V5-06: The First Report of Robotic Assisted Radical Nephrectomy with Retrohepatic Vena Caval Tumor Thrombectomy and Extended Retroperitoneal Lymph Node Dissection

Video

Introductions and Objectives
Robotic assisted kidney surgery has become a common treatment modality for renal cell carcinoma. However, there is less than handful of reports describing the experience of performing a robotic assisted radical nephrectomy with inferior vena caval (IVC) tumor thrombectomy. In this video, we present the first report of a robotic assisted radical nephrectomy with retrohepatic vena caval tumor thrombectomy (11cm) and extended retroperitoneal lymph node dissection for renal cell carcinoma.

Methods
A 52 year old female with large renal mass, 11cm IVC thrombus, and negative metastatic workup presented to our clinic and was consented to undergo robotic assisted radical nephrectomy. After the DaVinci robot was docked, mobilization of the colon and duodenum, followed by mobilization of the liver with division of several short hepatic veins was performed. Intraoperative US confirmed the presence of the retrohepatic tumor thrombus. After the division of the renal artery the control of the inferior vena cava above and below the tumor thrombus and contralateral renal vein was achieved with the removal of the level III IVC thrombus extending to the retrohepatic portion of the vena cava. Additionally, an extended retroperitoneal lymph node dissection for renal cell carcinoma was performed with robotic assistance.

Results
Total operative time was 6 hours and 6 minutes. Estimated blood loss was 1200cc. The final pathology demonstrated 8.5 cm, Fuhrman grade 3, ccRCC with sarcomatoid features and negative surgical margins. All 44 lymph nodes removed (hilar, paracaval, precaval, preaortic and interaortocaval) were negative for metastatic RCC. Final staging was pT3b, N0, M0. Patient was discharged to home 36 hours postoperatively and had experienced no perioperative or postoperative complications.

Conclusions
Robotic assisted radical nephrectomy with retrohepatic vena caval tumor thrombectomy and extended retroperitoneal lymph node dissection is technically feasible and has potential benefits. Given the magnitude of the surgery, the postoperative pain and ileus can be greatly reduced allowing for discharge to home 36 hours after surgery. The robotic assistance may allow for improved intracorporal repair of the IVC, shortened recovery time, while maintaining oncological principles.

Funding: None