Robotic Level III Inferior Vena Cava Tumor Thrombectomy: Initial Series

Abstract

Purpose: Level III inferior vena cava tumor thrombectomy for renal cancer is one of the most challenging open urologic oncology surgeries. We present the initial series of completely intracorporeal robotic level III inferior vena cava tumor thrombectomy.

Materials and methods: Nine patients underwent robotic level III inferior vena cava thrombectomy and 7 patients underwent level II thrombectomy. The entire operation (high intrahepatic inferior vena cava control, caval exclusion, tumor thrombectomy, inferior vena cava repair, radical nephrectomy, retroperitoneal lymphadenectomy) was performed exclusively robotically. To minimize the chances of intraoperative inferior vena cava thrombus embolization, an "inferior vena cava-first, kidney-last" robotic technique was developed. Data were accrued prospectively.

Results: All 16 robotic procedures were successful, without open conversion or mortality. For level III cases (9), median primary kidney (right 6, left 3) cancer size was 8.5 cm (range 5.3 to 10.8) and inferior vena cava thrombus length was 5.7 cm (range 4 to 7). Median operative time was 4.9 hours (range 4.5 to 6.3), estimated blood loss was 375 cc (range 200 to 7,000) and hospital stay was 4.5 days. All surgical margins were negative. There were no intraoperative complications and 1 postoperative complication (Clavien 3b). At a median 7 months of followup (range 1 to 18) all patients are alive. Compared to level II thrombi the level III cohort trended toward greater inferior vena cava thrombus length (3.3 vs 5.7 cm), operative time (4.5 vs 4.9 hours) and blood loss (290 vs 375 cc).

Conclusions: With appropriate patient selection, surgical planning and robotic experience, completely intracorporeal robotic level III inferior vena cava thrombectomy is feasible and can be performed efficiently. Larger experience, longer followup and comparison with open surgery are needed to confirm these initial outcomes.

Keywords: inferior; robotics; thrombectomy; vena cava.

Figure 1.

Inferior vena cava control for which individualized surgical planning is necessary. Note various locations of Rummel tourniquet placement for achieving proximal control of IVC as dictated by thrombus level.

Figure 2.

Right side level III caval tumor thrombus (7 cm in length, yellow arrows). Before referral to our center transjugular IVC filter had been inserted straight through tumor thrombus, apparently in attempt to secure distal bland thrombus (blue). Obliquely malpositioned IVC filter (white arrow) at level of left renal vein ostium was also removed during robotic IVC thrombectomy.

Figure 3.

Ligating SH veins. A, level III thrombectomy requires control of intrahepatic IVC and for this SH veins need to be transected. SH veins are short, wide, thin walled and 1 to 5 in number. B, anterior retraction of caudate lobe places SH veins on stretch. Each SH is individually controlled, thereby exposing intrahepatic IVC. C, after right adrenalectomy, mobilization and Rummel control of high intrahepatic IVC are achieved.

Figure 4.

Level III tumor thrombectomy. Rescue stitch is preplaced on IVC for safety in case emergent control is needed. Rummel tourniquets are secured from distal to proximal. A, cephalad tip of tumor thrombus (TT) being freed. Note: intrahepatic TT extends to within 1 cm of proximal IVC Rummel. B, IVC reconstruction using 4-zero Prolene or 5-zero Gore-Tex suture.

Figure 5.

Left side IVC tumor thrombus. CT showing 4.1 cm level III thrombus emanating from large left renal tumor (TU) via retroaortic left renal vein (LRV).

Figure 6.

Robotic IVC transection. Completely occlusive left side level III thrombus. A, patients with completely obstructive thrombi have nonfunctional, no-flow IVC. Since robust collaterals have long been recruited, complete robotic transection of IVC was performed with Endo GIA vascular stapler to prevent embolism of any distal bland thrombus after first cinching intrahepatic IVC and right renal vein tourniquets. B, left renal vein (LRV) transected with vascular stapler. Arrow denotes staple line of transected IVC.

Figure 7.

Control of suprahepatic IVC and porta hepatis. A, port placement for transthoracic control of IVC. After selective endotracheal intubation 4 transthoracic ports are placed into right hemithorax. To optimize operative exposure low pressure CO₂ is insufflated. B, completely thoracoscopic control of intrapericardial IVC. Pericardium is incised anterior to phrenic nerve. Diaphragm is retracted caudally with fan retractor to enable blunt retrocaval dissection. Umbilical tape is positioned around the intrapericardial IVC. C, Pringle maneuver. Using transabdominal ports, retroperitoneum is incised medial to IVC and lateral to hepatoduodenal ligament. Window is created posterior to porta hepatis into lesser omental sac and Rummel tourniquet is positioned. Note: patient had large, infiltrating, completely occluding, high intrahepatic tumor thrombus in nonfunctional IVC. Using techniques depicted in parts A to C, vascular control was exclusively achieved minimally invasively. Subsequently, inferior venacavectomy, juxtahepatic suture closure of IVC and radical nephrectomy were completed with open conversion.