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Robotic Right Nephrectomy and Inferior Vena Cava Tumor Thrombectomy with Caval Patch Graft Reconstruction

2013; Mary Ann Liebert, Inc.; Volume: 27; Issue: 4 Linguagem: Inglês

10.1089/vid.2013.0017

2151-1136

Ziho Lee, Christopher Reilly, Lindsey A. Parkes, Eric T. Choi, Jack H. Mydlo, Daniel Eun,

Renal and related cancers

Introduction: Despite the increasing popularity of laparoscopic and robotic approaches for renal tumors, open surgery is the standard approach for the surgical management of renal tumors with extension into the inferior vena cava (IVC).1 Abaza reported the first robot-assisted radical nephrectomy with IVC tumor thrombectomy in a series of five patients with good outcomes. Two patients necessitated cross-clamping of the IVC, and in all cases, the IVC cavotomy was closed using a two layer suture.2 We present our technique and perioperative results of the first robot-assisted radical nephrectomy and IVC tumor thrombectomy and reconstruction using a synthetic patch graft. Materials and Methods: A 61-year-old woman presented with an 8-cm right renal mass, bilateral pulmonary embolism, and IVC tumor thrombus extending into the subhepatic IVC. After counseling and discussion of all available treatment options, the patient opted for robotic-assisted surgical management. The procedure was performed by a single surgeon (D.E.) using the da Vinci® Si. There are eight major portions of our technique: (1) interaortocaval dissection for proximal renal artery clamping, (2) determination of tumor thrombus extent using a laparoscopic ultrasound probe, (3) retrohepatic caval resection, (4) confirmation of absent arterial inflow into the right kidney via intravenous indocyanine green visualization under near-infrared light, (5) staging lymphadenectomy, (6) clamping of suprarenal IVC, infrarenal IVC, and contralateral renal vein, (7) cavotomy, (8) vascular reconstruction using a 6×3-cm synthetic patch graft, and (9) radical nephrectomy. Results: IVC cross-clamp time was 69 minutes, estimated blood loss was 550 mL, and total console time was 205 minutes. The patient was transferred out of the Intensive Care Unit on postoperative day 1, and was discharged home on postoperative day 7 due to Coumadin optimization. There were no intraoperative and/or postoperative complications. Pathological analysis revealed a 7.1-cm poorly differentiated collecting duct carcinoma with tumor extension into the IVC wall, renal pelvis, sinus fat, perinephric fat, and ipsilateral adrenal gland; 7/25 nodes were positive. At 3 months postoperatively, her performance status was excellent and abdominal CT showed no disease progression. Conclusion: Robot-assisted IVC thrombectomy with cross-clamping and patch graft reconstruction is feasible in the appropriately selected candidate. Increased experience and longer follow-up are needed to assess the durability of our technique. Ziho Lee, Christopher Reilly, Lindsey Parkes, and Eric Choi have no disclosures. Jack Mydlo is a consultant to Medical Diagnostic Laboratories. Daniel Eun was a surgical proctor for Intuitive Surgical, and is a lecturer for Ethicon Endosurgery and Covidien. Runtime of video: 10 mins.