V9-01: Robotic-assisted level III IVC tumor thrombectomy: duplicating the open approach
To describe our surgical technique for robotic radical nephrectomy and thrombectomy for renal cell carcinoma (RCC) and associated level III inferior vena cava (IVC) thrombus.
Robotic IVC tumor thrombectomy is a novel technique that has only recently been described. In our video we present the case of a 75 year-old Caucasian man with a 10 cm right renal neoplasm and associated level III tumor thrombus. After preoperative imaging was reviewed, a robotic approach was planned. Real-time intraoperative transesophageal ultrasonography was performed to assess cranial extent of tumor thrombus. The major steps of our robotic technique include early inter-aortocaval control of the right renal artery, circumferential mobilization of the IVC, contralateral renal vein control, cavotomy, thrombectomy and IVC reconstruction.
Operative time was 5 hours and 53 minutes (353 minutes) with 150 mL estimated blood loss (EBL). The patient was allowed to have a clear liquid diet immediately after surgery and was discharged home on post-operative day (POD) 3. Final pathology demonstrated a 9.8 cm clear cell renal cell carcinoma (RCC), nuclear grade 3 with a pT3bN1 stage. Technique considerations to facilitate robotic level III IVC thromectomy include initial preservation of lateral renal attachments, use of intraoperative transesophageal ultrasound to delineate cranial extension of the thrombus, and use of the third robotic arm and two 12 mm assistant ports.
With adequate team experience and preparation, robotic radical nephrectomy and IVC thrombectomy for level III tumor thrombus is challenging but feasible. This video demonstrates our robotic technique which duplicates the open approach. While open radical nephrectomy and tumor thrombectomy is the gold standard, this minimally invasive approach may offer lower EBL, improved pain control and expedited recovery in select patients.