V07-07: Robot-Assisted Left Radical Nephrectomy with lateral clamping of the vena cava and lymph node dissection
Show the feasibility of a robot-assisted left radical nephrectomy, with a caval thrombectomy. This approach is seldom used in these risky cases, for security reasons when the patient, often fragile at this stage of the disease, could benefit significantly from this minimally invasive approach compared to the open route. With the necessary precautions, the minimally invasive approach gains meaning.
The key steps of the procedure, done with the Da Vinci surgical robot, with 3 operative arms, a 30-degree endoscope and two ports for the assistant are shown. A preoperative surgical planning with an MRI the day before surgery to check the extension of the thrombus into the vena cava is a compulsory prerequisite. Clinical data from this case were extracted from the French national database on kidney cancer UroCCR and were collected after patient consent.
The 79-year-old patient, presenting with general symptoms and hematuria, was diagnosed with a left renal 11cm-tumor. The tumor infiltrated the kidney entirely, with local lymph node involvement and a thrombus extension into the renal vein, reaching the vena cava. The first step was accessing, through the mesentery, the mid-line retroperitoneal space to allow the dissection of the vena cava, the aorta, to undertake the lymph node dissection and to clip the renal artery. The rest of the nephrectomy was done after the left colon was lowered. The extent of the thrombus into the renal vein allowed a lateral clamping of the vena cava with a laparoscopic clamp inserted through the abdominal wall. The vena cava was sutured under lateral clamping. The pathology report showed a poorly differentiated collecting duct carcinoma, pT3bN1 with capsular rupture. The patient was discharged on post-operative-day-4, without any complication, any transfusion. Follow-up showed a metastatic progression treated by antiangiogenic therapy.
A minimally-invasive robot-assisted approach, for this surgery, is feasible and should be considered when possible because such a patient could benefit from it. Crossing the mid-line was possible with this laparoscopic route because the patient was 75 degrees on his right flank.