V5-01: Totally Laparoscopic Radical Nephrectomy with Thrombectomy Level IV
VideoIntroductions and Objectives
Since the first laparoscopic nephrectomy performed by Clayman, in 1991, urological surgery has changed the paradigm for minimally invasive surgery. Every day, more diseases are being treated laparoscopically. Now, we describe a radical nephrectomy with thrombectomy level IV, performed totally laparoscopic, with deep hypothermia and circulatory arrest. To our knowledge, this clinical approach was not reported before.
A 38-year-old man presented with left lumbar pain, hematuria and palpable mass. Magnetic resonance imaging showed a 14 x11cm left renal mass with and thrombus extending to supra-diaphragmatic inferior vena cava. The patient accepted a minimally invasive surgical approach. A left laparoscopic radical nephrectomy was performed with the patient in right lateral decubitus, using 4 trocars. Renal artery was clipped and divided. The kidney was completely dissected but remained attached to the thrombotic vein. The patient was repositioned in left lateral decubitus. Vena cava and right renal vessels were dissected and repaired using 5 trocars. Then, repositioned the patient to modified dorsal decubitus. The cardiovascular surgery team initiated a minimally invasive Cardiopulmonary Bypass (CPB) with deep hypothermic and circulatory arrest. Immediately, vena cava was clamped with laparoscopic Satinski clamps. Cavotomy was made and thrombectomy performed. Then, vena cava was closed. Atriotomy was closed. The patient was rewarmed to 37oC and coming off CPB. Thoracic and abdominal cavities were drained. The specimen was removed through a Pfannenstiel incision.
Operative time was 765 minutes. Estimated blood loss was 1500 ml and he received blood transfusion (1200ml) intraoperatively. Circulatory arrest time was 43 minutes, but only 8 without cerebral circulation. Postoperatively showed no neurological complication. The patient developed pneumonia and sepsis related to mechanical ventilation. Remained 21 days in the ICU and was discharged in postoperative day 36. Histology revealed chromophobe renal tumor with free margins.
Laparoscopy has been progressively gaining acceptance in the urologic field, almost all the open surgery has been reproduced by laparoscopy, except radical nephrectomy with thrombectomy level IV. With this report, the last frontier in urologic laparoscopy was overcome. This case has shown that laparoscopic approach in the treatment of renal cell carcinoma with level IV vena cava thrombus is feasible and challenging and requires advanced laparoscopic skills.