V8-03: Robot assisted radical nephrectomy and inferior vena cava thrombectomy: surgical technique, perioperative and oncologic outcomes
In this video we highlight surgical steps of a right radical nephrectomy and level IIIb inferior vena cava (IVC) thrombectomy using an occluding balloon Fogarty catheter to control the upper boundary of IVC thrombus under transesophageal ultrasound guidance. Perioperative and oncologic outcomes of our first 35 patients treated with robotic radical nephrectomy and inferior vena cava thrombectomy in two tertiary referral centers were reported.
Key surgical steps are higlighted in the video. _x000D_ Preoperative arterial embolization was performed. A right template retroperitoneal lymph node dissection was performed and all lumbar veins were secured to achieve a complete IVC control; the left renal vein and the distal IVC segment were prepared and encircled with Roummel Tourniquet. Short hepatic veins were secured with Ligasure and the posterior aspect of the IVC was prepared. Proximal IVC was encircled and right renal vein was stapled._x000D_ The distal IVC and left renal vein Tourniquets were cinched down and a small cavotomy was performed to insert a Fogarty catheter with an occluding balloon tip. To ensure the correct placement of the catheter tip at the cranial edge of the thrombus we used transesophageal ultrasound. Once the balloon was inflated and distally attracted, cavotomy was performed and the thrombus progressively mobilized and secured into an endocatch bag. IVC lumen was inspected to ensure absence of any residual thrombus fragment and the balloon was deflated to restore IVC flow throw the major hepatic veins. The cava was sutured with a 3/0 Visi black monocryl suture. _x000D_ Thirty-five consecutive patients with renal tumor and IVC thrombus were treated between July 2011 and September 2016 in two tertiary referral centers; perioperative and oncologic data were reported._x000D_
Fogarty catheter was successfully used in 7 (20%) cases. Open conversion was necessary in one case (2.8%). Median operative time was 300 minutes. Ten patients (28.6%) required blood transfusion (Clavien grade 2); one patient (2.8%) had a Clavien grade 3a complication (gastroscopy); two patients (5.7%) had Clavien grade 3b complications (reintervention due to bleeding from adrenal gland and subphrenicascess requiring drainage, respectively); one patient (2.8%) experienced a PRESS syndrome requiring ICU admission (Clavien 4a). _x000D_ Out of 13 patients who underwent cytoreductive nephrectomy and IVC thrombectomy, only one patient died of disease progression 14 months postoperatively. Both 2-yr cancer specific and overall survival rates in this subpopulation were 88.9%._x000D_ Twenty-two patients received surgery with curative intent and 5 of these experienced disease recurrence: 2-yr metastasis free, cancer specific and overall survival rates were 56%, 100% and 94.4%, respectively._x000D_
The increasing experience with robotic surgery has made nephrectomy and IVC thrombectomy a feasible and safe treatment option in tertiary referral centers, associated with favourable perioperative outcomes and encouraging short term oncologic outcomes.