V10-08: Robotic Assisted Caval Replacement for Recurrent Renal Cell Carcinoma
To describe a case of robotic caval replacement using synthetic graft material for a patient with recurrent renal cell carcinoma (RCC) and extensive inferior vena cava (IVC) invasion.
A 46 year old male with history of prior open right partial nephrectomy for Grade III clear cell renal cell carcinoma presented to clinic for 5 year follow-up. Imaging revealed a recurrent mass in the right renal hilum measuring 7cm that was indistinguishable from the IVC. The patient consented to undergo right radical nephrectomy with possible IVC thrombectomy or caval reconstruction. During the procedure the extent of caval invasion by the tumor was determined to be quite significant, and it was felt the cava could not be spared. The mass and a segment of cava were resected requiring synthetic gortex vascular graft placement using robotic assistance.
The total operative time was 6 hours and 40 minutes. Estimated blood loss was 900 cc. Several teaching points are demonstrated in the video that include the importance of intraoperative ultrasound, caval control, caval excision, anastomotic technique, excision of the redundant graft and reanastomosis. The final pathology demonstrated a 7x5x5 cm, WHO/ISUP Grade 3, clear cell RCC with extensive IVC tumor involvement, and negative margins. All 13 lymph nodes removed (intra aortal caval, retro caval) were negative. Final staging was pT3c N0 M0. The patient was discharged home less than 48 hours postoperatively and experienced no perioperative or postoperative complications. At 6 months follow-up, the patient was free of disease with radiology read documenting “vascular structures within normal limits”.
Robotic caval resection with vascular graft reconstruction is technically feasible and able to be performed by a urologic surgeon skilled in robotics. This approach avoids the morbidity of an open procedure for reconstruction and grafting, allowing for quicker post-operative recovery while maintaining oncologic principals.