EURURO Vol. 72 No. 2

Introduction

Surgical management of patients with level II–III inferior

vena cava (IVC) tumor thrombus arising from a renal tumor

requires IVC thrombectomy, radical nephrectomy (RN), and

ipsilateral retroperitoneal lymphadenectomy (RPLND). This

complex major open surgical operation requires a large

muscle-cutting abdominal or thoracoabdominal incision to

achieve the necessary surgical access for vascular control

and thrombectomy. In patents without metastatic disease,

complete surgical excision is the first-line treatment and

provides 5-yr cancer-specific survival of up to 65%

[1]

, a 38%

complication rate, and an operative mortality rate of 4–10%

[2] .

Minimally invasive IVC tumor thrombectomy is a

relatively recent advancement. Building on early develop-

mental work in the laboratory

[3,4]

, the initial experience

for level 0 (renal vein) and level I–II thrombi were reported

in 2003 and 2011, respectively

[5,6]

. Robot-assisted surgery

for level III caval thrombi was first reported in 2015

[1]

and

2016

[7]

, and laparoscopic surgery for level IV caval thrombi

in 2015

[8]

. Spurred by these initial publications, additional

centers have recently reported early experiences attesting

to the increasing interest within the field for robot-assisted

caval thrombectomy surgery

[9–11]

. Although the litera-

ture just cited is indicative of progress, we believe that for

the robotic approach to duplicate open surgery reliably and

thus allow more teams to embark safely on robot-assisted

caval thrombectomy surgery, a description of a uniform and

reproducible technique is of value.

We carefully developed a step-by-step standardized

anatomic-based robotic approach for robot-assisted IVC

thrombectomy. This approach is primarily targeted towards

minimizing the chances of intraoperative tumor thrombo-

embolism and major hemorrhage, the two major complica-

tions of IVC thrombectomy surgery. This report describes

our University of Southern California technique in a step-

by-step fashion.

Patients and methods

2.1.

Study population

A renal database approved by an institutional review

board prospectively accrued data for all level II and III IVC

thrombectomy cases. A total of 25 patients have

completed a minimum follow-up of 1 yr and form the

basis for this two-center series. All cases were performed

by a single combined robotic team from July 2013 to

March 2015.

Exclusion criteria for this study comprised Mayo level 0–

I thrombi (extending

2 cm into the IVC), level IV thrombi

(supradiaphragmatic), and widespread metastatic disease

(more than one metastatic site). Also, to maintain consis-

tency in the reported technique, we excluded four patients

in whom intra- or retro-hepatic IVC control was obtained

via an intracaval Fogarty balloon

[12]

. All patients under-

went surgery with curative or cytoreductive intent.

2.2.

Preoperative assessment and surgical indication

All patients included in the study presented with a renal

mass and a level II or III IVC tumor thrombus and had good

performance status (Eastern Cooperative Oncology Group

performance status 0 or 1). Five patients (20%) had

preexisting small-volume metastasis.

Patients underwent a standard preoperative work-up

including cross-sectional abdominal imaging (computed

tomography and/or magnetic resonance imaging).

Angioembolization of the tumor-bearing kidney was

performed in a majority of cases (80%).

2.3.

Surgical technique

2.3.1.

Robotic instrumentation

The four-arm Si or Xi da Vinci Surgical System (Intuitive

Surgical Inc, Sunnyvale, CA, USA) with a six- to seven-port

approach was used including two assistant ports. Bariatric-

length robotic ports help minimize external robotic arm

clashing, and standard robotic instruments were used. A

double-fenestrated grasper is used to pass posterior to the

vena cava to establish Rummel tourniquet control of the

retrohepatic/intrahepatic IVC.

2.3.2.

Patient positioning, port placement, and robot docking

The patient is secured in a 75

lateral decubitus position

with the table fully flexed. For both right- or left-sided

tumors, the patient is initially secured right side up to

facilitate IVC exposure and control. For right-sided tumors,

the procedure proceeds directly to a right RN following IVC

thrombectomy; for left-sided tumors, the patient is

repositioned left side up and the robot’s redocked following

IVC thrombectomy

( Fig. 1

a–1d).

2.3.3.

Vena cava control (for right- or left-sided tumors)

The primary concept we developed in this regard is the

‘‘IVC-first, kidney-last’’ approach in a minimal IVC touch

manner, to minimize chances of tumor embolism and major

hemorrhage. The right colon and duodenum are reflected

medially to expose the vena cava. Retroperitoneal dissec-

tion begins infrarenally in the midline to expose the

interaortocaval region

( Fig. 2 a

–2b). The laparoscopic fan

retractor facilitates the medial retraction of bowel for

increased exposure.

Dissection of the infrarenal IVC involves control of all

relevant lumbar veins

( Fig. 2 c

) and the gonadal vein

( Fig. 2

d), which are taken with Hem-o-lok clips (Teleflex,

Wayne, PA, USA). The infrarenal IVC is encircled with a

double-loop tourniquet (Rummel) using a vessel loop (part

no. KDL311456694, Devon Surgical Vessel Loops [Covidien,

Dublin, Ireland]; dimensions: 12.5 4.9 5.8 in; volume:

0.206 ft

) passed through a half-inch piece of 20F red rubber

urethral catheter and secured in place with a Hem-o-lok clip

( Fig. 2

e). Dissection is carried cephalad within the inter-

aortocaval region. The left renal vein is mobilized and

encircled with a Rummel tourniquet

( Fig. 2 f

For proximal IVC control, careful interaortocaval dissec-

tion is performed towards the liver. For level III thrombi, the

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