V10-05: Level 2 vena cava Renal Cell Carcinoma thrombus management with robotic assistance
Robotic assistance enables the treatment of Renal Cell Carcinoma with vena cava involvement in a minimally invasive fashion. The objective of this video is to show the feasibility and present the technical steps of such a procedure for a retro-hepatic level 2 thrombus.
The surgery was performed with the Da-Vinci surgical robot, by using 3 operatives arms, a 30-degree endoscope and two ports for the assistant. Intraoperative ultrasound was used to determine the exact limits of the thrombus. Clinical data, collected after consent, were extracted from the french national database on kidney cancer UroCCR.
A 10 cm right renal tumor was diagnosed after full work-up of gross hematuria in a 73 years-old patient. The tumor was associated with a lymph node (hilar, retrocaval, para-aortic) and venous invasion (9cm level 2 IVC thrombus). A 15mm single pulmonary lesion was suspicious for metastasis. Clinical stage was cT3bN2M1. The first step consisted in the exposure of the vena cava and the inter-aorto-caval dissection performing the node dissection in the same time. The left renal vein was encircled with a Rummel tourniquet and the two right renal arteries were clipped. An intra-operative ultrasound was performed to identify the limits of the thrombus revealing its proximal extension in the infra-renal part of the vena cava up to the iliac division. The sequential clamping of the vena cava was initiated from low to top before a 20cm long opening of the IVC. The lower and cruoric part of the thrombus was removed and placed in an endobag whereas the tumor part was removed in monobloc with the specimen. A resection of the vena cava was performed for wall invasion suspicion and 4 Prolene 4.0 running sutures were used to close the cavotomy. Blood Loss was 100cc. The pathology reported a pT3bN2R0 type 2 papillary renal cell carcinoma, with capsular rupture. Follow-up showed a metastatic progression treated by anti-EGFR therapy.
The minimally invasive treatment of right renal cell carcinoma retro-hepatic level 2 thrombus appears to be feasible. The expected benefits are a blood loss reduction and faster post-operative recovery.