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Cheng G, Zhang X. Experiences of robot assisted thrombectomy with 2-year follow-up. Int J Med Robot 2023:e2611. [PMID: 38131413 DOI: 10.1002/rcs.2611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 11/12/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND No consensus has been reached on operative procedures since a limited case series of robot-assisted inferior vena cava thrombectomy (RA-IVCT) and robot-assisted radical nephrectomy (RA-RN) have been described. METHODS The clinical data of 21 patients who underwent RA-IVCT and RA-RN were retrieved from the database. Preoperative preparation was used for assessment of the tumour. Surgical procedures were recorded, and operative skills were summarised. RESULTS The median IVC clamping time was 23 min, and IVC wall invasion was pathologically found in 2 cases. The mean postoperative hospital stay was 8.4 days and most patients recovered to full ambulation and oral feeding on the fourth day. None of the patients had liver or kidney dysfunction at the last follow-up (median, 24 months). CONCLUSION RA-IVCT presents technical challenges to surgeons. IVC control is an important part of the surgical process and different sides require different techniques.
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Affiliation(s)
- Gong Cheng
- Department of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Institute of Urologic Surgery, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoping Zhang
- Department of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Institute of Urologic Surgery, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Chen J, Liu Z, Zhang H, Wang G, Tian X, Zhao X, Ge L, Tian Y, Zhang Q, Hong P, Li Y, Chen K, Gao Q, Liu X, Liu C, Ma L, Zhang S. Pure Retroperitoneal Laparoscopic Peritoneum Incision Technique in Right Nephrectomy and Inferior Vena Cava Tumor Thrombectomy: A Novel Surgical Technique and Long-Term Outcomes from a Large Chinese Center. J Endourol 2023; 37:986-994. [PMID: 37254522 DOI: 10.1089/end.2023.0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023] Open
Abstract
Purpose: To explore the safety and effectiveness of the Pure Retroperitoneal Laparoscopic Peritoneum Incision Technique (PREP-IT) in laparoscopic radical nephrectomy (LRN) and inferior vena cave (IVC) tumor thrombectomy for right renal-cell carcinoma (RCC) with level Mayo I to III venous tumor thrombus (VTT). Patients and Methods: From May 2015 to September 2020, 92 patients with right RCC and Mayo I to III VTT were retrospectively reviewed, including 57 patients who underwent retroperitoneal LRN and IVC thrombectomy using PREP-IT, and 35 patients who underwent open surgery. PREP-IT refers to dissecting the retroperitoneum and temporarily placing the right kidney into the abdominal cavity to enlarge the retroperitoneal workspace for a safer and faster IVC operation. Results: Compared with the open surgery group, the PREP-IT group had a larger tumor diameter, while a larger proportion of Mayo I tumor thrombus and smaller maximum tumor thrombus width. Two patients (3.5%) in the PREP-IT group had a history of abdominal surgery. No conversion to open surgery or standard laparoscopic surgery occurred in PREP-IT group. Laparoscopic surgery with PREP-IT was characterized by shorter operative time, less surgical blood loss, shorter postoperative hospital stay, and lower postoperative complication rate. With a 33-month (ranges: 2-86) follow-up time period, the estimated mean overall survival time was 57.2 ± 5.3 and 58.1 ± 71.5 months in the PREP-IT group and open surgery group, respectively. Log-rank test indicated no significant difference between the two groups in terms of overall survival and cancer-specific survival. Conclusions: The PREP-IT is relatively safe and feasible for retroperitoneal LRN with right renal tumor and IVC tumor thrombus, allowing for a large workspace and wide exposure for IVC operations.
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Affiliation(s)
- Jiyuan Chen
- Department of Urology, Peking University Third Hospital, Haidian, Beijing, China
| | - Zhuo Liu
- Department of Urology, Peking University Third Hospital, Haidian, Beijing, China
| | - Hongxian Zhang
- Department of Urology, Peking University Third Hospital, Haidian, Beijing, China
| | - Guoliang Wang
- Department of Urology, Peking University Third Hospital, Haidian, Beijing, China
| | - Xiaojun Tian
- Department of Urology, Peking University Third Hospital, Haidian, Beijing, China
| | - Xun Zhao
- Department of Urology, Peking University Third Hospital, Haidian, Beijing, China
| | - Liyuan Ge
- Department of Urology, Peking University Third Hospital, Haidian, Beijing, China
| | - Yu Tian
- Department of Urology, Peking University Third Hospital, Haidian, Beijing, China
| | - Qiming Zhang
- Department of Urology, Peking University Third Hospital, Haidian, Beijing, China
| | - Peng Hong
- Department of Urology, Peking University Third Hospital, Haidian, Beijing, China
| | - Yuxuan Li
- Department of Urology, Peking University Third Hospital, Haidian, Beijing, China
| | - Kewei Chen
- Department of Urology, Peking University Third Hospital, Haidian, Beijing, China
| | - Qiyue Gao
- Department of Urology, Peking University Third Hospital, Haidian, Beijing, China
| | - Xinchen Liu
- Department of Urology, Peking University Third Hospital, Haidian, Beijing, China
| | - Cheng Liu
- Department of Urology, Peking University Third Hospital, Haidian, Beijing, China
| | - Lulin Ma
- Department of Urology, Peking University Third Hospital, Haidian, Beijing, China
| | - Shudong Zhang
- Department of Urology, Peking University Third Hospital, Haidian, Beijing, China
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Sidiropoulos T, Parasyris S, Ntella V, Margaris I, Christodoulou S, Theodoraki K, Vassiliu P, Smyrniotis V, Arkadopoulos N. En-Bloc Resection of Renal Cell Carcinoma With Tumor Thrombus Propagating Into the Intrapericardial Inferior Vena Cava: Efficacy and Safety of Transabdominal Approach. Cureus 2023; 15:e42394. [PMID: 37621783 PMCID: PMC10446507 DOI: 10.7759/cureus.42394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Renal cell carcinoma (RCC) is the most common primary kidney cancer. In up to 4-10% of patients, the tumor is complicated with a malignant thrombus extending to the inferior vena cava (IVC). Complete surgical excision of the RCC and the neoplastic thrombus can be curative. We aim to present a safe and feasible alternative transabdominal operative technique with the omission of thoracotomy, as applied in six patients diagnosed with RCC and IVC thrombus extending over the diaphragm. METHODS This case series study was conducted in a tertiary university hospital in Athens, Greece. All six patients, who were operated on for RCC and a malignant thrombus exceeding in the intrapericardial IVC in our department from January 2009 until March 2020, were screened. Intraoperatively, the infrarenal and intrapericardial IVC were clamped simultaneously with the renal and liver blood inflow. Access to the intrapericardial IVC was obtained via the central tendon of the diaphragm. Intrathoracic extension of the tumor was confirmed by transesophageal or intraoperative ultrasonography. The intrathoracic IVC was exposed to direct vision and two finger palpation was applied to secure the clamping of the IVC above the tip of the thrombus. The tumor was resected through a longitudinal venotomy and the operation was completed on a standard radical nephrectomy. RESULTS During the study period six patients presented with RCC and intrapericardial IVC thrombus. All patients, five female and one male, underwent radical nephrectomy combined with IVC thrombectomy, without the need for a thoracotomy. The mean age was 66 years old and the mean operative time was 122.5 minutes. Mean blood loss was 338 ml and only four of the patients were transfused with two units of RBC. Operative and hospital mortality was 0%. The hospital stay was seven (six to nine) days. Only one patient required readmission and reoperation 30 days later, due to intrapericardial herniation. CONCLUSIONS The proposed surgical technique may be curative in patients with advanced intracaval thrombus and helps reduce the associated morbidity, mortality, and the overall cost of more extended operations.
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Affiliation(s)
- Theodoros Sidiropoulos
- 4th Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Stavros Parasyris
- 4th Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Vassiliki Ntella
- 4th Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Ioannis Margaris
- 4th Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Spyridon Christodoulou
- 4th Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Kassiani Theodoraki
- 1st Department of Anesthesiology, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Panteleimon Vassiliu
- 4th Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Vassilios Smyrniotis
- 4th Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Nikolaos Arkadopoulos
- 4th Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
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Scherñuk J, García Marchiñena PA, Carminatti T, Romeo A, Jurado AM. Renal Cell Carcinoma with Venous Extension: Safety of Laparoscopic Surgery for Thrombus Levels I-IIIa. J Endourol 2023; 37:786-792. [PMID: 37212234 DOI: 10.1089/end.2022.0752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023] Open
Abstract
Background: Novel studies are helping to consider minimally invasive surgery for treating patients with renal cell carcinoma and venous tumor thrombus. Evidence regarding its feasibility and safety is still sparse and does not include a subclassification for level III thrombi. We aim to compare the safety of laparoscopic vs open surgery in patients with levels I-IIIa thrombus. Materials and Methods: This is a cross-sectional comparative study using single-institutional data on adult patients treated surgically between June 2008 and June 2022. Participants were categorized into open and laparoscopic surgery groups. Primary outcome was difference in the incidence of 30-day major postoperative complications (Clavien-Dindo III-V) between groups. Secondary outcomes were differences in operative time, length of hospital stay, intraoperative blood transfusions, delta hemoglobin level, 30-day minor complications (Clavien-Dindo I-II), estimated overall survival, and progression-free survival between groups. A logistic regression model was performed including adjustment for confounding variables. Results: Overall, 15 patients in the laparoscopic group and 25 patients in the open group were included. Major complications occurred in 24.0% of patients within the open group and 6.7% of patients were treated laparoscopically (p = 0.120). Minor complications arose in 32.0% of patients treated with open surgery and in 13.3% of patients treated in the laparoscopic group (p = 0.162). Although not significant, there was a higher perioperative death rate within open surgery cases. The laparoscopic approach presented a crude odds ratio for major complications of 0.22 (95% confidence interval 0.02-2.1, p = 0.191) compared with open surgery. No differences were found between groups regarding oncologic outcomes. Conclusion: Laparoscopic approach for patients with venous thrombus levels I-IIIa seems to be as safe as open surgery.
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Affiliation(s)
- Jordán Scherñuk
- Department of Urology, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | | | - Tomás Carminatti
- Department of Urology, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Agustín Romeo
- Department of Urology, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Alberto M Jurado
- Department of Urology, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
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Zhang Y, Bi H, Fu Y, Zhang H, Zhang S, Liu K, Liu L, Li N, Liu C, Tian X, Ma L. Cephalic inferior vena cava non-clamping technique versus standard procedure for robot-assisted laparoscopic level II-III thrombectomy: a prospective cohort study. Int J Surg 2023; 109:1594-1602. [PMID: 37131326 PMCID: PMC10389522 DOI: 10.1097/js9.0000000000000209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 01/03/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND Renal tumour can invade the venous system and ~4-10% patients with renal tumour had venous thrombus. Although the feasibility of robot-assisted laparoscopic inferior vena cava thrombectomy (RAL-IVCT) in patients with inferior vena cava (IVC) thrombus has been validated, the wide application is still a challenge due to the complexity of IVC control. The objective was to describe our novel cephalic IVC non-clamping technique and to compare the outcomes versus standard RAL-IVCT. MATERIALS AND METHODS A prospective single-centre cohort containing 30 patients with level II-III IVC thrombus was established since August 2020. Fifteen patients underwent cephalic IVC non-clamping approach and 15 patients received standard RAL-IVCT. The authors decided the surgical technique according to the echocardiographic assessment of the right heart and IVC. RESULTS The non-clamping group had less operative time (median 148 versus 185 min, P =0.04), and lower Clavien-grade II complication rate (26.7% versus 80.0%, P =0.003). The median intraoperative blood loss were 400 ml [interquartile range (IQR) 275-615 mL] and 800 ml (IQR 350-1300 ml), respectively ( P =0.05). The most common complication in standard RAL-IVCT group was liver dysfunction. No gas embolism, hypercapnia or tumour thrombus dislodgment occurred in non-clamping group. After a median follow-up of 17.0 months (IQR 13.5-18.5 months) and 15.5 months (IQR 13.0-17.0 months), two patients (16.7%) in the non-clamping group and 3 patients (20.0%) in the standard RAL-IVCT group died (hazard ratio 0.59, 95% CI 0.10-3.54, P =0.55). CONCLUSIONS The cephalic IVC non-clamping technique can be performed safely with acceptable surgical outcomes and short-term oncologic outcomes in patients with level II-III IVC thrombus. Compared with standard procedure, it had less operative time and lower complication rate.
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Affiliation(s)
| | | | - YunJie Fu
- School of Basic Medical Sciences, Peking University, Beijing, China
| | | | | | | | | | - Nan Li
- Research Center of Clinical Epidemiology, Peking University Third Hospital
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Poirier T, Karam G, Bouchot O, De Vergie S, Branchereau J, Perrouin-Verbe MA, Rigaud J. [Results of the management of kidney cancer with extension into the inferior vena cava: A retrospective, single-center, observational study]. Prog Urol 2023; 33:333-343. [PMID: 37076361 DOI: 10.1016/j.purol.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 02/26/2023] [Accepted: 03/27/2023] [Indexed: 04/21/2023]
Abstract
OBJECTIVES The aim of our study was to evaluate the morbidity and mortality, as well as the oncogical results of patients who had undergone surgical procedure for a kidney cancer with thrombus extension into the inferior vena cava. MATERIALS AND METHODS Between January 2004 and April 2020, 57 patients were operated by enlarged nephrectomy with thrombectomy for kidney cancer with thrombus extension in the inferior vena cava. Twelve patients (21%) with the use of cardiopulmonary bypass because the thrombus was upper than the sus-hepatic veins. Twenty-three patients (40.4%) were metastatic at diagnosis. RESULTS Perioperative mortality was 10.5%, without difference according to surgical technique. Morbidity during hospitalization was 58%, without difference according to surgical technique. Median follow-up was 40.8±40.1months. Overall survival at 2 and 5years was 60% and 28%, respectively. At 5years, the principal prognostic factor was the metastatic status at diagnosis, in multivariate analysis (OR: 0.15, P=0.03). Progression free survival mean was 28.2±40.2months. Progression free survival at 2 and 5years was 28% and 18%, respectively. All the patients who were metastatic at diagnosis had a recurrence in an average time of 5.7months (median of 3months). Thirteen percent of patients can be considered cured at the end of the study. CONCLUSION Morbidity and mortality of this surgery remain important. The metastatic status at diagnosis has appeared to be the principal prognostic factor on the survival of these patients. LEVEL OF EVIDENCE Level 4: retrospective study.
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Affiliation(s)
- Thomas Poirier
- Service d'urologie et de transplantations rénales, CHU de Nantes Hôtel-Dieu, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France.
| | - Georges Karam
- Service d'urologie et de transplantations rénales, CHU de Nantes Hôtel-Dieu, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France
| | - Olivier Bouchot
- Service d'urologie et de transplantations rénales, CHU de Nantes Hôtel-Dieu, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France
| | - Stéphane De Vergie
- Service d'urologie et de transplantations rénales, CHU de Nantes Hôtel-Dieu, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France
| | - Julien Branchereau
- Service d'urologie et de transplantations rénales, CHU de Nantes Hôtel-Dieu, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France
| | - Marie-Aimée Perrouin-Verbe
- Service d'urologie et de transplantations rénales, CHU de Nantes Hôtel-Dieu, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France
| | - Jérôme Rigaud
- Service d'urologie et de transplantations rénales, CHU de Nantes Hôtel-Dieu, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France
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Wlodarczyk J, Brabender D, Gupta A, Gaur K, Madiedo A, Lee SW, Hsieh C. Increased cost burden associated with robot-assisted rectopexy: do patient outcomes justify increased expenditure? Surg Endosc 2023; 37:2119-2126. [PMID: 36315284 DOI: 10.1007/s00464-022-09728-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 10/11/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Robot-assisted surgical techniques have flourished over the years, with refinement in instrumentation and optics allowing for adaptation and increasing utilization across surgical fields. Transabdominal rectopexy with mesh for rectal prolapse may stand to benefit significantly from the use of a robotic platform. However, increased operative times and immediate associated costs of robotic surgery may provide a counterargument to widespread adoption. METHODS To determine which approach to the treatment of rectal prolapse, laparoscopic or robotic, is more cost effective and provides better outcomes with fewer complications, a retrospective review was performed at a single tertiary care academic institution from May 2013 to December 2020. Twenty-two patients underwent transabdominal mesh rectopexy through a robot-assisted DaVinci platform (Intuitive Sunnyvale, CA), and thirty through a laparoscopic platform. Main outcome measures included operative, hospital, and total cost as defined by total charges billed. Secondary outcomes included rate of recurrence, intra-operative complications, median operative time, post-operative complications, average hospital length of stay, inpatient pain medication usage, and post-operative functional outcomes. RESULTS Cost analysis for robot-assisted versus laparoscopic rectopexy demonstrated operating room costs of $46,118 ± $9329 for the robotic group, versus $33,090 ± $15,395 (p = 0.002) for the laparoscopic group. Inpatient hospital costs were $60,723 ± $20,170 vs. $40,798 ± $14,325 (p = 0.001), and total costs were $106,841 ± $25,513 vs. $73,888 ± $28,129 (p ≤ 0.001). When secondary outcomes were compared for the robotic versus laparoscopic groups, there were no differences in any of the aforementioned outcome variables except for operative time, which was 79 min longer in the robotic group (p ≤ 0.001). CONCLUSIONS Robot-assisted mesh rectopexy demonstrated no clinical benefit over traditional laparoscopic mesh rectopexy, with significantly higher operative and hospital costs. A reduction in the acquisition and maintenance costs for robotic surgery is needed before large-scale adoption and implementation of the robotic platform for this procedure.
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Affiliation(s)
- Jordan Wlodarczyk
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Danielle Brabender
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Abhinav Gupta
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Kshjitij Gaur
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Andrea Madiedo
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Sang W Lee
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Christine Hsieh
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA.
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Zhang JH, Zeinab MA, Ferguson EL, Beksac AT, Schwen ZR, Aminsharifi A, Eltemamy M, Kaouk J. Minimally-Invasive Radical Nephrectomy and Left-Sided Level II Caval Thrombectomy: A New Combined Technique. Urology 2023; 172:220-223. [PMID: 36436673 DOI: 10.1016/j.urology.2022.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/22/2022] [Accepted: 10/02/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To present a combined multiport robotic and open approach for left radical nephrectomy and inferior vena cava thrombectomy in patients with a primary left renal mass and level II inferior vena cava (IVC) tumor thrombus. METHODS A 69-year-old female was diagnosed with an 8.9cm left renal neoplasm with level II IVC thrombus. She was placed in the left-side-up flank position. The descending colon was mobilized and the left gonadal vein was identified. The left renal vein was identified and fully dissected. The left renal artery was dissected and stapled. The kidney was dissected and left detached with exception of the renal vein. The robot was undocked and the patient was positioned supine. Through a supra-umbilical midline incision, the ascending colon and duodenum were mobilized medially. The right renal vein and IVC were identified and dissected to the level of hepatic veins. The IVC was clamped using a Satinsky clamp. The right renal artery and vein remained patent during thrombectomy. The IVC was opened, the thrombus was evacuated, and IVC was closed. Clamps were removed and the kidney was removed. RESULTS Operative time was 405 minutes. IVC clamp time was 14 minutes. Estimated blood loss was 500cc. Recovery was uncomplicated. Length of stay was 4 days. Pathology showed clear cell carcinoma with negative margins. CONCLUSION IVC thrombectomy is challenging on left sided tumors. Combining a robotic and open technique together is feasible and allows a smaller supra-umbilical midline incision compared to standard open incision.
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Affiliation(s)
- Jj H Zhang
- Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, OH
| | | | - Ethan L Ferguson
- Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Alp Tuna Beksac
- Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Zeyad R Schwen
- Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, OH
| | | | - Mohamed Eltemamy
- Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Jihad Kaouk
- Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, OH.
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Zhang Y, Bi H, Yan Y, Liu Z, Wang G, Song Y, Zhang S, Liu C, Ma L. Comparative analysis of surgical and oncologic outcomes of robotic, laparoscopic and open radical nephrectomy with venous thrombectomy: a propensity-matched cohort study. Int J Clin Oncol 2023; 28:145-154. [PMID: 36380158 DOI: 10.1007/s10147-022-02265-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 11/02/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To provide insight into the surgical and oncological outcomes of robotic, laparoscopic and open radical nephrectomy with venous thrombectomy (RALRN-VT, LRN-VT, ORN-VT) in patients with renal tumor and venous thrombus. MATERIALS AND METHODS A propensity-matched retrospective cohort study containing 324 patients with renal tumor and venous thrombus from January 2014 to August 2021 was analyzed. We compared surgical outcomes and we used the Kalan-Meier method to assess the overall survival (OS), tumor-specific survival (TSS), metastasis-free survival (MFS) and local recurrence-free survival (LRFS). The Pearson chi-square test and Fisher exact test, Wilcoxon rank sum test, Cox proportional hazards regression model and log-rank test were used. RESULTS After matching, baseline characteristics were comparable in the RALRN-VT, LRN-VT and ORN-VT group. The RALRN-VT group had the least operative time (median 134 min vs 289 min vs 330 min, P < 0.001), the least blood loss (median 250 ml vs 500 ml vs 1000 ml, P < 0.001) and the fewest packed red blood cells transfusion (median 400 ml vs 800 ml vs 1200 ml, P < 0.001). The ORN-VT group had the highest complication rate (18.2 vs 22.7 vs 43.2%, P = 0.005), the highest Clavien grade (P = 0.001) and the longest postoperative hospital stay (median 7d vs 8d vs 10d, P < 0.001). No significant difference in OS, TSS and MFS between the minimally invasive procedures (MIP, including RALRN-VT and LRN-VT) group and ORN-VT group was found. The hazard ratio of LRFS for the MIP group was 0.20 (95% CI 0.06-0.70, P = 0.01) compared with ORN-VT group. CONCLUSIONS RALRN-VT can result in the best surgical outcomes compared with LRN-VT and ORN-VT. The MIP group had a better LRFS compared with ORN-VT group.
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Affiliation(s)
- Yu Zhang
- Department of Urology, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, 100191, People's Republic of China
| | - Hai Bi
- Department of Urology, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, 100191, People's Republic of China
| | - Ye Yan
- Department of Urology, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, 100191, People's Republic of China
| | - Zhuo Liu
- Department of Urology, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, 100191, People's Republic of China
| | - GuoLiang Wang
- Department of Urology, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, 100191, People's Republic of China
| | - YiMeng Song
- Department of Urology, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, 100191, People's Republic of China
| | - ShuDong Zhang
- Department of Urology, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, 100191, People's Republic of China.
| | - Cheng Liu
- Department of Urology, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, 100191, People's Republic of China.
| | - LuLin Ma
- Department of Urology, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, 100191, People's Republic of China.
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Dhanji S, Wang L, Liu F, Meagher MF, Saidian A, Derweesh IH. Recent Advances in the Management of Localized and Locally Advanced Renal Cell Carcinoma: A Narrative Review. Res Rep Urol 2023; 15:99-108. [PMID: 36879830 PMCID: PMC9985462 DOI: 10.2147/rru.s326987] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 01/28/2023] [Indexed: 03/06/2023] Open
Abstract
Purpose To review the current status of surgical and procedural treatments for renal cell carcinoma (RCC), focusing on oncological and functional outcomes, and the use of techniques for advanced disease over the last 10 years. Findings Partial nephrectomy (PN) has become the reference standard for most T1 and T2 masses. In cT2 RCC, PN exhibits oncological equivalence and improved functional outcomes compared to radical nephrectomy (RN). Additionally, emerging data suggest that PN may be used to treat cT3a RCC. The robot-assisted platform is increasingly used to treat locally advanced RCC. Studies suggest safety and feasibility of robotic RN and robotic inferior vena cava tumor thrombectomy. Additionally, single-port robot-assisted laparoscopic approaches are comparable to multiport approaches in select patients. Long-term data show that cryoablation, radiofrequency ablation, and microwave ablation are equipotent in management of small renal masses. Emerging data suggest that microwave may effectively treat cT1b masses.
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Affiliation(s)
- Sohail Dhanji
- Department of Urology, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Luke Wang
- Department of Urology, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Franklin Liu
- Department of Urology, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Margaret F Meagher
- Department of Urology, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Ava Saidian
- Department of Urology, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Ithaar H Derweesh
- Department of Urology, University of California San Diego School of Medicine, La Jolla, CA, USA
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11
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Review of Robotic-Assisted Radical Nephrectomy with Inferior Vena Cava Thrombectomy in Renal Cell Carcinoma. Curr Urol Rep 2022; 23:363-370. [PMID: 36454370 DOI: 10.1007/s11934-022-01120-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2022] [Indexed: 12/03/2022]
Abstract
PURPOSE OF REVIEW Recent advances in minimally invasive technology have compelled surgeons to perform nephrectomy with inferior vena cava thrombectomy using robotic assistance. Here, we aim to review the data comparing open versus robot-assisted nephrectomy with IVC thrombectomy, as well as review operative robotic techniques for nephrectomy with IVC thrombectomy. RECENT FINDINGS Over the last decade, there have been increasing reports of successful robotic-assisted IVC thrombectomy among skilled robotic surgeons, with case series detailing operative technique, as well as operative and oncologic outcomes for levels I-IV caval thrombus. While there is immense promise in the future of robotic-assisted IVC thrombectomy, further studies with direct comparison to open surgical intervention will be needed to ensure the oncologic principles and outcomes are non-inferior.
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12
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Liu Z, Li Y, Tang S, Zhao X, Chen K, Ge L, Zhu G, Hong P, Wu B, Wu Z, Zhang S, Tian X, Wang S, Liu C, Zhang H, Ma L. Preliminary experience of oblique occlusion technique in robot-assisted infrahepatic inferior vena cava thrombectomy: step-by-step procedures and short term outcomes. BMC Surg 2022; 22:377. [PMCID: PMC9636754 DOI: 10.1186/s12893-022-01821-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022] Open
Abstract
Abstract
Background
We aimed to compare the oncological outcomes between the oblique occlusion technique and the traditional technique for robot-assisted radical nephrectomy (RARN) with inferior vena cava (IVC) thrombectomy, and to explore the safety and effectiveness of the oblique occlusion technique.
Methods
Overall, 21 patients with renal cell carcinoma (RCC) and IVC tumor thrombus (TT) were admitted to our hospital from August 2019 to June 2020. All the patients underwent RARN with IVC thrombectomy, of which the IVC oblique occlusion technique was used in 11 patients and traditional occlusion technique was used in 10 patients. The oblique occlusion technique refers to oblique blocking from the upper corner of the right renal vein to the lower corner of the left renal vein using a vessel tourniquet or a vessel clamp (left RCC with IVCTT as an example).
Results
Compared with patients in the traditional group, those in the oblique group had lower serum creatinine at follow-up (3 month) (95 ± 21.1 vs. 131 ± 30.7 μmol/L, P = 0.03). There was no significant difference in operation time [149 (IQR 143–245) min vs. 148 (IQR 108–261) min, p = 0.86], IVC clamping time [18 (IQR 12–20) min vs. 20 (IQR 14–23) min, p = 0.41], and estimated intraoperative blood loss [300 (IQR 100–800) mL vs. 500 (IQR 175–738) mL, p = 0.51] between both groups. During a 16-month (range, 15–23 months) follow-up period, two cases progressed in the oblique group and three cases progressed in the traditional group.
Conclusions
The modified IVC oblique occlusion technique procedure is relatively safe and effective in RARN with IVC thrombectomy. The IVC oblique occlusion technique may play a role in the protection of renal function.
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13
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Abaza R, Kogan P. Robotic nephrectomy with IVC tumor thrombectomy: The original technique. UROLOGY VIDEO JOURNAL 2022. [DOI: 10.1016/j.urolvj.2021.100110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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14
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Merhe A, Horodyski L, Ritch CR, Kryvenko ON, Gonzalgo ML. Robotic partial nephrectomy with inferior vena cava thrombectomy. UROLOGY VIDEO JOURNAL 2022. [DOI: 10.1016/j.urolvj.2021.100108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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15
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Zhao GD, Zhang XP, Hu MG, Huang QB, Xu S, Wang BJ, Ma X, Zhang X, Zou WB, Zhang X, Zhao ZM, Tan XL, Chou S, Wang G, Liu R. Step-by-step and orderly lowering of the height of inferior vena cava tumor thrombus is the key to robot-assisted thrombectomy for Mayo III/IV tumor thrombus. BMC Cancer 2022; 22:151. [PMID: 35130848 PMCID: PMC8822687 DOI: 10.1186/s12885-022-09235-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 01/12/2022] [Indexed: 11/14/2022] Open
Abstract
Background The surgical management of Mayo III/IV tumor thrombi is difficult and risky, and robotic surgery is even more difficult. The purpose of this study was to introduce the step-by-step and orderly lowering of the height of inferior vena cava tumor thrombus, which was the core technique of robot operation for Mayo III/IV tumor thrombus. Method A total of 18 patients were included in this study. The average tumor thrombus height was 2.4 cm above the level of the second porta hepatis (SPH), and 9 patients were prepared for cardiopulmonary bypass (CPB) before surgery. During the operation, the height of the tumor thrombus was lowered orderly for 2-3 times, and the blood flow blocking method was changed sequentially. The CPB was required when tumor thrombus in the atrium; After the height of the thrombus was lowered to the atrium entrance, CPB was stopped and the blood flow was blocked in the upper- and retro-hepatic inferior vena cava (IVC); After the tumor thrombus continued to descend to the lower part of the SPH, liver blood flow could be restored, and then, the blood flow was simply blocked in the retro-hepatic IVC to complete the removal of the thrombus and the repair or resection of the IVC. Finally, the diseased kidney and renal vein were removed. Results All operations were successfully completed, and 2 cases were transferred to laparotomy. Seven cases received CPB, while the other 11 did not. 15 patients underwent two times of the lowering of the tumor thrombus, 2 patients underwent one time and 1 patient underwent three times. The mean liver/IVC dissociation and vascular suspension time was 22.0 min. All patients had less than Clavien-Dindo grade III complications, no serious complications occurred during operation, and no patient died within 90 days. Conclusions The step-by-step and orderly decline of tumor thrombus height is the key to the success of robot Mayo III / IV tumor thrombus surgery. This method can shorten FPH and CPB time and improve the success rate of surgery.
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Affiliation(s)
- Guo-Dong Zhao
- Faculty of Hepato-Biliary-Pancreatic Surgery, Chinese People's Liberation Army (PLA) General Hospital, Institute of Hepatobiliary Surgery of Chinese PLA, 28 Fuxing Road, Beijing, 100853, China
| | - Xiu-Ping Zhang
- Faculty of Hepato-Biliary-Pancreatic Surgery, Chinese People's Liberation Army (PLA) General Hospital, Institute of Hepatobiliary Surgery of Chinese PLA, 28 Fuxing Road, Beijing, 100853, China
| | - Ming-Gen Hu
- Faculty of Hepato-Biliary-Pancreatic Surgery, Chinese People's Liberation Army (PLA) General Hospital, Institute of Hepatobiliary Surgery of Chinese PLA, 28 Fuxing Road, Beijing, 100853, China
| | - Qing-Bao Huang
- Faculty of Urology Surgery, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Shuai Xu
- Faculty of Hepato-Biliary-Pancreatic Surgery, Chinese People's Liberation Army (PLA) General Hospital, Institute of Hepatobiliary Surgery of Chinese PLA, 28 Fuxing Road, Beijing, 100853, China.,School of Medicine, Nankai University, Tianjin, China
| | - Bao-Jun Wang
- Faculty of Urology Surgery, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Xin Ma
- Faculty of Urology Surgery, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Xu Zhang
- Faculty of Urology Surgery, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Wen-Bo Zou
- Faculty of Hepato-Biliary-Pancreatic Surgery, Chinese People's Liberation Army (PLA) General Hospital, Institute of Hepatobiliary Surgery of Chinese PLA, 28 Fuxing Road, Beijing, 100853, China
| | - Xuan Zhang
- Faculty of Hepato-Biliary-Pancreatic Surgery, Chinese People's Liberation Army (PLA) General Hospital, Institute of Hepatobiliary Surgery of Chinese PLA, 28 Fuxing Road, Beijing, 100853, China
| | - Zhi-Ming Zhao
- Faculty of Hepato-Biliary-Pancreatic Surgery, Chinese People's Liberation Army (PLA) General Hospital, Institute of Hepatobiliary Surgery of Chinese PLA, 28 Fuxing Road, Beijing, 100853, China
| | - Xiang-Long Tan
- Faculty of Hepato-Biliary-Pancreatic Surgery, Chinese People's Liberation Army (PLA) General Hospital, Institute of Hepatobiliary Surgery of Chinese PLA, 28 Fuxing Road, Beijing, 100853, China
| | - Sai Chou
- Faculty of Hepato-Biliary-Pancreatic Surgery, Chinese People's Liberation Army (PLA) General Hospital, Institute of Hepatobiliary Surgery of Chinese PLA, 28 Fuxing Road, Beijing, 100853, China
| | - Gang Wang
- Faculty of Hepato-Biliary-Pancreatic Surgery, Chinese People's Liberation Army (PLA) General Hospital, Institute of Hepatobiliary Surgery of Chinese PLA, 28 Fuxing Road, Beijing, 100853, China
| | - Rong Liu
- Faculty of Hepato-Biliary-Pancreatic Surgery, Chinese People's Liberation Army (PLA) General Hospital, Institute of Hepatobiliary Surgery of Chinese PLA, 28 Fuxing Road, Beijing, 100853, China. .,School of Medicine, Nankai University, Tianjin, China.
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16
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Surgical treatment of renal cell carcinoma with inferior vena cava tumor thrombus. Surg Today 2022; 52:1125-1133. [PMID: 34977987 DOI: 10.1007/s00595-021-02429-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 07/08/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE The present report discusses the indications of cardiopulmonary bypass (CPB) in open nephrectomy and surgical outcomes of conventional and minimally invasive surgical techniques for treating advanced renal cell carcinoma with inferior vena cava tumor thrombus. METHODS The present study involved a comprehensive retrieval of pertinent literature from the most recent two decades. RESULTS Comparisons between radical nephrectomy procedures in terms of open, laparoscopic and robotic-assisted surgeries revealed that open surgery had more blood loss, a longer operation time and higher mortality rates than laparoscopic and robotic-assisted surgeries. Furthermore, surgery with CPB was associated with more blood loss than non-CPB surgery. Rates of early and late deaths were much higher in patients with CPB than in those without CPB. CONCLUSIONS Different surgical techniques had different indications in terms of levels of inferior vena cava tumor thrombus. The laparoscopic, robotic-assisted, open surgical techniques and CPB with deep hypothermic circulatory arrest were indicated for Levels I, II, III and III-IV inferior vena cava tumor thrombus, respectively. Laparoscopic and robotic-assisted surgeries cause less trauma than open surgery but require more complicated equipments to support the procedure. CPB should be avoided in radical nephrectomy whenever possible. The increased application of laparoscopic and robotic techniques in the future is anticipated.
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17
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Ma J, Sun W, Qian W, Min J, Zhang T, Yu D. Modified vein clamping technique for renal cell carcinoma complicated with level I-II IVC thrombi: a study at a single centre. BMC Urol 2021; 21:179. [PMID: 34933681 PMCID: PMC8691095 DOI: 10.1186/s12894-021-00947-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 12/14/2021] [Indexed: 11/17/2022] Open
Abstract
Objectives To share our initial experience with the modified vein clamping technique for the treatment of renal cell carcinoma complicated with level I–II IVC thrombi. Methods From March 2018 to April 2021, 11 patients with renal cell carcinoma (RCC) involving an IVC tumour thrombus were admitted to our hospital. They all underwent laparoscopic radical nephrectomy and IVC thrombectomy (LRN-IVCTE) using a modified vein clamping technique. Results All procedures were successfully completed without conversion to open surgery. The median operative time was 185.00 min (145.00–216.00 min); the median estimated blood loss was 200.00 ml (155.00–300.00 ml), and four patients received an intraoperative transfusion. In addition, the median IVC clamping time was 18.00 min (12.00–20.00 min); the median postoperative hospital stay was 6.00 days (4.00–7.00 days), while the median follow-up period was 28.00 months (4.00–34.00 months). Conclusions The modified vein clamping technique for the treatment of renal cell carcinoma complicated with level I–II IVC thrombi may be a safe and technically feasible alternative technique.
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Affiliation(s)
- Jiaxing Ma
- Department of Urology, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Rd, Hefei, 230032, Anhui, People's Republic of China
| | - Wei Sun
- Department of Urology, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Rd, Hefei, 230032, Anhui, People's Republic of China
| | - Weiwei Qian
- Department of Urology, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Rd, Hefei, 230032, Anhui, People's Republic of China
| | - Jie Min
- Department of Urology, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Rd, Hefei, 230032, Anhui, People's Republic of China
| | - Tao Zhang
- Department of Urology, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Rd, Hefei, 230032, Anhui, People's Republic of China
| | - Dexin Yu
- Department of Urology, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Rd, Hefei, 230032, Anhui, People's Republic of China.
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18
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Masic S, Smaldone MC. Robotic renal surgery for renal cell carcinoma with inferior vena cava thrombus. Transl Androl Urol 2021; 10:2195-2198. [PMID: 34159102 PMCID: PMC8185684 DOI: 10.21037/tau.2019.06.15] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Surgical management of renal cell carcinoma (RCC) with inferior vena cava (IVC) thrombus is inherently complex, posing challenges for even the most experienced urologists. Until the mid-2000s, nephrectomy with IVC thrombectomy was exclusively performed using variations of the open technique initially described decades earlier, but since then several institutions have reported their robotic experiences. Robotic IVC thrombectomy was initially reported for level I and II thrombi, and more recently in higher-lever III thrombi. In general, the robotic approach is associated with less blood loss and shorter hospital stays compared to the open approach, low rates of open conversion in reported cases, relatively low rates of high-grade complications, and favorable overall survival on short-term follow-up in limited cohorts. Operative times are longer, costs are significantly higher, and left-sided tumors always require intraoperative repositioning and usually require preoperative embolization. To date, criteria for patient selection or open conversion have not been defined, and long-term oncologic outcomes are lacking. While the early published robotic experience demonstrates feasibility and safety in carefully selected patients, longer-term follow-up remains necessary. Patient selection, indications for open conversion, logistics of conversion particularly in emergent settings, necessity and safety of preoperative embolization, the value proposition, and long-term oncologic outcomes must all be clearly defined before this approach is widely adopted.
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Affiliation(s)
- Selma Masic
- Fox Chase Cancer Center, Philadelphia, PA, USA
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19
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Rosen GH, Hargis PA, Cunningham C, Pokala N. Robotic Excision of Recurrent Renal Cell Carcinoma Inferior Vena Cava Tumor Thrombus. J Endourol Case Rep 2020; 6:392-395. [PMID: 33457682 DOI: 10.1089/cren.2020.0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Renal cell carcinoma (RCC) recurrence can present in nearly any location. Rarely, recurrence is within the venous system. Previous reports of such recurrent tumor thrombectomy have all used an open approach. For the first time, we present robotic excision of recurrent RCC tumor thrombus. Case Presentation: This is a 59-year-old man who was referred to us 3 years after right robotic radical nephrectomy and renal vein tumor thrombectomy with positive margins. He had been lost to follow-up after 1 year. He presented again 3 years after surgery and was found to have recurrence with inferior vena cava (IVC) tumor thrombus to the caudal margin of the liver. He was taken for robotic tumor thrombectomy, which was completed with 900 mL of estimated blood loss, requiring a single unit of packed red blood cells. The surgery was complicated by increased bleeding caused by an undiagnosed arteriovenous fistula between the right renal artery and vein remnants. Conclusion: Robotic excision of recurrent RCC IVC thrombus is a potential treatment for selected patients under the care of experienced robotic surgeons.
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Affiliation(s)
- Geoffrey H Rosen
- Division of Urology, Department of Surgery, University of Missouri, Columbia, Missouri, USA
| | - Paige A Hargis
- School of Medicine, University of Missouri, Columbia, Missouri, USA
| | | | - Naveen Pokala
- Division of Urology, Department of Surgery, University of Missouri, Columbia, Missouri, USA
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20
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Abstract
Minimally invasive renal surgery has revolutionized the surgical management of renal cancer since the initial report of laparoscopic nephrectomy in 1991. Laparoscopic nephrectomy became the mainstay of management in surgically resectable renal masses since the 1990s. The growing body of literature supporting nephron-sparing surgery over the last two decades has meant that minimally invasive radical nephrectomy (MI-RN) is now the preferred treatment for renal tumors not amenable to partial nephrectomy. While there is a well-described experience with complex radical nephrectomy using standard laparoscopy, robot-assisted surgery has shortened the learning curve and facilitated greater uptake of minimally invasive surgery in difficult surgical scenarios traditionally performed open surgically. Increased experience and expertise with robot-assisted renal surgery has led to expansion of the indications for MI-RN to include larger masses, locally advanced renal masses invading adjacent tissues or regional hilar/retroperitoneal lymph nodes, cytoreductive nephrectomy (CN) in metastatic disease, and concurrent venous tumor thrombectomy for renal vein or inferior vena cava (IVC) involvement. In this article, we review the various surgical techniques and adjunctive procedures associated with MI-RN.
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Affiliation(s)
- Akbar N Ashrafi
- USC Institute of Urology and Catherine & Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.,Division of Surgery, North Adelaide Local Health Network, SA Health, Adelaide, South Australia, Australia.,Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Inderbir S Gill
- USC Institute of Urology and Catherine & Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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21
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Nini A, Muttin F, Cianflone F, Carenzi C, Luciano R, Catena M, Larcher A, Salvioni M, Cazzaniga W, Pederzoli F, Matloob R, Colombo R, Paganelli M, Salonia A, Briganti A, Doglioni C, Zangrillo A, DE Cobelli F, Rigatti P, Freschi M, Cornero G, Nicoletti R, Aldrighetti L, Montorsi F, Capitanio U, Bertini R. Perioperative and oncologic outcomes of open radical nephrectomy and inferior vena cava thrombectomy with liver mobilization and Pringle maneuver for Mayo III level tumor thrombus: single institution experience. Minerva Urol Nephrol 2020; 73:746-753. [PMID: 33242949 DOI: 10.23736/s2724-6051.20.03844-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Scarce data are available regarding the technique and outcomes for patients with RCC and Mayo III caval thrombi. The aim of this study was to report surgical and oncological outcomes of RCC patients with Mayo III thrombi treated with radical nephrectomy and thrombectomy after liver mobilization (LM) and Pringle maneuver (PM). METHODS Retrospective analysis of surgical technique, outcomes and cancer control in 19 patients undergoing LM and PM in a single tertiary care institution were analyzed. RESULTS Overall, 78% of the patients had performance status ECOG 1 and 58% had a Comorbidity Index >2. Median surgical time was 305 minutes (IQR 264-440). Intraoperative complications were reported for 39% of patients and postoperative complications for 58% (only grade 1 and 2). Intensive Care Unit support was necessary in 16% of the cases. Median length of hospital stay was 9 days (IQR: 7-11). Thirty- and 90-day mortality were 5% and 15%. Two-year overall survival and cancer-specific survival were 60% and 62%, respectively. CONCLUSIONS We reported surgical techniques, intra- and perioperative complications and follow-up in the largest cohort of RCC patients requiring LM and PM.
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Affiliation(s)
- Alessandro Nini
- Department of Urology, IRCCS San Raffaele Hospital, Milan, Italy.,Unit of Urology, Division of Experimental Oncology, IRCCS San Raffaele Hospital, Milan, Italy.,Department of Urology and Pediatric Urology, Saarland University Medical Center, Saarland University, Homburg, Germany
| | - Fabio Muttin
- Department of Urology, IRCCS San Raffaele Hospital, Milan, Italy.,Unit of Urology, Division of Experimental Oncology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Francesco Cianflone
- Department of Urology, IRCCS San Raffaele Hospital, Milan, Italy.,Unit of Urology, Division of Experimental Oncology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Cristina Carenzi
- Department of Urology, IRCCS San Raffaele Hospital, Milan, Italy.,Unit of Urology, Division of Experimental Oncology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Roberta Luciano
- Unit of Pathology, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Marco Catena
- Unit of Hepatobiliary Surgery, Department of General Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Larcher
- Department of Urology, IRCCS San Raffaele Hospital, Milan, Italy.,Unit of Urology, Division of Experimental Oncology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Marco Salvioni
- Unit of Radiology, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Walter Cazzaniga
- Department of Urology, IRCCS San Raffaele Hospital, Milan, Italy.,Unit of Urology, Division of Experimental Oncology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Filippo Pederzoli
- Department of Urology, IRCCS San Raffaele Hospital, Milan, Italy.,Unit of Urology, Division of Experimental Oncology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Rayan Matloob
- Department of Urology, IRCCS San Raffaele Hospital, Milan, Italy.,Unit of Urology, Division of Experimental Oncology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Renzo Colombo
- Department of Urology, IRCCS San Raffaele Hospital, Milan, Italy.,Unit of Urology, Division of Experimental Oncology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Michele Paganelli
- Unit of Hepatobiliary Surgery, Department of General Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Salonia
- Department of Urology, IRCCS San Raffaele Hospital, Milan, Italy.,Unit of Urology, Division of Experimental Oncology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Alberto Briganti
- Department of Urology, IRCCS San Raffaele Hospital, Milan, Italy.,Unit of Urology, Division of Experimental Oncology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Claudio Doglioni
- Unit of Pathology, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Alberto Zangrillo
- Unit of Anesthesiology, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco DE Cobelli
- Unit of Radiology, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Patrizio Rigatti
- Department of Urology, IRCCS San Raffaele Hospital, Milan, Italy.,Unit of Urology, Division of Experimental Oncology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Massimo Freschi
- Unit of Pathology, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Guglielmo Cornero
- Unit of Anesthesiology, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Nicoletti
- Unit of Radiology, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Luca Aldrighetti
- Unit of Hepatobiliary Surgery, Department of General Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Montorsi
- Department of Urology, IRCCS San Raffaele Hospital, Milan, Italy.,Unit of Urology, Division of Experimental Oncology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Umberto Capitanio
- Department of Urology, IRCCS San Raffaele Hospital, Milan, Italy.,Unit of Urology, Division of Experimental Oncology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Roberto Bertini
- Department of Urology, IRCCS San Raffaele Hospital, Milan, Italy - .,Unit of Urology, Division of Experimental Oncology, IRCCS San Raffaele Hospital, Milan, Italy
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22
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Vuong NS, Ferriere JM, Michiels C, Calen L, Tesi L, Capon G, Bensadoun H, Alezra E, Estrade V, Robert G, Bladou F, Bernhard JC. Robot-assisted versus open surgery for radical nephrectomy with level 1-2 vena cava tumor thrombectomy: a French monocenter experience (UroCCR study #73). Minerva Urol Nephrol 2020; 73:498-508. [PMID: 33200900 DOI: 10.23736/s2724-6051.20.04052-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The aim of this paper was to assess the feasibility of robot-assisted radical nephrectomy (RN) with inferior vena cava thrombectomy (RRVCT) and compare perioperative and oncological outcomes of this approach to open surgery for renal tumors with level 1-2 inferior vena cava (IVC) thrombus. METHODS We performed a retrospective analysis of patients surgically treated for renal cancer with IVC level 1-2 thrombus in the Urology department of Bordeaux University Hospital between December 2015 and December 2019. Patients were stratified by surgical approach in two groups: open vs. robotic procedures. Pre-, per- and postoperative data were collected within the framework of the UroCCR project (NCT03293563). Univariate and multivariate analysis using regression models were performed. RESULTS A total of 40 patients underwent RN with IVC tumor thrombus. Open and robotic surgery represented respectively 30 and 10 cases. The two groups were comparable regarding pre-operative tumor and patient characteristics. Robotic procedures were associated with lower estimated blood loss (EBL) (500 vs. 1250 mL, P=0.02), shorter Intensive Care Unit stay (2 vs. 4 days, P=0.03) and decrease of global length of stay (LOS) (7 vs. 10 days, P<0.01). Operative Time (OT) was significantly longer in the robotic group (350.5 vs. 208 min, P<0.01). No difference were observed between the two approaches regarding complications and oncological outcomes. CONCLUSIONS Robotic approach induced lower bleeding and shorter LOS but required longer OT. This technique is feasible and safe for selected cases and experimented surgical teams. Complications rate and oncological outcomes are not different compared to standard open procedures.
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Affiliation(s)
- Nam-Son Vuong
- Department of Urology, Bordeaux University Hospital, Bordeaux, France -
| | | | - Clément Michiels
- Department of Urology, Bordeaux University Hospital, Bordeaux, France
| | - Laura Calen
- Department of Urology, Bordeaux University Hospital, Bordeaux, France
| | - Lorenso Tesi
- Department of Urology, Bordeaux University Hospital, Bordeaux, France
| | - Grégoire Capon
- Department of Urology, Bordeaux University Hospital, Bordeaux, France
| | - Henri Bensadoun
- Department of Urology, Bordeaux University Hospital, Bordeaux, France
| | - Eric Alezra
- Department of Urology, Bordeaux University Hospital, Bordeaux, France
| | - Vincent Estrade
- Department of Urology, Bordeaux University Hospital, Bordeaux, France
| | - Grégoire Robert
- Department of Urology, Bordeaux University Hospital, Bordeaux, France
| | - Franck Bladou
- Department of Urology, Bordeaux University Hospital, Bordeaux, France
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Ghoreifi A, Djaladat H. Surgical Tips for Inferior Vena Cava Thrombectomy. Curr Urol Rep 2020; 21:51. [PMID: 33090290 DOI: 10.1007/s11934-020-01007-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to describe the preoperative evaluation, surgical techniques, and postoperative management of patients with renal cell carcinoma (RCC) undergoing radical nephrectomy (RN) and inferior vena cava (IVC) thrombectomy. RECENT FINDINGS RN and IVC thrombectomy remains the standard management option in non-metastatic RCC patients with IVC thrombus. A comprehensive preoperative workup, including high-quality imaging, blood works, and appropriate consultations are required for all patients. The aim of the surgery is complete resection of all tumor burden, which requires a skillful surgical team for such a challenging procedure and is inherently associated with a high rate of perioperative morbidity and mortality. Preoperative CT or MRI is essential for surgical planning. The surgical approach is mainly determined by the level of the tumor thrombus. The open approach has been the standard, though minimally invasive and robotic techniques are emerging in selected cases by experienced surgeons.
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Affiliation(s)
- Alireza Ghoreifi
- Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, 1441 Eastlake Ave. Suite 7416, Los Angeles, CA, 90089, USA
| | - Hooman Djaladat
- Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, 1441 Eastlake Ave. Suite 7416, Los Angeles, CA, 90089, USA.
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Li J, Peng L, Cao D, Cheng B, Gou H, Li Y, Wei Q. Comparison of Perioperative Outcomes of Robot-Assisted vs. Laparoscopic Radical Nephrectomy: A Systematic Review and Meta-Analysis. Front Oncol 2020; 10:551052. [PMID: 33072578 PMCID: PMC7531174 DOI: 10.3389/fonc.2020.551052] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 08/12/2020] [Indexed: 02/05/2023] Open
Abstract
Background: The use of robot-assisted radical nephrectomy (RARN) for renal cell carcinoma (RCC) has increased in recent years, but the advantages of RARN over laparoscopic radical nephrectomy (LRN) remain controversial. This study aimed to compare the perioperative outcomes between RARN and LRN. Methods: We systematically searched the EMBASE, PubMed, Web of Science, and CNKI databases to identify eligible comparative studies. The parameters were perioperative outcomes including operating time (OT), estimated blood loss (EBL), length of stay (LOS), conversion rate, and complications. Stata 15.0 software was used for the meta-analysis. Results: Seven studies with 1,832 patients were included in the analysis. Among them, 532 underwent RARN and 840 underwent LRN for RCC. There were no significant differences in OT (weighted mean difference [WMD], 29.05; 95% confidence interval [CI], -0.31, 58.41; p = 0.05), EBL (WMD, -4.56; 95% CI, -29.79, 20.67; p = 0.72), LOS (WMD, -0.34; 95% CI, -0.68, 0.00; p = 0.05), conversion rate (WMD, 2.67; 95% CI, 0.68, 10.46; p = 0.05), transfusion rate (odds ratio [OR], 1.30; 95% CI, 0.74, 2.27; p = 0.36), intraoperative complications (OR, 1.13; 95% CI, 0.61, 2.12; p = 0.62), and postoperative complications (OR, 1.07; 95% CI, 0.68, 1.67; p = 0.62) between the two groups. Conclusion: RARN was not superior to LRN in patients with RCC in terms of perioperative outcomes. Before establishing conclusive clinical recommendations, high-quality prospective large-scale randomized controlled trials with long-term follow-up are needed.
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Affiliation(s)
- Jinze Li
- Department of Urology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Lei Peng
- Department of Urology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Dehong Cao
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Bo Cheng
- Department of Neurology, The Affiliated Hospital of Medical College, North Sichuan Medical College, Nanchong, China
| | - Haocheng Gou
- Department of Otolaryngology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Yunxiang Li
- Department of Urology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Qiang Wei
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
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25
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Complex robotic nephrectomy and inferior vena cava tumor thrombectomy: an evolving landscape. Curr Opin Urol 2020; 30:83-89. [PMID: 31725003 DOI: 10.1097/mou.0000000000000690] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Robotic nephrectomy for complex renal masses and in the setting of inferior vena cava (IVC) tumor thrombus has been shown to be a well tolerated and reproducible surgical option. Recent developments in such procedures will be discussed as they continue to evolve. RECENT FINDINGS Multiple case series have demonstrated the application of robotic surgery in the management of the most complex renal tumors and for IVC thrombi with acceptable oncologic and perioperative outcomes. Prior to the advent of robotic surgery, massive tumors, contiguous organ invasion, need for lymphadenectomy, and IVC tumor thrombus were thought by many to require open surgery. Since 2011, several studies have reported robotic nephrectomy for complex tumors with recent comparisons of robotic and open approaches finding similar oncologic and survival outcomes but with shorter length of stay (LOS) and less blood loss with robotic surgery. SUMMARY Robotic surgery is a feasible and well tolerated alternative to open surgery for the management of complex renal tumors and IVC thrombi. The potential benefits of shorter LOS, less blood loss, and earlier convalescence suggest this approach should continue to be evaluated. Patient selection and surgeon experience are of paramount importance.
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26
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Leibovich BC, Lohse CM, Cheville JC, Potretzke TA, Tsivian M, Shah PH, Boorjian SA, Thompson RH, Lyon TD. Renal Cell Carcinoma with Inferior Vena Cava Extension: Can Classification Be Optimized to Predict Perioperative Outcomes? KIDNEY CANCER 2020. [DOI: 10.3233/kca-190070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | | | - John C. Cheville
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Paras H. Shah
- Division of Urology, Albany Medical College, Albany, NY, USA
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27
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Wang B, Huang Q, Liu K, Fan Y, Peng C, Gu L, Shi T, Zhang P, Chen W, Du S, Niu S, Liu R, Zhao G, Li Q, Xiao C, Wang R, Li S, Wang M, Liu F, Wang H, Li H, Ma X, Zhang X. Robot-assisted Level III-IV Inferior Vena Cava Thrombectomy: Initial Series with Step-by-step Procedures and 1-yr Outcomes. Eur Urol 2020; 78:77-86. [DOI: 10.1016/j.eururo.2019.04.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 04/12/2019] [Indexed: 11/15/2022]
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Seetharam Bhat KR, Moschovas MC, Onol FF, Rogers T, Roof S, Patel VR, Schatloff O. Robotic renal and adrenal oncologic surgery: A contemporary review. Asian J Urol 2020; 8:89-99. [PMID: 33569275 PMCID: PMC7859360 DOI: 10.1016/j.ajur.2020.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 03/30/2020] [Accepted: 04/22/2020] [Indexed: 01/20/2023] Open
Abstract
Robot-assisted surgery has evolved over time. Radical nephrectomy with inferior vena cava thrombectomy is feasible and safe for level I, II and III thrombus in high volume centers. Though it is feasible for level IV thrombus, this procedure needs a multi-departmental co-operation. However, the safety of robot-assisted procedures in this subset is still unknown. Robot-assisted partial nephrectomy has been universally approved and found oncologically safe. Robotic adrenalectomy has been increasingly utilized for select cases, especially in bilateral tumors and for retroperitoneal adrenalectomy.
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Affiliation(s)
| | | | - Fikret Fatih Onol
- Global Robotics Institute, AdventHealth Celebration Health, Celebration, FL, USA
| | - Travis Rogers
- Global Robotics Institute, AdventHealth Celebration Health, Celebration, FL, USA
| | - Shannon Roof
- Global Robotics Institute, AdventHealth Celebration Health, Celebration, FL, USA
| | - Vipul R Patel
- Global Robotics Institute, AdventHealth Celebration Health, Celebration, FL, USA
| | - Oscar Schatloff
- Global Robotics Institute, AdventHealth Celebration Health, Celebration, FL, USA.,Sudmedica Health, Chile
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29
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Shen D, Du S, Huang Q, Gao Y, Fan Y, Gu L, Liu K, Peng C, Xuan Y, Li P, Li H, Ma X, Zhang X, Wang B. A modified sequential vascular control strategy in robot-assisted level III-IV inferior vena cava thrombectomy: initial series mimicking the open 'milking' technique principle. BJU Int 2020; 126:447-456. [PMID: 32330369 DOI: 10.1111/bju.15094] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To introduce a modified sequential vascular control strategy, mimicking the open 'milking' technique principle, for the early release of the first porta hepatis (FPH) and to stop cardiopulmonary bypass (CPB) in level III-IV robot-assisted inferior vena cava (IVC) thrombectomy (RA-IVCTE). PATIENTS AND METHODS From November 2014 to June 2019, 27 patients with a level III-IV IVC tumour thrombus (IVCTT) underwent RA-IVCTE in our department. The modified sequential control strategy was used in 12 cases. Previously, we released the FPH after the thrombus was resected and the IVC was closed completely, and CPB was stopped at the end of surgery (15 patients). Presently, using our modified strategy, we place another tourniquet inferior to the second porta hepatis (SPH) once the proximal thrombus is removed from the IVC below the SPH. Then, we suture the right atrium and perform early release of the FPH, and stop CPB. Finally, tumour thrombectomy, vascular reconstruction, and radical nephrectomy are performed. RESULTS Compared with the previous strategy, the modified steps resulted in a shorter median FPH clamping (19 vs 47 min, P < 0.001) and CPB times (60 vs 87 min, P < 0.05); a lower rate of Grade II-IV perioperative complications (25% vs 60%, P < 0.05); and better postoperative hepatorenal and coagulation function, including better median serum alanine aminotransferase (172.7 vs 465.4 U/L, P < 0.001), aspartate aminotransferase (282.4 vs 759.8 U/L, P < 0.001), creatinine (113.4 vs 295 μmol/L, P < 0.01), blood urea nitrogen (7.3 vs 16.7 mmol/L, P < 0.01), and D-dimer (5.9 vs 20 mg/L, P < 0.001) levels. CONCLUSION With the early release of the FPH and stopping CPB, the modified sequential vascular control strategy in level III-IV RA-IVCTE reduced the perioperative risk for selected patients and improved the feasibility and safety of the surgery. We would recommend this approach to other centres that plan to develop robotic surgery for renal cell carcinoma with level III-IV IVCTT in the future.
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Affiliation(s)
- Donglai Shen
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - Songliang Du
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China.,School of Medicine, Nankai University, Tianjin, China
| | - Qingbo Huang
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - Yu Gao
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - Yang Fan
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - Liangyou Gu
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - Kan Liu
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - Cheng Peng
- Department of Urology, The Seventh Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yundong Xuan
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - Pin Li
- Department of Pediatric Urology, Bayi Children's Hospital Affiliated to The Seventh Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Hongzhao Li
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - Xin Ma
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - Xu Zhang
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - Baojun Wang
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
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Du S, Huang Q, Yu H, Shen D, Gu L, Yan F, Liu F, Zhang X, Ma X, Wang B. Initial Series of Robotic Segmental Inferior Vena Cava Resection in Left Renal Cell Carcinoma With Caval Tumor Thrombus. Urology 2020; 142:125-132. [PMID: 32339559 DOI: 10.1016/j.urology.2020.03.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 03/18/2020] [Accepted: 03/24/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To present our preliminary experience of robotic left radical nephrectomy (LRN) and segmental inferior vena cava (IVC) resection without caval replacement for left renal cell carcinoma (RCC) with inferior vena cava tumor thrombus. MATERIALS AND METHODS Between 2017 and 2018, 7 patients underwent segmental IVC resection and LRN robotically. All patients underwent preoperative cavography, demonstrating complete IVC occlusion. Computed tomography-based 3-dimensional reconstruction revealed sufficient collateralization of the IVC and right renal vein (RRV). The cephalic IVC was circumferentially resected and ligated just below the second porta hepatis. The caudal IVC was circumferentially resected above the RRV with preservation of the major collaterals. The RRV was not dissected during the procedure to avoid compromising its neocollaterals. The IVC portion between the RRV and the second porta hepatis was removed en bloc with the tumor thrombus, and the LRN was performed. RESULTS All cases were successfully performed by robotic surgery without conversion. Median operative time was 420 minutes. Median intensive care unit stay was 3 days. Four grade Ⅱ complications occurred in 2 patients. One patient had mild LEE postoperatively and recovered without special medication. Median preoperative and 3-6 months follow-up serum creatinine was 118.7 μmol/L and 135.2 μmol/L, respectively. No patient needed dialysis postoperatively. One case occurred disease progression. No patient died during the follow-up period. CONCLUSION Robotic segmental IVC resection for left RCC with inferior vena cava tumor thrombus is feasible in well-selected cases. Three-dimensional reconstruction and cavography are helpful in the preoperative evaluation of neocollaterals in patients with suprarenal IVC occlusion.
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Affiliation(s)
- Songliang Du
- School of Medicine, Nankai University, Tianjin, China; Department of Urology/ State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital, Beijing, China
| | - Qingbo Huang
- Department of Urology/ State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital, Beijing, China
| | - Hongkai Yu
- Department of Urology/ State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital, Beijing, China
| | - Donglai Shen
- Department of Urology/ State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital, Beijing, China
| | - Liangyou Gu
- Department of Urology/ State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital, Beijing, China
| | - Fei Yan
- Department of Radiology, Chinese PLA General Hospital, Beijing, China
| | - Fengyong Liu
- Department of Interventional Radiology, Chinese PLA General Hospital, Beijing, China
| | - Xu Zhang
- School of Medicine, Nankai University, Tianjin, China; Department of Urology/ State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital, Beijing, China
| | - Xin Ma
- School of Medicine, Nankai University, Tianjin, China; Department of Urology/ State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital, Beijing, China
| | - Baojun Wang
- School of Medicine, Nankai University, Tianjin, China; Department of Urology/ State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital, Beijing, China.
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Shen D, Wang H, Wang C, Huang Q, Li S, Wu S, Xuan Y, Gong H, Li H, Ma X, Wang B, Zhang X. Cumulative Sum Analysis of the Operator Learning Curve for Robot-Assisted Mayo Clinic Level I-IV Inferior Vena Cava Thrombectomy Associated with Renal Carcinoma: A Study of 120 Cases at a Single Center. Med Sci Monit 2020; 26:e922987. [PMID: 32107362 PMCID: PMC7063847 DOI: 10.12659/msm.922987] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background This study aimed to use cumulative sum analysis of the operator learning curve for robot-assisted Mayo Clinic level I–IV inferior vena cava (IVC) thrombectomy associated with renal carcinoma, and describes the development of an optimized operative procedure at a single center. Material/Methods A retrospective study included 120 patients with Mayo Clinic level I–IV IVC thrombus who underwent robotic surgery between 2013 and 2018. Points in the learning curve were identified using cumulative sum analysis, and their impact was assessed by multiple regression analysis. Perioperative indicators analyzed included operative time, estimated blood loss, early complications, and the 90-day progression rate. Results Cumulative sum analysis identified three phases in the learning curve of robot-assisted IVC thrombectomy. The median operative time decreased from 265 min (range, 212–401 min) to 207 min (range, 146–276 min) (p=0.003), the median estimated blood loss decreased from 775 ml (range, 413–1500 ml) to 300 ml (range, 163–813 ml) (p=0.006), and the early complication rate decreased from 52.5% to 15.0% (p<0.001). Multivariate analysis showed that for an initial 40 cases and a further 80 cases, the learning phase, the affected side, the Mayo Clinic level, and the surgical method were independent factors that affected operative time, estimated blood loss, and the rate of early complications. Conclusions Experience from an initial 40 cases and a further 80 cases of Mayo Clinic level I–IV IVC thrombectomy associated with renal carcinoma were found to provide acceptable surgical and clinical outcomes.
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Affiliation(s)
- Donglai Shen
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Hanfeng Wang
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Chenfeng Wang
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Qingbo Huang
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Shichao Li
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Shengpan Wu
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Yundong Xuan
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Huijie Gong
- Department of Urology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China (mainland)
| | - Hongzhao Li
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Xin Ma
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Baojun Wang
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Xu Zhang
- Department of Urology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
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Rose KM, Navaratnam AK, Faraj KS, Abdul-Muhsin HM, Syal A, Elias L, Moss AA, Eversman WG, Stone WM, Money SR, Davila VJ, Tyson MD, Castle EP. Comparison of Open and Robot Assisted Radical Nephrectomy With Level I and II Inferior Vena Cava Tumor Thrombus: The Mayo Clinic Experience. Urology 2020; 136:152-157. [DOI: 10.1016/j.urology.2019.11.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 10/24/2019] [Accepted: 11/02/2019] [Indexed: 10/25/2022]
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33
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Abaza R, Gerhard RS, Martinez O. Robotic Radical Nephrectomy for Massive Renal Tumors. J Laparoendosc Adv Surg Tech A 2020; 30:196-200. [DOI: 10.1089/lap.2019.0630] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ronney Abaza
- Robotic Surgery, OhioHealth Dublin Methodist Hospital, Dublin, Ohio
| | | | - Oscar Martinez
- Robotic Surgery, OhioHealth Dublin Methodist Hospital, Dublin, Ohio
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34
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Trends and outcomes in contemporary management renal cell carcinoma and vena cava thrombus. Urol Oncol 2019; 37:576.e17-576.e23. [DOI: 10.1016/j.urolonc.2019.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 04/12/2019] [Accepted: 05/13/2019] [Indexed: 11/22/2022]
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35
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Fan Y, Li H, Zhang X, Wang B, Liu K, Huang Q, Gao Y, Gu L, Ma X. Robotic Radical Nephrectomy and Thrombectomy for Left Renal Cell Carcinoma with Renal Vein Tumor Thrombus: Superior Mesenteric Artery as an Important Strategic Dividing Landmark. J Endourol 2019; 33:557-563. [PMID: 31106582 DOI: 10.1089/end.2019.0159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Objective: The aim of this study was to explore a new treatment strategy for left renal vein tumor thrombus directed at the thrombus level and the therapeutic effect of robotic surgery. Materials and Methods: Fifteen patients with left renal cell carcinoma with renal vein tumor thrombus (Mayo level 0) who underwent robotic radical nephrectomy and thrombectomy from July 2013 to July 2017 were included in this series. If the left renal vein thrombus transcended the superior mesenteric artery (SMA), the thrombus was classified as level 0b, the patient was positioned right side up for thrombectomy and repositioned left side up for nephrectomy, and angioembolization of left renal artery was necessary; otherwise, the thrombus was classified as level 0a and the patient was positioned left side up for both nephrectomy and thrombectomy. Baseline, perioperative, and follow-up data were analyzed. Results: Of all 15 patients, 10 had a level 0a tumor thrombus and 5 had a level 0b tumor thrombus. For level 0a patients, median operating time was 130 minutes, median estimated blood loss was 125 mL, with no patient receiving transfusion, and median hospital stay was 3.5 days. For level 0b patients, median operating time was 180 minutes, median estimated blood loss was 250 mL, with one patient receiving transfusion, and median hospital stay was 5 days. No perioperative complications or positive surgical margins occurred. For level 0a patients, one patient with preexisting lumbar vertebral metastasis died during a median follow-up of 39 months. For level 0b patients, all patients were alive at a median follow-up of 16.5 months. Conclusions: Our initial experience shows that the new treatment strategy for left renal vein tumor thrombus with the SMA as a dividing landmark directed at the thrombus level is safe and feasible. A larger cohort of level 0b patients and longer-term follow-up are needed to further assess the strategic advantages.
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Affiliation(s)
- Yang Fan
- Department of Urology, State Key Laboratory of Kidney Diseases, Chinese People's Liberation Army General Hospital, PLA Medical School, Beijing, People's Republic of China
| | - Hongzhao Li
- Department of Urology, State Key Laboratory of Kidney Diseases, Chinese People's Liberation Army General Hospital, PLA Medical School, Beijing, People's Republic of China
| | - Xu Zhang
- Department of Urology, State Key Laboratory of Kidney Diseases, Chinese People's Liberation Army General Hospital, PLA Medical School, Beijing, People's Republic of China
| | - Baojun Wang
- Department of Urology, State Key Laboratory of Kidney Diseases, Chinese People's Liberation Army General Hospital, PLA Medical School, Beijing, People's Republic of China
| | - Kan Liu
- Department of Urology, State Key Laboratory of Kidney Diseases, Chinese People's Liberation Army General Hospital, PLA Medical School, Beijing, People's Republic of China
| | - Qingbo Huang
- Department of Urology, State Key Laboratory of Kidney Diseases, Chinese People's Liberation Army General Hospital, PLA Medical School, Beijing, People's Republic of China
| | - Yu Gao
- Department of Urology, State Key Laboratory of Kidney Diseases, Chinese People's Liberation Army General Hospital, PLA Medical School, Beijing, People's Republic of China
| | - Liangyou Gu
- Department of Urology, State Key Laboratory of Kidney Diseases, Chinese People's Liberation Army General Hospital, PLA Medical School, Beijing, People's Republic of China
| | - Xin Ma
- Department of Urology, State Key Laboratory of Kidney Diseases, Chinese People's Liberation Army General Hospital, PLA Medical School, Beijing, People's Republic of China
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Campi R, Tellini R, Sessa F, Mari A, Cocci A, Greco F, Crestani A, Gomez Rivas J, Fiori C, Lapini A, Gallucci M, Capitanio U, Roupret M, Abaza R, Carini M, Serni S, Ficarra V, Porpiglia F, Esperto F, Minervini A. Techniques and outcomes of minimally-invasive surgery for nonmetastatic renal cell carcinoma with inferior vena cava thrombosis: a systematic review of the literature. MINERVA UROL NEFROL 2019; 71:339-358. [PMID: 30957477 DOI: 10.23736/s0393-2249.19.03396-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Current guidelines recommend considering surgical excision of non-metastatic renal cell carcinoma (RCC) with inferior vena cava (IVC) thrombosis in patients with acceptable performance status. Of note, several authors have pioneered specific techniques for laparoscopic and robotic management of renal cancer with level I-IV IVC thrombosis. EVIDENCE ACQUISITION A systematic review of the English-language literature on surgical techniques and perioperative outcomes of minimally-invasive radical nephrectomy (RN) and IVC thrombectomy for nonmetastatic RCC was performed without time filters using the MEDLINE (via PubMed), Cochrane Central Register of Controlled Trials and Web of Science (WoS) databases in September 2018 according to the PRISMA statement recommendations. EVIDENCE SYNTHESIS Overall, 28 studies were selected for qualitative analysis (N.=13 on laparoscopic surgery, N.=15 on robotic surgery). The quality of evidence according to GRADE was low. Laparoscopic techniques included hand-assisted, hybrid and pure laparoscopic approaches. Most of these series included right-sided tumors with predominantly level I or II IVC thrombi. Similarly, most robotic series reported right-sided RCC with level I-II IVC thrombosis; yet, few authors extended the indication to level III thrombi and to left-sided RCC. Surgical techniques for minimally-invasive IVC thrombectomy evolved over the years, with specific technical nuances aiming to tailor surgical strategy according to both tumor side and thrombus extent. Among the included studies, perioperative outcomes were promising. CONCLUSIONS Minimally-invasive surgery is technically feasible and has been shown to achieve acceptable perioperative outcomes in selected patients with renal cancer and IVC thrombosis. The evidence is premature to draw conclusions on intermediate-long term oncologic outcomes. Robotic surgery allowed to extend surgical indications to more challenging cases with more extensive tumor thrombosis. Nonetheless, global experience on minimally-invasive IVC thrombectomy is limited to high-volume surgeons at high-volume Centers. Future research is needed to prove its non-inferiority as compared to open surgery and to define its benefits and limits.
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Affiliation(s)
- Riccardo Campi
- Department of Urology, Careggi University Hospital, Florence, Italy - .,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy -
| | - Riccardo Tellini
- Department of Urology, Careggi University Hospital, Florence, Italy
| | - Francesco Sessa
- Department of Urology, Careggi University Hospital, Florence, Italy
| | - Andrea Mari
- Department of Urology, Careggi University Hospital, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Andrea Cocci
- Department of Urology, Careggi University Hospital, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | | | - Alessandro Crestani
- Unit of Urology, Santa Maria della Misericordia Academic Medical Center Hospital, Udine, Italy
| | - Juan Gomez Rivas
- Department of Urology, La Paz University Hospital, Madrid, Spain
| | - Cristian Fiori
- Department of Urology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
| | - Alberto Lapini
- Department of Urology, Careggi University Hospital, Florence, Italy
| | - Michele Gallucci
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy
| | - Umberto Capitanio
- Unit of Urology, San Raffaele Hospital IRCCS, Vita-Salute San Raffaele University, Milan, Italy.,Unit of Renal Cancer, Division of Oncology, Urological Research Institute (URI), San Raffaele Hospital IRCCS, Milan, Italy
| | - Morgan Roupret
- Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Ronney Abaza
- Unit of Robotic Urologic Surgery, Ohio Health Dublin Methodist Hospital, Columbus, OH, USA
| | - Marco Carini
- Department of Urology, Careggi University Hospital, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Sergio Serni
- Department of Urology, Careggi University Hospital, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Vincenzo Ficarra
- Department of Human Pathology of Adult and Evolutive Age, University of Messina, Messina, Italy
| | - Francesco Porpiglia
- Department of Urology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
| | | | - Andrea Minervini
- Department of Urology, Careggi University Hospital, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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Tohi Y, Makita N, Suzuki I, Suzuki R, Kubota M, Sugino Y, Inoue K, Kawakita M. En bloc laparoscopic radical nephrectomy with inferior vena cava thrombectomy: A single-institution experience. Int J Urol 2018; 26:363-368. [PMID: 30508876 DOI: 10.1111/iju.13873] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 11/04/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To report the outcomes of laparoscopic radical nephrectomy with inferior vena cava thrombectomy for right renal cell carcinoma at Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan. METHOD A retrospective review of the clinical records of five patients who underwent laparoscopic radical nephrectomy with inferior vena cava thrombectomy for right renal cell carcinoma between 2013 and 2017 was carried out. The surgical procedure included ligation and cutting of the right renal artery, followed by kidney mobilization. The left renal vein, and the caudal and cephalad sides of the inferior vena cava thrombus were clamped using laparoscopic vascular clamps, and the inferior vena cava was incised. The free kidney and tumor thrombus were placed en bloc in a retrieval bag. Subsequently, the inferior vena cava was laparoscopically closed using a continuous suture. RESULTS The median operative time, pneumoperitoneum time, blood loss and postoperative hospital stay were 316 min, 266 min, 400 mL and 7 days, respectively. The median clamp time was 28 min (range 13-105 min). One patient (20%) required a perioperative blood transfusion. The surgical margin was negative in all patients. Only one patient experienced a major complication (Clavien-Dindo grade ≥3), namely a postoperative hemorrhage requiring transarterial embolism. CONCLUSION En bloc laparoscopic radical nephrectomy with inferior vena cava thrombectomy is a challenging yet feasible procedure for experienced surgeons in carefully selected patients. Further studies of this surgical procedure are required for standardization and safe application.
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Affiliation(s)
- Yoichiro Tohi
- Department of Urology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Noriyuki Makita
- Department of Urology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Issei Suzuki
- Department of Urology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Ryosuke Suzuki
- Department of Urology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Masashi Kubota
- Department of Urology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Yoshio Sugino
- Department of Urology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Koji Inoue
- Department of Urology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Mutsushi Kawakita
- Department of Urology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
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Phung MC, Lee BR. Recent advancements of robotic surgery for kidney cancer. Asian J Endosc Surg 2018; 11:300-307. [PMID: 30168283 DOI: 10.1111/ases.12635] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 06/27/2018] [Accepted: 07/03/2018] [Indexed: 01/20/2023]
Abstract
Surgical management of renal cell carcinoma has undergone a transformation in recent decades, especially with the dissemination of the robotic platform. Increasingly, larger and more complex renal lesions are now being treated in a minimally invasive fashion. The purpose of this article is to review advances in the use of the robotic approach for treatment of renal cell carcinoma, including nephron-sparing surgery, radical nephrectomy, and cytoreductive nephrectomy.
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Affiliation(s)
- Michael C Phung
- Division of Urology, Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Benjamin R Lee
- Division of Urology, Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona, USA
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Robotic-assisted Laparoscopic Nephrectomy with Vein Thrombectomy: Initial Experience and Outcomes from a Single Surgeon. Curr Med Sci 2018; 38:834-839. [PMID: 30341517 DOI: 10.1007/s11596-018-1950-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 05/21/2018] [Indexed: 10/28/2022]
Abstract
This study was designed to explore the safety and feasibility of robotic-assisted laparoscopic nephrectomy with vein thrombectomy (RAL-NVT) for the treatment of renal cell carcinoma (RCC) with venous tumor thrombus (VTT). Clinical data of 6 patients treated with RAL-NVT between July 2016 and November 2017 in our hospital were retrospectively collected and analyzed. There were 5 males and 1 female with their age ranging from 48 years to 68 years. Five renal tumors were right-sided and one left-sided. Three cases fell in level 0 VTT, one in level I and two in level II. Preoperative imaging revealed lymph node involvement in 1 case and distant metastasis in 2 cases. For RCC with level 0 VTT, the renal vein of the affected side was adequately and carefully dissected around the thrombus to the proximity of inferior vena cava (IVC) and was ligated with Hem-o-loks without cross-clamping the IVC. For level I and II VTT, the IVC was crossclamped cephalically and caudally around the tumor thrombus and all tributaries were sequentially blocked to ensure the safe retrieval of VTT. All operations were successfully completed without conversion to open operation. The mean operative time was 150 (115-230) min. Cross-clamping of the IVC happened in 3 cases, and the blocking time was 14, 19 and 20 min, respectively. The mean estimated blood loss during the operation was 400 (200-580) mL. The peritoneal drainage tube was removed 5 to 9 days after the operation, and all patients were postoperatively discharged at 6 to 11 days. Postoperative pathological analysis confirmed that the RCCs were comprised of 4 clear cell RCCs, 1 papillary cell RCC, and 1 medullary cell RCC; 2 cases were Fuhrman grade II, 3 cases grade III, and 1 case undefined grade. No recurrence or progression was observed during the follow-up of 4.2 (3-6) months. We concluded that RAL-NVT is highly challenging but safe and feasible for the treatment of RCC with VTT.
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Estébanez Zarranz J, Belloso Loidi J, Gutierrez García M, Rubio Calaveras V, Morales Higelmo G, Melendo Tercilla P, Busto Leis L, Sanz Jaka J. Radical robot-assisted laparoscopic nephrectomy with thrombectomy in the vena cava. Actas Urol Esp 2018; 42:538-541. [PMID: 29699882 DOI: 10.1016/j.acuro.2018.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 02/26/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Renal cell carcinoma has a natural tendency to extend through the renal vein. When the thrombus reaches the vena cava, thrombectomy and the necessary reconstruction of the vena cava are typically performed by open pathway. Robot-assisted technology provides advantages for performing this complex technique, using a minimally invasive access. MATERIAL AND METHODS We present the technique we employed in the first case performed in our department. After performing renal artery embolisation, we conducted the surgery with the Vinci S robotic system. The main steps of the surgery are as follows: detachment and Kocher manoeuvre; release of the lower renal pole; clamping and sectioning of the renal artery; endocavitary ultrasound to locate the thrombus; placement of tourniquets in the vena cava below and above the renal veins and in the left renal vein; closure of the 3 tourniquets; opening of the vena cava; resection and extraction of the thrombus; suture of the vena cava; opening of the tourniquets; complete release of the kidney; bagging and extraction of the specimen. RESULTS The surgery was performed without complications. The patient required a transfusion of 2 units of packed red blood cells and was discharged with modest renal failure (creatinine level of 1.60mg/dl). CONCLUSIONS Radical nephrectomy with thrombectomy in the vena cava is a technique susceptible to severe complications and has, to date, been performed in few centres. We believe that the technique is reproducible and has clear advantages for our patients.
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Zhang X, Wang B. Robot-assisted Surgery for Renal Cell Carcinoma with Caval Thrombosis. Eur Urol Focus 2018; 4:639-640. [DOI: 10.1016/j.euf.2018.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 06/07/2018] [Indexed: 11/16/2022]
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Robotic Inferior Vena Cava Thrombectomy: Are We Entering the House Through an Attic Window? Eur Urol Focus 2018; 4:641-642. [DOI: 10.1016/j.euf.2018.10.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 10/10/2018] [Accepted: 10/23/2018] [Indexed: 11/18/2022]
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Abstract
Twenty years after it was introduced, robotic surgery has become more commonplace in urology – we examine its current uses and controversies
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Reply by Authors. J Urol 2018; 199:1352. [PMID: 29428636 DOI: 10.1016/j.juro.2017.12.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Aghazadeh MA, Goh AC. Robotic Left-sided Level II Caval Thrombectomy and Nephrectomy Using a Novel Supine, Single-dock Approach: Primary Description. Urology 2018; 112:205-208. [DOI: 10.1016/j.urology.2017.10.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 10/10/2017] [Accepted: 10/13/2017] [Indexed: 10/18/2022]
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Robot-assisted Retrohepatic Inferior Vena Cava Thrombectomy: First or Second Porta Hepatis as an Important Boundary Landmark. Eur Urol 2017; 74:512-520. [PMID: 29223604 DOI: 10.1016/j.eururo.2017.11.017] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 11/17/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Robot-assisted retrohepatic inferior vena cava (IVC) thrombectomy (RA-R-IVCTE) has been reported only for limited series. OBJECTIVE To describe in detail the techniques for RA-R-IVCTE with regard to the relationship of a proximal thrombus to either the first porta hepatis (FPH) or second porta hepatis (SPH). DESIGN, SETTING, AND PARTICIPANTS From May 2013 to July 2016, 22 patients with R-IVC tumor thrombi were admitted to our hospital. SURGICAL PROCEDURE RA-R-IVCTE was performed using the Rummel tourniquet technique. For a proximal thrombus inferior to the FPH, we ligated some short hepatic veins (SHVs; typically 1-3). For a thrombus between the FPH and SPH, we mobilized the right lobe of the liver from the IVC by ligating additional SHVs. For a thrombus near or above the SPH but below the diaphragm, we mobilized both the right and left lobes of the liver to obtain high proximal control of the suprahepatic and infradiaphragmatic IVC, and simultaneously clamped the FPH. MEASUREMENTS Detailed techniques were described for various scenarios and perioperative outcomes were recorded. RESULTS AND LIMITATIONS The median operation time was 285min (interquartile range [IQR] 191-390). Intraoperative estimated blood loss was 1350ml (IQR 1000-2075ml). Some 63.6% of patients required an intraoperative blood transfusion and 68% were transferred to the intensive care unit after surgery. Grade IV complications developed in five cases. Vascular injuries (4 cases) were treated with intraoperative endoscopic sutures. An intestinal fistula was found on postoperative day 7 in one case; treatment with gastrointestinal decompression and drainage resolved the condition by 1 mo. CONCLUSIONS Even though the risks involved are high, RA-R-IVCTE is feasible for selected patients. The FPH/SPH is an important boundary landmark for RA-R-IVCTE. The location of proximal IVC tumor thrombi in relation to the FPH or SPH should determine the technique used. PATIENT SUMMARY Robot-assisted thrombectomy for retrohepatic inferior vena cava tumor thrombus is feasible in selected patients.
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Silva MA, See AP, Shah SK, Khandelwal P, Patel NJ, Lyu H, Menard MT, Aziz-Sultan MA. Endovascular Renal Artery Stent Retriever Embolectomy in a Young Patient With Cardiac Myxoma: Case Report and Review of the Literature. Vasc Endovascular Surg 2017; 52:70-74. [DOI: 10.1177/1538574417739746] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Purpose: Cardiac myxomas are common tumors of the heart with disproportionate impact on young patients, occasionally with dramatic systemic dissemination of tumor emboli with catastrophic multiorgan system ischemia. The coincident comorbidities can increase the risk of traditional treatments for tumor embolus in each region. Case report: A young patient with previously unknown cardiac myxoma presented with seizure and was found to have stress cardiomyopathy, multiple cerebral large vessel occlusions with acute ischemic stroke, bilateral lower extremity tumor emboli and rhabdomyolysis, and renal tumor embolus with acute tubular necrosis. We describe a multidisciplinary approach applying cerebrovascular stent retriever devices in tumor embolectomy of the renal artery of a young patient with systemic morbidity, preventing safe laparotomy for open surgical tumor embolectomy. Conclusion: We describe 2-month renal function outcomes and the considerations in applying a neuroendovascular mechanical thrombectomy device within the renal artery. This was a radiographically successful technique and her renal function appears to be improving at the 2-month follow-up, although this is complicated by other renal insults and support.
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Affiliation(s)
- Michael A. Silva
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Alfred P. See
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Samir K. Shah
- Division of Vascular Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Priyank Khandelwal
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Nirav J. Patel
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Heather Lyu
- Division of Vascular Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Matthew T. Menard
- Division of Vascular Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Mohammad Ali Aziz-Sultan
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Abstract
Robot assistance has been rapidly adopted by urological surgeons and has become particularly popular for oncological procedures involving the retroperitoneal space. The wide dissemination of robot assistance probably reflects the limited amount of operating space available within the retroperitoneum and the advantages provided by robot-assisted approaches, including 3D imaging, wristed instrumentation and the shorter learning curve compared with that associated with the equivalent laparoscopic techniques. Surgical procedures that have traditionally been performed using an open or laparoscopic approach, such as partial nephrectomy, radical nephrectomy, retroperitoneal lymph node dissection, nephroureterectomy and adrenalectomy, are now often being performed using robot assistance. The frontiers of robot-assisted retroperitoneal oncological surgery are constantly expanding, with an emphasis on maintaining oncological and functional outcomes, while minimizing the level of surgical invasiveness.
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Cadeddu JA. The Initial Case of Laparoscopic Nephrectomy. J Urol 2016; 197:S187-S188. [PMID: 28010962 DOI: 10.1016/j.juro.2016.10.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Jeffrey A Cadeddu
- Department of Urology, University of Texas, Southwestern Medical Center, Dallas, Texas
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Abaza R, Eun DD, Gallucci M, Gill IS, Menon M, Mottrie A, Shabsigh A. Robotic Surgery for Renal Cell Carcinoma with Vena Caval Tumor Thrombus. Eur Urol Focus 2016; 2:601-607. [DOI: 10.1016/j.euf.2017.01.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 12/18/2016] [Accepted: 01/04/2017] [Indexed: 11/25/2022]
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