Robot-assisted radical nephrectomy with inferior vena cava thrombectomy –⁠ technique

Overview

Introduction: Radical nephrectomy with thrombectomy is the standard treatment for locally advanced renal tumors with inferior vena cava (IVC) tumor thrombus, in the absence of distant metastases. The presence of a tumor thrombus is a significant prognostic factor, with 5-year survival rates ranging from 36 to 57% [1–4]. Most of these surgical procedures are performed with open approach, with an intraoperative mortality rate of 2–10% [1,3,4–8]. The introduction of robotic technology into urology and vascular surgery has enabled the use of this technology in selected patients with this diagnosis. Radical nephrectomy with IVC thrombectomy has been performed at the Department of Urology, Second Faculty of Medicine, Charles University and University Hospital Motol and Homolka since 2002. To date, a total of 46 operations have been performed, all using an open approach. Twenty-seven of these cases involved a multidisciplinary surgical procedure with the participation of the Department of cardiovascular Surgery at University Hospital Motol and Homolka. Experience gained and progress made in establishing robotic systems in urological surgery led to the selection of two patients with renal cell carcinoma (RCC) and IVC tumor thrombosis for robot-assisted radical nephrectomy with thrombectomy. Both cases involved a multidisciplinary procedure.

Video: The video presents a surgical procedure performed on a 49-year-old male with no significant comorbidities (ECOG 0). An incidental tumor measuring 50 × 30 × 40 mm was detected in the lower pole of the right kidney; preoperative imaging revealed a tumor thrombus extending at least 2 cm above the junction of the renal vein and the IVC (cT3b N0 M0). According to the Mayo Clinic classification was classified as level II [9]. CT imaging showed no evidence of metastatic disease. The procedure was performed with the patient in the left flank position using the da Vinci Xi system. Four robotic trocars were placed in a configuration typical for robot-assisted renal resection, with a slight medial shift –⁠ with one 13 mm assistant trocar. The posterior peritoneum was opened lateral to the colon, and it was mobilized medially. Dissection of the hilum followed, identifying one renal vein containing a visible tumor thrombus and two renal arteries. The IVC was mobilized from the retroperitoneum and secured with tourniquets both caudally and cranially to the right renal vein junction. The left renal vein was secured in the same manner. The right hilar vessels were dissected, the renal vein with the thrombus was fully mobilized, and both renal arteries were clipped and transected. The upper pole of the kidney and the adrenal gland were then mobilized from the IVC and the liver. The ureter was clipped and transected, and the kidney was mobilized from retroperitoneum –⁠ including Gerota’s fascia –⁠ while remaining attached laterally to the parietal peritoneum. The vascular surgeon then continued the procedure, performing intraoperative ultrasonography of the IVC to identify the extent of the tumor thrombus, which reached higher than indicated on the preoperative CT scan –⁠ approximately 1 cm below the diaphragm but caudal to the the hepatic veins. It was probably due to progression of the local findings. With traction, the thrombus was successfully mobilized caudally. Using atraumatic laparoscopic endovascular (“bulldog”) clamps, the IVC was occluded above the thrombus, distal to the right renal vein junction and the left renal vein was clamped. A venotomy was performed on the right renal vein anteriorly at its junction with the IVC, extending the incision cranially. Under visual control, the tumor thrombus was mobilized and extracted through the venotomy. The posterior wall of the right renal vein was dissected. After irrigation of the lumen, the longitudinal IVC incision (approximately 5 cm in length) was closed in two layers using continuous Gore-Tex CV-5 sutures. The sutures were knotted and secured with clips. Hemostasis was verified, and the IVC was found to be patent without narrowing. Urologist completed the mobilization of the kidney from the retroperitoneum. The specimen was placed in an extraction bag and removed via incision in the right hypogastrium. After inspection of the operative field and abdominal wall, two Easy-Flow drains were placed in the retroperitoneum. The procedure was performed without the use of heparin.

Results: Blood loss was to 350 mL. Operative time was 3 hours and 30 minutes. Robotic instruments used: scissors, needle driver, Maryland dissector, large and medium clip appliers –⁠ all 8 mm. Sealing instruments were not used. The postoperative course was uncomplicated. The hospital stay was 7 days, including 4 days in the intensive care unit. Histopathological examination revealed Grade 3 papillary RCC, with an unexpected finding of a metastasis in the ipsilateral adrenal gland. There is currently no established standard adjuvant systemic therapy for completely resected papillary RCC based on the results of randomized trials.

Conclusions: Aggressive surgical treatment of RCC with a tumor thrombus in the IVC improves the likelihood of 5-year survival. Robot-assisted nephrectomy with IVC thrombectomy is safe in selected patients and offers the general benefits of minimally invasive surgery. Multidisciplinary collaboration reduces the risk of perioperative mortality. We consider the limitations of robot-assisted nephrectomy with IVC tumor thrombus extraction to include the overall size of the specimen-requiring sufficient space for the trocar placement and the extent of tumor thrombosis within the limits of Level II. The procedure may be indicated in selected cases.

Keywords:

renal cancer – tumor trombus – nefrectomy – robotic surgery – robotic surgery – Renal cancer – tumor trombus – nefrectomy