Robot assisted radical nephrectomy and inferior vena cava thrombectomy: surgical technique, perioperative and oncologic outcomes
Radical nephrectomy with Inferior vena cava (IVC) thrombectomy for renal cancer is one of the most challenging urologic surgical procedures. We describe surgical technique and present perioperative and oncologic outcomes of 35 consecutive cases of completely intracorporeal robot-assisted radical nephrectomy with IVC level I (5.7%) II (65.7%) and III (28.6%) tumor thrombectomy treated at two tertiary referral centers.
Materials and Methods
Thirty-five consecutive patients with renal tumor and IVC thrombus were treated between July 2011 and September 2016. Baseline, perioperative and follow-up data were collected into prospectively maintained IRB approved databases. Key steps of surgery include: a meticulous isolation of IVC; the isolation and sealing of all lumbar and collateral vessels, a full monolateral retroperitoneal dissection for staging purpose and to have a complete control of IVC; isolation of left renal vein, Tourniquet placement and infrarenal IVC control. IVC incision and thrombectomy; cava suture with 3/0 visi-black monocryl or 5/0 goretex; restoration of IVC flow; nephrectomy. We report perioperative and oncologic outcomes of 35 consecutive patients treated in two tertiary referral centers.
All procedures were successfully completed; open conversion was necessary in one case (2.8%). Median operative time was 300 minutes. Twenty-one patients (68.6%) did not experience any complication. 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 subphrenic ascess requiring drainage, respectively); one patient (2.8%) experienced a PRESS syndrome requiring ICU admission (Clavien 4a).
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%.
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.
Robotic IVC thrombectomy is a challenging surgical procedure. In tertiary referral centers this procedure is feasible, safe and associated with favorable perioperative outcomes and encouraging short term oncologic outcomes.
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