A Decade of Robotic-Assisted Radical Nephrectomy with Inferior Vena Cava Thrombectomy: A Systematic Review and Meta-Analysis of Perioperative Outcomes

Surgical and Oncological Outcomes of Level III-IV Versus Level I-II Inferior Vena Cava Thrombectomy: A Decennial Experience of a High-Volume European Referral Center

BACKGROUND

In patients with renal cell carcinoma (RCC) the role of the extent of tumor thrombus into the inferior vena cava (IVC) has never been addressed from a surgical and oncologic standpoint. This study aims to evaluate differences between level III-IV versus level I-II patients concerning peri- and postoperative morbidity, additional treatments and long-term oncological outcomes.

PATIENTS AND METHODS

Overall, 40 patients with RCC underwent radical nephrectomy (RN) with IVC thrombectomy at a single European institution between 2010 and 2023. Complications were reported according to the European Union (EAU) guidelines recommendations. Spider chart served as graphical depiction of surgical and oncologic outcomes.

RESULTS

Overall, 22 (55%) and 18 (45%) patients harbored level III-IV and I-II IVC thrombus. Level III-IV patients experienced significantly higher rates of intraoperative transfusions (68 vs 39%), but not significantly higher rates of intraoperative complications (32% vs 28%). Level III-IV patients had significantly higher rates of postoperative transfusions (82% vs 33%) and Clavien Dindo ≥3 complications (41% vs 15%). In level III-IV versus level I-II patients, median follow up was 482 and 1070 days, the rate of distant recurrence was 59% and 50%, the rate of systemic progression was 27% and 13%, and the rate of additional treatment/s was 64% and 61%, respectively (all p values > 0.05). Overall survival was 36% in level III-IV patients and 67% in level I-II (p = 0.001).

CONCLUSIONS

Our findings suggest that patients with level III-IV RCC who are candidates for IVC thrombectomy should be counselled about the higher likelihood of postoperative severe adverse events and worse overall survival relative to level I-II counterparts.

A nomogram predicting intraoperative adverse events during minimally invasive radical nephrectomy and thrombectomy

BACKGROUND

To define the incidence and independent predictive factors of intraoperative adverse events (IOAEs) after minimally invasive radical nephrectomy and thrombectomy (RNAT) and to determine the impact of intraoperative adverse events on oncological outcomes.

PATIENTS AND METHODS

A total of 294 patients underwent minimally invasive RNAT from January 2010 to December 2023 in our center were included. IOAEs are defined as any deviation from the normal surgical procedure during the operation course. Multivariate logistic regression analysis was performed to identify the independent predictive factors of IOAEs. The Kaplan-Meier curves was used to compare overall survival and cancer-specific survival between patients with IOAEs or not.

RESULTS

Seventy-four IOAEs occurred in 57 of 294 patients (19.4%) and the most frequent IOAEs were conversion to open surgery (42/74, 56.7%), followed by excessive hemorrhage (20/74, 27.0%). In multivariate logistic analysis, side (OR 0.0929; 95%Cl 0.0367-0.2160; p < 0.001), operation approach (OR 0.1762; 95%Cl 0.06828-0.4109; p < 0.001), and Mayo grade (OR 6.321; 95%Cl 3.846-11.13; p < 0.001) were independent predictive predictors of IOAEs during minimally invasive RNAT. IOAEs (OR 2.713; 95%Cl 1.242-5.897; p = 0.012) was an independent risk factor of the occurrence of postoperative complications. Between the patients with IOAEs or not, neither overall survival (OS) nor cancer-specific survival (CSS) showed statistical differences. Patients with postoperative complications show shorter OS and CSS.

CONCLUSION

We found that the independent predictive factors of  minimally invasive RNAT were side, operation approach and Mayo grade, and it is a risk factor of the occurrence of postoperative complications. In addition, the occurrence of IOAEs had no effect on long-term oncological outcomes.

Robot-assisted vascular surgery: literature review, clinical applications, and future perspectives

Although robot-assisted surgical procedures using the da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA) have been performed in more than 13 million procedures worldwide over the last two decades, the vascular surgical community has yet to fully embrace this approach (Intuitive Surgical Investor Presentation Q3 (2023) https://investor.intuitivesurgical.com/static-files/dd0f7e46-db67-4f10-90d9-d826df00554e . Accessed February 22, 2024). In the meantime, endovascular procedures revolutionized vascular care, serving as a minimally invasive alternative to traditional open surgery. In the pursuit of a percutaneous approach, shorter postoperative hospital stay, and fewer perioperative complications, the long-term durability of open surgical vascular reconstruction has been compromised (in Lancet 365:2179-2186, 2005; Patel in Lancet 388:2366-2374, 2016; Wanhainen in Eur J Vasc Endovasc Surg 57:8-93, 2019). The underlying question is whether the robotic-assisted laparoscopic vascular surgical approaches could deliver the robustness and longevity of open vascular surgical reconstruction, but with a minimally invasive delivery system. In the meantime, other surgical specialties have embraced robot-assisted laparoscopic technology and mastered the essential vascular skillsets along with minimally invasive robotic surgery. For example, surgical procedures such as renal transplantation, lung transplantation, and portal vein reconstruction are routinely being performed with robotic assistance that includes major vascular anastomoses (Emerson in J Heart Lung Transplant 43:158-161, 2024; Fei in J Vasc Surg Cases Innov Tech 9, 2023; Tzvetanov in Transplantation 106:479-488, 2022; Slagter in Int J Surg 99, 2022). Handling and dissection of major vascular structures come with the inherent risk of vascular injury, perhaps the most feared complication during such robotic procedures, possibly requiring emergent vascular surgical consultation. In this review article, we describe the impact of a minimally invasive, robotic approach covering the following topics: a brief history of robotic surgery, components and benefits of the robotic system as compared to laparoscopy, current literature on "vascular" applications of the robotic system, evolving training pathways and future perspectives.

Bibliometric analysis of renal cell carcinoma with venous tumor thrombus

Objectives: To identify the cooperation of authors, countries, institutions and explore the hot spots regarding research of renal cell carcinoma with venous tumor thrombus. Methods: Relevant articles were obtained from the Web of Science Core database (WoSC) from 1999 to 2024. CiteSpace was used to perform the analysis and visualization of scientific productivity and emerging trends. Network maps were generated to evaluate the collaborations between different authors, countries, institutions, and keywords. Results: A total of 2180 related articles were identified. We observed an increased enthusiasm in related fields during the past two decades. The USA dominated the field in all countries, and the University of Miami was the core institution. Ciancio G might have a significant influence with more publications and co-citations. Current research hotspots in this field mainly included thrombectomy, tyrosine kinase inhibitors, immune checkpoint inhibitors, vena cava inferior, and microvascular invasion. Thrombectomy complications, thrombectomy survival outcome, and preoperative neoadjuvant immunotherapy represented the frontiers of research in this field, undergoing an explosive phase. Conclusion: This is the first bibliometric study that comprehensively visualize the research trends and status of RCC with VTT. We hope that this work will provide new ideas for advancing the scientific research and clinical application.

A Contemporary Clinicopathologic Analysis of Patients With Renal Cell Carcinoma and Vena Cava Involvement

Renal cell carcinoma (RCC) is occasionally associated with vena cava involvement. Despite recent advances in therapeutic modalities, the 5-year survival in this population continues to be poor. Therefore, further studies are required to better characterize this patient population, especially from the clinicopathologic standpoint. A comprehensive review of patients with RCC and vena cava involvement managed at our institution from 2014 to 2022 was performed. Multiple clinicopathologic parameters including follow-up were obtained. A total of 114 patients were identified. The mean patient age was 63 years (range: 30-84 years). The cohort consisted of 78/114 (68%) males and 36/114 (32%) females. The mean primary tumor size (excluding tumor thrombus) was 11 cm. The majority of tumors (104/114, 91%) were unifocal. Tumor stages were categorized as follows: pT3b (51/114, 44%), pT3c (52/114, 46%), and pT4 (11/114, 10%). Most of the tumors were clear cell RCC 89/114 (78%), although other more aggressive RCC subtypes were also present. Most tumors were WHO/ISUP grade 3 (44/114, 39%) or 4 (67/114, 59%) with sarcomatoid differentiation present in 39/67 (58%). Necrosis was present in 94/114 (82%) tumors. Twenty-three of 114 (20%) tumors were categorized as pM1 and the ipsilateral adrenal gland was the most common site of metastasis. Of the 91 patients categorized as pM, not applicable at nephrectomy, 42/91 (46%) subsequently developed metastasis, most frequently to the lung. Of all patients, only 16/114 (14%) had positive vascular margins and 7/114 (6%) had positive soft tissue margins despite having very advanced disease and a subset considered inoperable at other centers.

Robotic Vena Cava Thrombectomy with Three-dimensional Augmented Reality Guidance

Robotic surgery has recently been used for treatment of renal cell carcinoma (RCC) and neoplastic thrombus located in the renal vein or inferior vena cava (IVC). Accurate identification of the thrombus location is crucial, and three-dimensional augmented reality (3D AR) may be valuable in achieving this. We enrolled patients with nonmetastatic RCC and level 0-I venous thrombus (Mayo Clinic classification) for robot-assisted radical nephrectomy and thrombectomy with 3D AR guidance. Five patients were prospectively enrolled; three had a level 0 thrombus and two had a level I thrombus. The mean operative time was 123 ± 15 min, mean IVC clamping time was 9.4 ± 6.8 min, and mean estimated blood loss was 750 ± 150 ml. The AR system allowed precise estimation of the thrombus location in all cases. No intraoperative complications or postoperative Clavien-Dindo grade >2 complications occurred. Use of 3D AR guidance allowed correct estimation of the limits of the thrombus and guided the surgeon in selecting an appropriate surgical strategy.

Neoadjuvant therapy in renal cell carcinoma with tumor thrombus: A systematic review and meta-analysis

To evaluate the efficacy, feasibility and safety of neoadjuvant therapy (NAT) for renal cell carcinoma with tumor thrombus (RCC-TT) in terms of response, perioperative and oncological outcomes, and compare the results between neoadjuvant and non-neoadjuvant groups. Overall, 29 single-arm studies and 5 cohort studies were included. Of the 204 patients undergoing NAT, 16.2% were level I, 35.3% level II, 24.0% level III and 18.6% level IV thrombus. Most of patients underwent preoperative targeted therapy, immunotherapy-based combination therapy was applied in 5.4% patients. The total reduction rate of thrombus level was 29.4%. NAT is associated with a shorter operative time, less blood loss (p<0.05 for both). Rate of complications and oncological outcomes were similar between two groups. Overall, 32.1% (34/106) ≥ grade 3 adverse events occurred in patients undergoing NAT. Neoadjuvant therapy is safe and feasible with acceptable perioperative outcomes in RCC-TT.

A Narrative Review on Robotic Surgery as Treatment for Renal Cell Carcinoma with Inferior Vena Cava Thrombus

Renal cell carcinoma (RCC) is a common diagnosis, of which a notable portion of patients present with an extension into the venous circulation causing an inferior vena cava (IVC) tumor thrombus. Venous extension has significant implications for staging and subsequent treatment planning, with recommendations for more aggressive surgical removal, although associated surgical morbidity and mortality is relatively increased. The methods for surgical removal of RCC with IVC thrombus remain complex, particularly surrounding the use of robot-assisted surgery. Robot assistance for radical nephrectomy in this context is recently emerging. Thrombus level has important implications for surgical technique and prognosis. Other preoperative considerations may include location, laterality, size, and wall invasion. The urology literature on treatment of such tumors is largely limited to case series and institutional studies that describe the feasibility of various surgical options for these complex tumors. Further understanding of the outcomes and patient-specific risk factors would shed increased light on the optimal treatment for such cases. This narrative review provides a thorough overview on the previously reported use of robot-assisted nephrectomy in RCC with IVC thrombus to inform further studies which may optimize outcomes and guide shared decision-making.

Sarcomatoid renal cell carcinoma with an inferior vena cava tumor thrombus that was completely resected by robot-assisted laparoscopic radical nephrectomy after neoadjuvant therapy nivolumab plus ipilimumab: a case report

We here present a patient with a sarcomatoid renal cell carcinoma complicated by inferior vena cava tumor thrombus that we treated with nivolumab plus ipilimumab. This resulted in shrinkage of the tumor, enabling complete resection by robot-assisted laparoscopic radical nephrectomy. The patient is still alive with no evidence of recurrence.

Robot-assisted radical nephrectomy with inferior vena cava thrombectomy: a case report

Background

Recently, robot-assisted surgery has been widely used to treat several urological cancers. Robot-assisted radical nephrectomy (RARN) was approved by the health insurance system in April 2022; however, RARN with inferior vena cava tumor thrombectomy (IVCTT) is still challenging. Also, its safety and feasibility have not yet been established owing to lack of literature, especially in Japan.

Case Description

We performed RARN with IVCTT in four patients between April 2022 and March 2023 at Fujita Health University Hospital. To reduce the risk of tumor embolism and major hemorrhage, an "IVC-first, kidney-last" robotic technique was developed. The safety and feasibility of RARN with IVCTT were evaluated by assessing the perioperative outcomes. Three women and one man were enrolled in this study. The median age was 72 years, and the tumor was on the right side in all cases. According to the Mayo Clinic thrombus classification, two patients were classified as level I, and the others were classified as level II. The two patients at level I did not undergo presurgical treatments, whereas the others at level II underwent presurgical treatments, which were combinations of tyrosine kinase inhibitors and immune-checkpoint inhibitors. The median operation and console times were 341 and 247 min, respectively. The median bleeding volume was 577 mL, and no complications beyond grade III of the Clavien-Dindo classification were observed. The median length of postoperative hospital stay was 10 days.

Conclusions

Although the sample size was relatively small, we demonstrated the safety and feasibility of RARN with IVCTT in the Japanese population.