Robotic Right Radical Nephrectomy with IVC Thrombectomy
Tenny R. Zhang, BA1; Joan C. Delto, MD2; Chintan Patel, MD3; Andrew A. Wagner, MD2
1Harvard Medical School, Boston, MA; 2Beth Israel Deaconess Medical Center, Boston, MA; 3Lahey Clinic, Burlington, MA
BACKGROUND: Radical nephrectomy with IVC thrombectomy is a challenging surgery that is often performed through an open approach. We present our robotic technique for performing this procedure and highlight concepts that enable its safe and efficacious completion.
METHODS: The patient is a 74-year-old man who presented with a right renal mass and IVC thrombus found incidentally on follow-up imaging of a known renal cyst. He was completely asymptomatic. Preoperative CT/MRI with contrast revealed a 12cm infiltrative mass in the right kidney, level I IVC tumor thrombus, and suspicious para-aortic lymph nodes. CT chest was negative for metastases. The patient elected to undergo robotic right radical nephrectomy with IVC thrombectomy. After mobilizing the right colon and duodenum and identifying the renal hilum, we began with a retroperitoneal lymph node dissection. Large lumbar veins were clipped and ligated. We then proceeded with radical nephrectomy, which was challenging due to the size of tumor, its adherence to surrounding structures, and presence of a large IVC tumor thrombus. We first dissected around and stapled the right renal artery. Next we circumnavigated the right renal vein, which was thickened with tumor thrombus. Intra-operative ultrasound was used to identify thrombus borders, which extended superiorly to 2-4cm below the short hepatic veins. Smaller short hepatics were taken with the bipolar, larger ones with clips, and a very large vein stapled, enabling excellent superior lift on the liver and IVC exposure. We placed bulldog clamps inferiorly on the distal IVC, left renal vein, and superiorly on the proximal IVC. We then used endoshears to open the IVC and found tumor thrombus adherent to IVC at the os of the right renal vein. We performed a wide dissection, taking an ellipse of IVC with our specimen. However we safely left an adequate amount of IVC for primary repair with a 4-0 Goretex running suture. The distal bulldog clamp was released, revealing brisk bleeding from a small lumbar vein which was oversewn with 5-0 Prolene. Finally we removed the clamps from proximal IVC and left renal vein. Hemostasis remained excellent, and no significant reduction of IVC diameter was noted.
RESULTS: Estimated blood loss was 300cc, and IVC clamp time 29 minutes. The patient was discharged on POD2 after an unremarkable postoperative course. Pathology revealed a 13cm, grade 2-3, pT3b type 2 papillary renal cell carcinoma with negative margins and no malignancy identified in 18 para-aortic lymph nodes.
CONCLUSIONS: Key points for the case include adequate preoperative imaging to characterize extent of thrombus, intra-operative ultrasound to confirm thrombus boundaries, complete venous control and mobilization of IVC before its opening, and maintaining adequate IVC lumen diameter. The same oncologic principles of open surgery apply, and there should be a low threshold for conversion if those principles are in question. With appropriate patient selection, adequate surgical planning, and robotic experience, radical nephrectomy and IVC thrombectomy through a robotic approach can be performed safely and effectively with low blood loss and good patient recovery. Additional studies may be useful in determining long-term oncologic outcomes.
Back to 2018 Program