V3-03: Robotic Left-sided Level II Caval Thrombectomy and Nephrectomy: Primary Description of Novel Supine, Single-dock Approach.
Initial descriptions of robotic management of renal cell carcinoma with Inferior Vena Cava (IVC) thrombus employ a lateral approach predicated on early IVC exposure and control. However, for left-sided renal masses and associated tumor thrombi, this approach requires re-positioning and re-docking steps, as well as pre-operative left renal artery embolization. Herein, we describe a novel supine, single dock technique for robotic left nephrectomy and caval thrombectomy.
We perform robotic nephrectomy and caval thrombectomy on a 79 y.o. male with a 6cm left renal mass and level II IVC thrombus. The patient is placed supine, in steep trendelenburg. We employ a 6-port trans-peritoneal technique and dock the robot such that arms are directed cephalad. Key steps critical to the procedure include: 1) Exposure of the retroperitoneum 2) IVC exposure and control 3) Left Renal Hilar Control 4) Cavotomy, thrombectomy, and reconstruction 5) Nephrectomy and lymph node dissection (LND). Peri-operative outcomes are reported and compared to previously published case series.
Robotic left nephrectomy and level II caval thrombectomy was performed successfully via a single-dock, supine approach. This method yielded excellent and early access to the IVC and left renal hilum, and allowed for concomitant nephrectomy/LND without re-positioning. Total operative time was 420 minutes with 330 minutes robotic console time (174 minutes for exposure, 27 minutes IVC clamp time, 84 minutes for nephrectomy/LND). EBL was 500cc without need for peri-operative transfusions and no intraoperative complications. Length of stay was 5 days and no major perioperative complications were noted. Outcomes compare favorably to previously reported robotic caval thrombectomy procedures employing the lateral approach.
We demonstrate successful robotic left nephrectomy with Level II caval thrombectomy using a supine, single-dock approach. To our knowledge, this is the first description of this approach for robotic caval thrombectomy. In appropriately selected patients, this versatile approach allows for rapid caval control, bilateral renal hilar access, and obviates the need for patient re-positioning.