453 - Robot-Assisted Radical Nephrectomy with Inferior Vena Cava Thrombectomy

The predominant method for addressing RCC involv- ing IVC thrombus is open resection, as this allows for the safe handling of the IVC and minimizes the risks of perioperative complications. 9 In fact, prior to the advent of robotic surgery, it was thought that IVC tumor thrombi, need for lymphad- enectomy, contiguous organ invasion, and other oncological complications would always require open surgery. 13 However, since 2011, 9 the robot-assisted thrombectomy has become a viable option, and complete surgical resection of the tumor remains the standard practice with the best patient outcomes. 5 Robot-assisted radical nephrectomy with IVC thrombectomy has been shown to be feasible, safe, and effective in treating aggressive RCC in selected patients. 2,5,9,10,13 As exciting as this new surgical frontier may be, it is not without significant risks. Studies have demonstrated a periop- erative mortality rate for patients undergoing IVC thrombec- tomy of 5-8%. 9 Urologists performing this operation should communicate with their facility’s vascular surgery and/or cardiothoracic surgery team beforehand to coordinate and develop a plan for addressing complications.Whether a con- sultation with vascular or cardiothoracic surgery is indicated will be based on the size of the thrombus and how far up the IVC it extends. Familiarization with robotic IVC thrombec- tomy techniques may prove crucial for urologists who per- form robotic nephrectomies 10 and may help them to expand their practice. For these reasons, meticulous preoperative plan- ning, patient selection, and surgeon experience are essential to preventing perioperative complications. 2,5 In addition to the typical risks of hemorrhage (greatly amplified in this proce- dure), surgical site infection (SSI), and tumor recurrence, one must consider the potential for unique complications. A tumor thrombus in so large a vessel presents not only a risk of metas- tasizing, but also of the thrombus either occluding the IVC or embolizing and traveling to the right atrium and potentially points beyond due to a misplaced clamp. Despite these risks, there are numerous advantages to a robotic approach when compared to an open approach in these patients. One study comparing the robotic approach against the traditional open approach found that “Robotic procedures have been reported to have shorter hospital stays, less blood loss and transfusions, and a lower complication rate” (Kishore et al., 2020). Other studies have shown similar oncologic and survival outcomes. 13 A 2019 study conducted at the Mayo Clinic, specifically comparing open radical nephrectomy with tumor thrombus versus robot-assisted radical nephrectomy with tumor thrombus, concluded that “[Robot-assisted radi- cal nephrectomy with tumor thrombus] produced a shorter length of stay, less transfusions, and a lower rate of complica- tions with no significant difference in overall survival.” (Rose et al., 2020). Tumor thrombus level Definition Surgical strategy O Tumor thrombus is limited to the renal vein Radical nephrectomy of renal cell carcinoma I Tumor thrombus extend into IVC with <2cm above the renal vein Tumor thrombus could be extended to renal vein and then radical nephrectomy II Tumor thrombus extends into IVC >2cm above the renal vein but below the hepatic veins The transaction of liver is required; blocking up the section of the IVC underneath hepatic vein III Tumor thrombus which extends above the hepatic veins but below diaphragm The mobilization of the liver; vena-venous bypass is required IV Tumor thrombus is above diaphragm Intraoperative extracorporeal circulation is requisite Source:Roseetal,2020 Tumor thrombus level Open radical nephrectomy, with tumor thrombus Robot-assisted radical nephrec- tomy with tumor thrombus p-value N 27 24 Average Length of Stay (days) 7 3 0.03 Average Estimated Blood Loss (mL.) 1800 450 <0.01 Transfusion Rate (%) 82 21 <0.01 Fever Complications (%) 43 17 <0.01 Source:Peng,etal,2020 | The Surgical Technologist | SEPTEMBER 2021 400