Robotic surgery and minimally invasive management of renal tumors with vena caval extension

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.

Surgical management of renal cell carcinoma with subhepatic inferior vena cava tumor thrombus: a case report and review of the literature

BACKGROUND

Renal cell carcinomas are the most common form of kidney cancer in adults. In addition to metastasizing in lungs, soft tissues, bones, and the liver, it also spreads locally. In 2-10% of patients, it causes a thrombus in the renal or inferior vena cava vein; in 1% of patients thrombus reaches the right atrium. Surgery is the only curative option, particularly for locally advanced disease. Despite the advancements in laparoscopic, robotic and endovascular techniques, for this group of patients, open surgery continues to be among the best options.

CASE REPORT

Here we present a case of successful tumor thrombectomy from the infrahepatic inferior vena cava combined with renal vein amputation and nephrectomy. Our patient, a 58 year old Albanian woman presented to the doctors office with flank pain, weight loss, fever, high blood pressure, night sweats, and malaise. After a comprehensive assessment, which included urine analysis, complete blood count, electrolytes, renal and hepatic function tests, as well as ultrasonography and computed tomography, she was diagnosed with left kidney renal cell carcinoma involving the left renal vein and subhepatic inferior vena cava. After obtaining informed consent from the patient we scheduled her for surgery, which went well and without complications. She was discharged one week after to continue treatment with radiotherapy, chemotherapy, and immunotherapy.

CONCLUSION

Open surgery is a safe and efficient way to treat renal cell carcinoma involving the renal vein and inferior vena cava. It is superior to other therapeutic modalities. When properly done it provides acceptable long time survival and good quality of life to patients.

Current Approaches in Surgical and Immunotherapy-Based Management of Renal Cell Carcinoma with Tumor Thrombus

Renal cell carcinoma (RCC) accounts for 2-3% of all malignant disease in adults, with 30% of RCC diagnosed at locally advanced or metastatic stages of disease. A form of locally advanced disease is the tumor thrombus (TT), which commonly grows from the intrarenal veins, through the main renal vein, and up the inferior vena cava (IVC), and rarely, into the right cardiac chambers. Advances in all areas of medicine have allowed increased understanding of the underlying biology of these tumors and improved preoperative staging. Although the development of several novel system agents, including several clinical trials utilizing immune checkpoint inhibitors and combination therapies, has been shown to lower perioperative morbidity and increase post-operative recurrence-free and progression-free survival, surgery remains the mainstay of therapy to achieve a cure. In this review, we provide a description of specific surgical approaches and techniques used to minimize intra- and post-operative complications during radical nephrectomy and tumor thrombectomy of RCC with TT extension of various levels. Additionally, we provide an in-depth review of the major developments in neoadjuvant and adjuvant immunotherapy-based treatment and the impact of ongoing and recently completed clinical trials on the surgical treatment of advanced RCC.

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

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.

Surgical treatment of renal cell carcinoma with inferior vena cava tumor thrombus

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.

Recent advancements of robotic surgery for kidney cancer

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.

Robotic-assisted Laparoscopic Nephrectomy with Vein Thrombectomy: Initial Experience and Outcomes from a Single Surgeon

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.

Impact of Microscopic Wall Invasion of the Renal Vein or Inferior Vena Cava on Cancer-specific Survival in Patients with Renal Cell Carcinoma and Tumor Thrombus: A Multi-institutional Analysis from the International Renal Cell Carcinoma-Venous Thrombus Consortium

BACKGROUND

Microscopic vein invasion (MVI), with local destruction and invasion of the endothelium by tumor, is of controversial predictive value in renal cell carcinoma (RCC).

OBJECTIVE

To assess the impact of venous extension and wall invasion in RCC on survival.

DESIGN, SETTING, AND PARTICIPANTS

Data for 1023 RCC patients with vena cava thrombus treated with radical nephrectomy and complete tumor thrombectomy were collected within a prospectively maintained international consortium (1995-2012).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The Kaplan-Meier method and univariable and multivariable Cox regression analyses were used to assess the impact of MVI on cancer-specific survival (CSS). The main two variables of interest were microscopic renal vein wall invasion (MRVI) and microscopic vena cava wall invasion (MVCI).

RESULTS

MRVI was found in 725 cases (70.9%) and MVCI in 230 (22.5%). Patients with MRVI had larger tumors (p=0.005), longer hospital stay (p<0.001), higher clinical stage 0.039), higher Fuhrman grade (p=0.028), and more frequent fat invasion. Presence of MVCI was associated with larger tumors (p<0.001), longer hospital stay (p<0.001), higher clinical stage (p<0.001), lymph node involvement (p=0.045), higher Fuhrman grade (p<0.001), and higher thrombus level (p<0.001). With median follow-up of 52 mo, overall 5-yr CSS was 57.4%. Multivariable analysis showed that presence of MRVI was an independent factor related to CSS (hazard ratio 2.24, 95% confidence interval 1.24-3.59, p=0.006). The main limitation was the inability to report MVI percentages.

CONCLUSIONS

Patients with MRVI experience significantly worse survival outcomes after radical nephrectomy and tumor thrombectomy. Consideration of MRVI at final pathology is appropriate to improve decision-making for risk-adapted follow-up.

PATIENT SUMMARY

The behavior of locally advanced renal cell carcinoma (RCC) depends on clinical and pathologic factors. Analysis revealed that RCC patients with microscopic renal vein wall invasion experience significantly worse cancer-specific survival.

Robot-assisted retroperitoneal lymph node dissection: Feasibility and outcome in postchemotherapy residual mass in testicular cancer

INTRODUCTION

We aimed to evaluate the surgical feasibility, complication, and oncological outcome of robot-assisted retroperitoneal lymph node dissection (RA-RPLND) in patients of testicular tumor with postchemotherapy residual retroperitoneal mass.

METHODS

A total of 13 patients underwent RA-RPLND between January 2012 and September 2016 at our institute. A study was started on December 2015, so data were collected retrospectively and prospectively regarding patient demography, tumor characteristics, surgical, pathological outcome, and oncological outcome.

RESULTS

RA-RPLND was successfully completed in all the 13 patients. Lateral approach was used in initial 12 patients with unilateral dissection in 11 patients and bilateral dissection after in 1 patient after repositioning in bilateral position. Supine robotic approach used in 1 patient. Median operative time was 200 min, median estimated blood loss was 120 ml, and median length of hospital stay was 4 days. The median yield of lymph node was 20. Three patients had positive lymph nodes, all had teratoma germ cell tumor. Ten patients had only necrosis in lymph nodes. After median follow-up 23 months (range 3-58 months), no systemic or retroperitoneal recurrence was found. Four patients developed chyle leak. One patient was managed conservatively with diet modification, one with intranodal lipiodol lymphangiography and two patients were managed surgically.

CONCLUSION

RA-RPLND is safe and feasible for postchemotherapy residual mass with accepted compilation rate, but larger studies are required to establish its diagnostic and therapeutic utility along with safety of the procedure.

Laparoscopic partial nephrectomy

Laparoscopic partial nephrectomy (LPN) compares favorably to traditional open nephron-sparing surgery (NSS) in terms of oncologic and surgical principles for kidney tumors. Studies have shown the modality to be feasible with similar oncologic efficacy and superior renal functional outcomes compared with laparoscopic radical nephrectomy (LRN) for tumors. The main advantages of LPN include marked improvements in estimated blood loss, decreased surgical site pain, shorter postoperative convalescence, better cosmesis, and nephron preservation. This review article evaluates the literature regarding LPN and discusses the main steps of the operation, the perioperative workup and management, surgical complications, and its role in the surgical management of kidney masses.

Robot-assisted Laparoscopic Retroperitoneal Lymph Node Dissection for Testicular Cancer: Evolution of the Technique

BACKGROUND

Retroperitoneal lymph node dissection (RPLND) is an accepted staging and treatment option for nonseminomatous germ cell tumor. Robotic surgery offers technical advantages and is being increasingly used in urologic procedures.

OBJECTIVE

To determine the feasibility and safety of robotic surgery for RPLND.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective review of robotic (R)-RPLND performed by a single surgeon from April 2008 to October 2014 using two approaches was performed. In total, 20 procedures in 19 patients were evaluated. Eleven men had clinical stage (CS) I disease, six had CS II, one of whom had prior chemotherapy, and two had CS III disease and had also undergone previous chemotherapy.

SURGICAL PROCEDURE

A lateral robotic approach was initially used; however, a supine robotic approach was developed to allow for bilateral dissection in one setting without repositioning. Template dissection with nerve sparing was performed for CS I patients and full bilateral dissection for patients with CS II or higher disease and for those who had active disease according to intraoperative frozen section results.

OUTCOME MEASUREMENTS

Mean operative time, estimated blood loss, hospital stay, and lymph node count were retrospectively reviewed, as was the presence of recurrence or the need for adjuvant therapy over median follow-up of 49 mo (interquartile range [IQR] 37.4-70.5). Intraoperative and postoperative complications were also reviewed.

RESULTS AND LIMITATIONS

R-RPLND was performed successfully in 20 procedures in 19 patients; 11 were performed from a lateral approach and nine from a supine approach. The median operating time (available for 19 of 20 cases) was 293min (IQR 257.5-317). Median estimated blood loss and length of stay were 50ml (IQR 50-100) and 1 d (IQR 1-2), respectively. Some 70% (14/20) of patients were discharged after one night. The median lymph node yield was 19.5 (IQR 13.8-27. 3). Eleven patients had pathologic stage I disease, and eight had residual disease on pathology. There was one ureteral transection that was repaired robotically at the time of surgery with no long-term sequelae. There were no open conversions or transfusions. Two patients had ejaculatory dysfunction following bilateral RPLND. There has been no evidence of retroperitoneal disease recurrence during the follow-up period. Limitations include the retrospective nature of the study and the single surgeon experience.

CONCLUSIONS

R-RPLND can be successfully performed and provides improved visualization and dexterity over conventional laparoscopy. Patients experience significantly reduced morbidity and the nodal yield is comparable to open surgical techniques.

PATIENT SUMMARY

We studied our experience with robot-assisted removal of lymph nodes from the abdomen among men with testicular cancer. This method was found to be safe and effective with a very short hospital stay.

Multi-Institutional Experience with Robotic Nephrectomy with Inferior Vena Cava Tumor Thrombectomy

PURPOSE

Since the first report of robotic management of renal tumors with inferior vena cava tumor thrombi, few additional cases have been reported in the literature. We report our combined experience with this procedure, to our knowledge the first multi-institutional and largest series reported to date.

MATERIALS AND METHODS

A retrospective, multi-institutional review of robotic nephrectomy with inferior vena cava tumor thrombectomy was performed with institutional review board approval.

RESULTS

A total of 32 cases were performed among 9 surgeons at 9 institutions since the first known procedure in 2008. Of these cases 30 were level II and 2 were level III thrombi with no level I thrombi (renal vein only) included in the analysis. Each surgeon performed between 1 and 10 procedures. Mean patient age was 63 years (range 43 to 81) with a mean body mass index of 30 kg/m(2) (range 17 to 43) and mean maximal tumor diameter of 9.6 cm (range 5.4 to 20). The length of inferior vena cava tumor thrombi ranged from 1 to 11 cm (median 4.2) on preoperative imaging. The inferior vena cava required cross-clamping in 24 cases. One patient had 2 renal veins with 2 caval thrombi and 1 patient required synthetic patch cavoplasty. Mean operative time was 292 minutes (range 180 to 411) with a mean blood loss of 399 cc (range 25 to 2,000). There were no conversions to open surgery or aborted procedures and there were 3 transfusions of 1 to 3 units. All but 2 patients ambulated by postoperative day 1 and mean hospital stay was 3.2 days (range 1 to 7). Lymphadenectomy in 24 patients yielded a mean of 11 nodes and 8 patients had node positive disease. There were 7 patients who experienced distant recurrence at a mean followup of 15.4 months, including 4 who had node positive disease on postoperative pathological examination.

CONCLUSIONS

Robotic nephrectomy in the setting of inferior vena cava tumor thrombus is feasible and was performed safely in selected patients. Despite the complex and critical nature of these procedures, our series demonstrates favorable outcomes and reproducibility with adequate robotic experience.

Robotic-assisted Radical Nephrectomy With Retrohepatic Vena Caval Tumor Thrombectomy (Level III) Combined With Extended Retroperitoneal Lymph Node Dissection

OBJECTIVE

To describe a case of robotic-assisted radical nephrectomy (RARN) with level III retrohepatic vena caval tumor thrombectomy (11 cm) and extended retroperitoneal lymph node dissection (RPLND) for renal cell carcinoma (RCC).

MATERIALS AND METHODS

A 52-year-old woman with a large right renal mass, 11-cm (level III) inferior vena cava (IVC) thrombus, with a negative metastatic workup presented to our clinic and was consented to undergo RARN. Intraoperative ultrasound confirmed the presence of tumor thrombus. After the division of the renal artery, control of the vena cava above and below the tumor thrombus as well as contralateral renal vein was obtained. A cavotomy was performed, the thrombus was removed, and the cavotomy was repaired. Additionally, an extended RPLND was performed with robotic assistance.

RESULTS

Total operative time was 6 hours and 6 minutes. Estimated blood loss was 1200 cc. The final pathology demonstrated an 8.5-cm, Fuhrman grade 3, clear cell RCC with sarcomatoid features and negative surgical margins. All 44 lymph nodes removed (hilar, paracaval, precaval, retrocaval, interaortocaval, and preaortic) were negative. Final staging was pT3b, N0, M0. The patient was discharged to home 36 hours postoperatively and experienced no perioperative or postoperative complications.

CONCLUSION

RARN with retrohepatic (level III) vena caval tumor thrombectomy and extended RPLND is technically feasible and has potential benefits. Robotic assistance may allow for improved intracorporal repair of the IVC and shortened recovery time, while maintaining oncologic principles.

Clinical and oncological outcomes in Chinese patients with renal cell carcinoma and venous tumor thrombus extension: single-center experience

BACKGROUND

To evaluate the clinical and oncological outcomes and to identify prognostic factors for survival in Chinese patients with renal cell carcinoma (RCC) and venous tumor thrombus (VTT).

METHODS

A total of 86 patients who underwent nephrectomy and tumor thrombectomy for RCC and venous tumor thrombus extension from 2003 to 2013 were included in this retrospective study. The records of these patients were reviewed. Kaplan-Meier analysis was used to determine cancer-specific survival (CSS). Prognostic factors for CSS were identified by univariate and multivariate analyses using the Cox proportional hazards regression mode.

RESULTS

All patients in this cohort received radical nephrectomy and tumor thrombectomy. Median follow-up period was 27.0 months (range 3-111). No patients died intraoperatively, and the complication rate was 36.0%. The 1-, 3-, and 5-year CSS rates for all patients were 93.0%, 70.9%, and 58.1%, respectively, and those for patients without distant metastasis at presentation were 95.3%, 82.6%, and 68.6%, respectively. Multivariate Cox regression analysis showed that lymph node invasion, distant metastasis at presentation, and invasion of the inferior vena cava (IVC) wall were the independent prognostic factors for CSS in all patients. For patients without distant metastasis, tumor grade, lymph node invasion, and perinephric fat invasion were significantly associated with CSS on multivariate analysis.

CONCLUSIONS

Survival rates for patients with RCC and VTT were still poor. Our results indicated that lymph node invasion, distant metastasis at presentation, and invasion of the IVC wall were independent negative prognostic factors.

Laparoscopic Radical Nephrectomy and Inferior Vena Cava Thrombectomy in the Treatment of Renal Cell Carcinoma

BACKGROUND

Radical nephrectomy with inferior vena cava (IVC) thrombectomy is the preferred treatment for renal cell carcinoma (RCC) with IVC thrombus. However, IVC thrombectomy using a laparoscopic approach has not been reported for high-level thrombi.

OBJECTIVE

To describe the surgical technique for laparoscopic IVC thrombectomy in patients with different thrombus levels and to assess its safety and feasibility.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective review of medical records for 11 patients with right-side RCC, including six patients with level II IVC thrombus and five patients with level IV thrombus.

SURGICAL PROCEDURE

Laparoscopic thrombectomy for level II thrombus was performed after clamping the infrarenal IVC, left renal vein, and infrahepatic IVC. Laparoscopic thrombectomy and thoracoscope-assisted open atriotomy for level IV thrombus were performed after establishing cardiopulmonary bypass and clamping the infrarenal IVC, left renal vein, and hepatoduodenal ligament.

MEASUREMENTS

The intraoperative variables, postoperative complications, and surgical outcomes were assessed.

RESULTS AND LIMITATIONS

The median operative time was 210min. The median IVC clamping time for patients with level II and level IV thrombus was 16.5 and 31min, respectively. The median estimated blood loss was 510ml, and no major intraoperative or postoperative complications occurred. One patient with level IV thrombus died of brain metastasis 6 mo after the operation, and the remaining ten patients had no local recurrence or distant metastasis during a median follow-up period of 31 mo.

CONCLUSIONS

Laparoscopic IVC thrombectomy for level II thrombus and well-selected level IV thrombus may be a safe and technically feasible alternative to open surgery.

PATIENT SUMMARY

We studied the treatment of patients with an inferior vena cava thrombus at different levels using a laparoscopic approach. This technique was safe and feasible in well-selected patients.

Clinical management of renal cell carcinoma with venous tumor thrombus

OBJECTIVES

Venous invasion is common in advanced renal cell carcinoma (RCC) due to the unique biology of this cancer. The presence of a tumor thrombus often makes clinical management challenging. In this review, we detail specific preoperative, perioperative, and surgical strategies involving the care of the complex kidney cancer patient with venous tumor involvement.

METHODS

We performed a comprehensive review of selected peer-reviewed publications regarding RCC tumor thrombus biology, medical and surgical management techniques, and immediate and long-term outcomes.

RESULTS

The perioperative management may require special imaging techniques, preoperative testing, very recent imaging, and consultation with other surgical services. There are various approaches to these patients as the clinical presentation, stage of disease, primary tumor size, level of thrombus, degree of venous occlusion, presence of bland thrombus, and primary tumor laterality influence management. Select patients with metastatic disease can do well with cytoreductive nephrectomy and thrombectomy. Those with localized disease have a high risk of recurrence; however, some patients can exhibit durable survival with surgery alone. The evolving surgical and medical treatments are discussed.

CONCLUSIONS

Even when these surgeries are performed in high volume centers, significant perioperative complications are common and greater complications are seen with higher thrombus extent. If surgery is attempted, it is important for urologic oncologists to follow strict attention to specific surgical principles. These general principles include complete vascular control, avoidance of thrombus embolization, close hemodynamic monitoring, and institutional resources for caval resection/replacement and venous bypass if necessary.

The role of laparoscopy and robotic surgery in the management of small renal masses

Increased utilization of cross-sectional abdominal imaging has led to a significant increase in the incidence of small renal masses. There is a growing body of literature suggesting that these lesions have a low malignant potential, thus supporting surveillance as a therapeutic option, particularly in the elderly population. Over the last decade, there has been an explosion of minimally invasive techniques for managing these lesions, including laparoscopic nephrectomy, laparoscopic partial nephrectomy, cryotherapy, radiofrequency ablation and, more recently, robotic-assisted surgery. The aim of this article is to review recent literature and assess the role of laparoscopic and robotic-assisted surgery in the management of small renal masses.

Initial series of robot-assisted laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell testicular cancer

Robotic technology has enabled urologists to perform a variety of laparoscopic surgeries. Robotic surgery offers enhanced optical magnification and visualization with precise surgical movements. We report the first case series of robot-assisted laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous testicular cancer in three consecutive patients. All procedures were performed using a modified template nerve-sparing approach. The mean patient age was 31 yr. Estimated blood loss was 150-200 ml; operative time was 150-240 min. Length of stay was 2 d, and there were no perioperative complications. This early series in carefully selected and well-informed patients represented a limited experience. These results may not be applicable to all surgeons. Further long-term follow-up with a larger number of patients are warranted to validate these preliminary findings.