V10-03: Indocyanine green guided Robot assisted Radical Nephrectomy and level III Inferior Vena cava tumor thrombectomy
Robot-assisted Radical nephrectomy (RN) with Inferior vena cava (IVC) thrombectomy for renal cancer is one of the most challenging urologic surgical procedures. A crucial step is the control of the cranial edge of the thrombus. In this video we highlighted surgical steps of a right RN and level III IVC thrombectomy using Indocyanine green (ICG) guidance for the management of the upper boundary of IVC tumour thrombus.
Preoperative embolization of renal artery is usually was performed. Key surgical steps are: liver mobilization, with an extensive incision of triangular ligament to expose the retrohepatic IVC; meticulous IVC isolation, cranially and distally to the neoplastic thrombus, for tourniquets placement; ligation and dissection of all lumbar and right gonadal veins, left renal vein isolation for tourniquet encircling. After right renal arteries transection, the previously applied tourniquets were synched down after confirming, with near infrared fluorescence imaging (NIFI), 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 with 3-0 monocryl running suture. After tourniquets removal, NIFI was used to inspect IVC lumen and to confirm proper restoration of IVC flow. Finally, nephrectomy was completed. Patients with renal tumour and level III IVC thrombus treated between October 2017 and August 2018 were included. Baseline, preoperative, perioperative and pathologic characteristics were reported in Table 1.
Overall, NIFI guidance was used in 4 patients with right side level III IVC thrombi. Mean follow-up was 8 months. Mean operative time was 282.5 minutes, with a mean IVC clamp time of 35 minutes. One patient required blood transfusion. Clavien grade 2 complication occurred in one patient; one patient experienced atrial fibrillation in post-operative day 3, which required intensive care unit management (Clavien grade 4a).
NIFI represents a significant technical advancement in the management of level III tumour thrombi, to improve control of the cranial thrombus edge and to confirm proper restoration of IVC flow after Cava suture.