranial edge of the thrombus, which can be made with the assistance of indocyanine green (ICG) guidance.

METHODS: Preoperative embolization of right renal arteries was performed. Liver was mobilized to expose the retrohepatic IVC. IVC was prepared, cranially and distally to the neoplastic thrombus. All lumbar veins, visible short hepatic veins and right gonadal vein were secured, while left renal vein was isolated for tourniquet encircling.
Right renal arteries were transected and previously applied tourniquets were synched down after confirming with near infrared fluorescence (NIF) the proper control of cranial thrombus edge. Cavotomy was performed and the thrombus delivered and secured into an endo catch bag. IVC lumen was copiously irrigated with heparin saline solution and IVC suture performed. After tourniquets removal, NIF was used to confirm proper restoration of IVC flow. Finally, nephrectomy was completed.

RESULTS: Operative time was 300 minutes. EBL was 350 ml. Patients was discharged on 7th postoperative day. Postoperative course was uneventful.

CONCLUSIONS: NIF imaging represents a significant technical advancement in management of level III IVC tumor thrombi, to improve control of cranial thrombus edge and to confirm proper restoration of IVC flow after cava suture.