EURURO Vol. 72 No. 2

267 320

Surgery in Motion
Robot-assisted Level II–III Inferior Vena Cava Tumor
Thrombectomy: Step-by-Step Technique and 1-Year Outcomes
Sameer Chopra y, Giuseppe Simone , Charles Metcalfe , Andre Luis de Castro Abreu
Jamal Nabhani Mariaconsiglia Ferriero Alfredo Maria Bove Rene Sotelo
Monish Aron Mihir M. Desai Michele Gallucci Inderbir S. Gill
a USC Institute of Urology, Departments of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; b‘‘Regina Elena’’ National
Cancer Institute, Rome, Italy
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Article info
Article history:
Accepted August 30, 2016
Associate Editor:
Christian Gratzke
Keywords:
Robotics
Vena cava
inferior
Thrombectomy
Kidney cancer
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Abstract
Background: Level II–III inferior vena cava (IVC) tumor thrombectomy for renal cell
carcinoma is among the most challenging urologic oncologic surgeries. In 2015, we
reported the initial series of robot-assisted level III caval thrombectomy.
Objective: To describe our University of Southern California technique in a step-by-step
fashion for robot-assisted IVC level II–III tumor thrombectomy.
Design, setting, and participants: Twenty-five selected patients with renal neoplasm
and level II–III IVC tumor thrombus underwent robot-assisted surgery with a minimum
1-yr follow-up (July 2011 to March 2015).
Surgical procedure: Our standardized anatomic-based ‘‘IVC-first, kidney-last’’ tech-
nique for robot-assisted IVC thrombectomy focuses on minimizing the chances of an
intraoperative tumor thromboembolism and major hemorrhage.
Outcome measurements and statistical analysis: Baseline demographics, pathology
data, 90-d and 1-yr complications, and oncologic outcomes at last follow-up were
assessed.
Results and limitations: Robot-assisted IVC thrombectomy was successful in 24 patients
(96%) (level III: n = 11; level II: n = 13); one patient was electively converted to open
surgery for failure to progress. Median data included operative time of 4.5 [1_TD$DIFF]h, estimated
blood loss was 240 ml, hospital stay 4 [2_TD$DIFF]d; five patients (21%) received intraoperative
blood transfusion. All surgical margins were negative. Complications occurred in four
patients (17%): two were Clavien 2, one was Clavien 3a, and one was Clavien 3b.
All patients were alive at a 16-[3_TD$DIFF]mo median follow-up (range: 12–39 mo).
Conclusions: Robotic IVC tumor thrombectomy is feasible for level II–III thrombi. To
maximize intraoperative safety and chances of success, a thorough understanding of
applied anatomy and altered vascular collateral flow channels, careful patient selection,
meticulous cross-sectional imaging, and a highly experienced robotic team are essential.
Patient summary: We present the detailed operative steps of a new minimally invasive
robot-assisted surgical approach to treat patients with advanced kidney cancer. This
type of surgery can be performed safely with low blood loss and excellent outcomes.
Even patients with advanced kidney cancer could now benefit from robotic surgery with
a quicker recovery.
# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.
y These authors contributed equally to this manuscript
* Corresponding author. USC Institute of Urology, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA
90089, USA. Tel. +1 323 865 3794; Fax: +1 323 865 0120.
E-mail address: (I.S. Gill).
0302-2838/# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.