V9-11: Robot-assisted Partial Nephrectomy for Renal Cell Carcinoma and Management of Venous Tumor Thrombus
VideoIntroductions and Objectives
Today, most renal tumors can be managed with a minimally invasive approach. Robotic surgery has increased the utilization of partial nephrectomy. With increasing experience larger more complex tumors are being treated with robot-assisted partial nephrectomy (RAPN). The feasibility of RAPN for RCC involving main and/or segmental renal vein(s) has been described. All of the cases reported were identified on pre-operative imaging. However, venous tumor thrombi (VTT) can be discovered incidentally during surgery. We describe our experience with 4 patients undergoing RAPN in the setting of VTT.
We identified 4 patients at our institution with RCC who had undergone RAPN and were found to have a VTT. Patient characteristics and outcomes were reviewed, including RENAL nephrometry score, tumor complexity, conversion rate, length of stay (LOS), and complications.
Mean age was 65 years (range, 62-71); BMI was 33 Kg/m2 (range, 28-38). Mean tumor nephrometry score was 9.5 (range, 8-11) with a mean pathologic tumor size of 5.0 cm (range, 3-8). Mean warm ischemia time was 34 minutes (range 32-36) and mean estimated blood loss was 800mL (range 600-1000mL). In all but one patient, VTT had been discovered incidentally in a segmental renal vein at the time of surgery. Three patients underwent RAPN with removal of VTT and one patient with a completely endophytic tumor was converted to radical nephrectomy to ensure a safe oncologic outcome. There were no intraoperative complications. Mean LOS was 2.3 days. There were no readmissions. All patients had negative surgical margins with clear cell RCC pT3a. Clavien II complications occurred in two patients who required a blood transfusion.
VTT may be discovered incidentally during RAPN. Surgeons performing partial nephrectomies need to be aware of the potential to encounter a VTT and should have a plan to manage it. Many VTT can be successfully removed during RAPN but it is imperative to keep oncologic principles in mind and conversion to radical nephrectomy may be prudent in certain cases.