V08-03: Techniques for dealing with hemorrhage during robotic assisted renal tumor thrombectomy for IVC renal tumor thrombus
Open radical nephrectomy with inferior vena cava (IVC) thrombectomy has been considered to be the preferred treatment for renal cell carcinoma with IVC thrombus, due to clinician concern over management of hemorrhage. In this video, we highlight surgical tips and tricks for robotic caval renal tumor thrombectomy to manage bleeding safely.
57 year old woman, with a right sided 7x7.5x6.5 cm renal mass,with evidence of renal vein and IVC thrombus extending 2cm cranially, underwent right robotic assisted radical nephrectomy. In the video the following surgical techniques were highlighted to prevent bleeding during the IVC thrombectomy: early ligation of renal artery, use of doppler for visualisation of thrombus extent, ICG guidance for kidney perfusion, division of short hepatics for greater cranial IVC exposure and utilisation of slings.
The techniques for management of unforeseen intraoperative bleeding during cavotomy included the following: test venotomy of the gonadal vein stump with re-clipping as needed for bleeding, further retrocaval dissection and division of lumbar veins and renal artery to allow greater mobilization of the IVC to help identify a previously missed gonadal vein, use of bulldog clamps in addition to slings, lateral kidney mobilisation and division of ureter/gonadal vessel tissue to ensure no accessory inflow. Bleeding was abated and the procedure was completed without complication. Blood loss was 300cc. The patient suffered with a Clavien 2 complication (antibiotics for community acquired lower respiratory tract infection) delaying discharge to day 6. Histology revealed clear cell RCC, 7cm, grade3, pT3bN0.
Management strategies for intraoperative bleeding complications, during cavotomy and thrombus excision, allow for safe utilisation of robotic techniques in renal tumour thrombus surgery.