Robotic radical nephrectomy with vena caval tumor thrombectomy: experience of novice robotic surgeons

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

PURPOSE

Open radical nephrectomy with inferior vena cava thrombectomy (O-CT) is standard management for renal cell carcinoma with inferior vena cava thrombus. First reported a decade ago, robotic-assisted radical nephrectomy with inferior vena cava thrombectomy (R-CT) is a minimally invasive option for this disease. We aimed to perform a systematic review to assess the safety and feasibility of R-CT in terms of perioperative outcomes and compare the outcomes between R-CT and O-CT.

MATERIALS AND METHODS

The PubMed®, Scopus®, Cochrane Central Register of Controlled Trials and Web of ScienceTM databases were searched using the free-text and MeSH terms "renal cell carcinoma," "inferior vena cava," "thrombosis" or "thrombus," "robot" and "thrombectomy." Studies reporting perioperative outcomes of R-CT and studies comparing R-CT with O-CT were included. The review was done in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

RESULTS

The search retrieved 28 articles describing R-CT, including 7 comparative studies. This systematic review included 1,375 patients, out of which 329 patients were in single-arm studies and 1,046 patients were in comparative studies. Of the 329 patients who underwent R-CT, 14.7% were level I, 60.9% level II, 20.4% level III and 2.5% level IV thrombus. Operative time ranged from 150 to 530 minutes; blood transfusion was administered in 38.2% (126). The overall complication rate was 30.3% (99). R-CT, in comparison to O-CT, was associated with a lower blood transfusion rate (18.4% vs 64.3%, p=0.002) and a lower complication rate (14.5% vs 36.7%, p=0.005). Major complication and 30-day mortality rates were similar in both groups.

CONCLUSIONS

R-CT has acceptable perioperative outcomes in carefully selected patients. Compared with O-CT, R-CT is associated with a lower blood transfusion rate and fewer overall complications. In experienced hands with carefully selected patients, R-CT is feasible and safe, with acceptable outcomes; however, selection bias limits definitive inference of these results, and optimal patient selection criteria remain to be described.

Case reports of robot-assisted laparoscopic radical nephrectomy and inferior vena cava tumor thrombectomy: A retrospective analysis

Renal cell carcinoma is one common type of urologic cancers. It has tendencies to invade into the inferior vena cava (IVC) and usually requires an open surgery procedure. High rates of operative complications and mortality are usually associated with an open surgery procedure. The recently emerged robot-assisted laparoscopic radical nephrectomy (RAL-RN) and IVC tumor thrombectomy have shown to reduce operative related complications in patients with renal cell carcinoma.This case series study aimed to summarize technical utilization, perioperative outcomes, and efficacies of RAL-RN and IVC tumor thrombectomy in our hospital. A retrospective analysis was performed on clinical data from 20 patients who underwent RAL-RN and IVC tumor thrombectomy from January 2017 to December 2019 in our department.Patients had a median age of 59 years (interquartile range [IQR], 46-68). Four patients had renal neoplasm on left side and 16 on right side. Nineteen patients underwent RAL-RN (level 0: n = 2) or RAL-RN with IVC thrombectomy (n = 17) (level I: n = 3; level II: n = 12; and level III: n = 3) and 1 patient was converted into an open surgery. The median operative time was 328 minutes (IQR, 221-453). The estimated median blood loss was 500 mL (IQR, 200-1200). The median size of removed renal carcinoma was 67 cm2 (IQR, 40-91); the length of IVC tumor thrombus was 5 cm (IQR, 3-7). The postsurgery hospital length of stay was 6 days (IQR, 5-7). The complications included intestinal obstruction (n = 1), lymphatic fistula (n = 1), heart failure (n = 1), and low hemoglobin level (n = 1). The outcomes for patients after 16 months (IQR, 11-21) follow-up were tumor-free (n = 10), tumor progression (n = 4), loss of contact (n = 1), and death (n = 5).We concluded that RAL-RN and IVC thrombectomy renders good safety profiles including minimal invasiveness, low estimated median blood loss, short hospitalization, low morbidity, and quick renal function recovery. The long-term efficacy needs a further investigation.

Minimally invasive radical nephrectomy: a contemporary review

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.

Robot-assisted versus open surgery for radical nephrectomy with level 1-2 vena cava tumor thrombectomy: a French monocenter experience (UroCCR study #73)

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.

Techniques and outcomes of minimally-invasive surgery for nonmetastatic renal cell carcinoma with inferior vena cava thrombosis: a systematic review of the literature

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.

Robot-assisted Retrohepatic Inferior Vena Cava Thrombectomy: First or Second Porta Hepatis as an Important Boundary Landmark

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.

Robotic Level III IVC Tumor Thrombectomy: Duplicating the Open Approach

OBJECTIVES

To describe our surgical technique for robotic radical nephrectomy and thrombectomy for renal cell carcinoma and associated level III inferior vena cava (IVC) thrombus with retroperitoneal lymph node dissection.

METHODS

The patient is a 75-year-old Caucasian man with a 10-cm right renal neoplasm and associated level III tumor thrombus. After preoperative imaging was reviewed, a robotic approach was planned. Real-time intraoperative transesophageal ultrasonography was performed to assess the cranial extent of tumor thrombus. The major steps of our technique include early inter-aortocaval control of the right renal artery, circumferential mobilization of the IVC, contralateral renal vein control, cavotomy, thrombectomy, and reconstruction of the IVC.

RESULTS

Operative time was 5 hours and 53 minutes (353 minutes) with 150 mL estimated blood loss. The patient was allowed to have a clear liquid diet immediately after surgery and was discharged home on postoperative day 3. Final pathology demonstrated a 9.8-cm clear cell renal cell carcinoma, nuclear grade 3 with a pT3bN1 stage.

CONCLUSIONS

With adequate team experience and preparation, robotic radical nephrectomy and IVC tumor thrombectomy for level III tumor thrombus is challenging but feasible in select patients. Herein we describe our robotic technique which duplicates the open approach. This minimally invasive approach may offer lower estimated blood loss, improved pain control, and expedited recovery.

Robot-assisted Laparoscopic Inferior Vena Cava Thrombectomy: Different Sides Require Different Techniques

BACKGROUND

The safety and feasibility of robot-assisted laparoscopic inferior vena cava (IVC) thrombectomy (RAL-IVCTE) have been investigated in limited reports.

OBJECTIVE

To share our initial experience with RAL-IVCTE, as well as describe respectively the detailed techniques for RAL-IVCTE for left or right renal cell carcinoma (RCC).

DESIGN, SETTING, AND PARTICIPANTS

From May 2013 to July 2014, 17 patients with RCC involving IVC tumor thrombus were admitted to our hospital.

SURGICAL PROCEDURE

For right RCC, the caudal IVC, left renal vein, and cephalic IVC were sequentially clamped. The IVC wall was cut, and the thrombus was removed. For left RCC, the left renal vein, which included the thrombus, was ligated with Endo-GIA. The caudal IVC, right renal artery, right renal vein, and cephalic IVC were sequentially clamped.

MEASUREMENTS

The detailed techniques for RAL-IVCTE for different sides were described and the perioperative outcomes recorded.

RESULTS AND LIMITATIONS

The operations were successfully performed without open conversion. Median operation time was 131min (100-150min) and 250min (190-275min) for the right and left RCC, respectively. Median estimated blood loss was 240ml (145-320ml). Median IVC blocking time was 17min (12-25min). For left RCC, median warm ischemia time for the right kidney was 18min (14-22min). A grade IV complication-bleeding from tributaries of the IVC-developed in one case and was successfully resolved with intraoperative endoscopic suture.

CONCLUSIONS

RAL-IVCTE is safe and feasible. For left RCC involving IVC thrombus, right renal warm ischemia time is necessary during the procedure, requiring a more advanced technical skill. The therapeutic effect and overall survival rate require further investigation with a larger sample size and longer follow-up.

PATIENT SUMMARY

Robot-assisted laparoscopic inferior vena cava thrombectomy is technically challenging but safe and feasible. The therapeutic effect needs further investigation.

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 laparoscopic nephrectomy

The introduction of robot-assisted surgery has helped practitioners implement laparoscopic approached to complex retroperitoneal and renal surgery. Urologists are now more frequently completing surgeries such as radical nephroureterectomy, radical nephrectomy with IVC thrombectomy, and retroperitoneal lymphadentectomy via a laparoscopic approach than ever before. This review discusses the rational of the above surgeries as well as a technical step-by-step description of our robotic nephroureterectomy surgical approach.

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.

Robotic radical nephrectomy for renal cell carcinoma: a systematic review

Background

Laparoscopic radical nephrectomy (LRN) is the actual gold-standard for the treatment of clinically localized renal cell carcinoma (RCC) (cT1-2 with no indications for nephron-sparing surgery). Limited evidence is currently available on the role of robotics in the field of radical nephrectomy. The aim of the current study was to provide a systematic review of the current evidence on the role of robotic radical nephrectomy (RRN) and to analyze the comparative studies between RRN and open nephrectomy (ON)/LRN.

Methods

A Medline search was performed between 2000–2013 with the terms “robotic radical nephrectomy”, “robot-assisted laparoscopic nephrectomy”, “radical nephrectomy”. Six RRN case-series and four comparative studies between RRN and (ON)/pure or hand-assisted LRN were identified.

Results

Current literature produces a low level of evidence for RRN in the treatment of RCC, with only one prospective study available. Mean operative time (OT) ranges between 127.8-345 min, mean estimated blood loss (EBL) ranges between 100–273.6 ml, and mean hospital stay (HS) ranges between 1.2-4.3 days. The comparison between RRN and LRN showed no differences in the evaluated outcomes except for a longer OT for RRN as evidenced in two studies. Significantly higher direct costs and costs of the disposable instruments were also observed for RRN. The comparison between RRN and ON showed that ON is characterized by shorter OT but higher EBL, higher need of postoperative analgesics and longer HS.

Conclusions

No advantage of robotics over standard laparoscopy for the treatment of clinically localized RCC was evidenced. Promising preliminary results on oncologic efficacy of RRN have been published on the T3a-b disease. Fields of wider application of robotics should be researched where indications for open surgery still persist.

Technical considerations in robotic nephrectomy with vena caval tumor thrombectomy

Robotic surgery has been applied to increasingly complex urologic procedures since its initial widespread adoption for prostatectomy. While laparoscopic nephrectomy was initially reported over 2 decades ago, renal tumors involving the inferior vena cava (IVC) appeared to be a limitation to the application of laparoscopy. Laparoscopic management had only been reported in a limited fashion for short tumor thrombi not requiring cross-clamping of the IVC. The first robotic nephrectomy for renal cancer with IVC tumor thrombus was performed in 2008 with the first series reported in 2011, including for larger tumor thrombi requiring IVC cross-clamping for thrombus extraction. Since then, several surgeons at various institutions have adopted robotic surgery for these complex procedures. With experience and meticulous surgical technique, the procedure can be reproduced in properly selected cases. Further adoption and reports of multi-institutional experiences are necessary to validate this still relatively new procedure, and such work is already underway.