Robotic Radical Nephrectomy with IVC Thrombectomy
Renal cell carcinoma is a condition that can have varied presentations ranging from being asymptomatic to pain in the loin or even blood in the urine. This cancer has a propensity to invade through adjacent vessels, such as the renal vein and inferior vena cava (IVC), as a tumour thrombus. It is important to diagnose this condition early and treat it in time.
Classically, patients with renal masses and venous thrombosis have been managed through open surgery as it is the most familiar technique and provides better control over the vessels. However, with the advent of robotic surgery, principles of open surgery can be replicated and combined with the advantages of minimally invasive surgery. Very few centres have reported the experience of performing robot-assisted radical nephrectomy with IVC thrombectomy. We report one such patient with right renal mass and IVC thrombus (Level 2) who underwent robotic right radical nephrectomy and IVC thrombectomy.
Case Study
A 65-year-old male presented at
Medanta - Gurugram with the chief complaint of two episodes of haematuria (blood in urine) for 2 months. It was associated with the passage of long, thread-like clots. He had no other urological complaints. He had no addiction to smoking tobacco or any other substances. On examination, he was stable and had no evidence of pallor or any lymphadenopathy. The abdominal examination did not reveal any positive findings. Initially, he underwent an abdominal ultrasound at another centre that revealed a 65mmx50mmx65mm right renal mass. An abdominal contrast-enhanced computed tomogram (CECT) done elsewhere showed a right renal mass of size 88mmx65mmx103mm with a tumour thrombus infiltrating the right renal vein and IVC.
Further, whole-body FDG-PET (fluorodeoxyglucose-positron emission tomography) scan was done to confirm the absence of distant metastasis. His haemoglobin was 10.2gm/dL and creatinine was 1.2mg/dL. Other blood investigations were unremarkable. After a thorough discussion and imaging review, the patient was planned for robot-assisted radical nephrectomy with IVC thrombectomy. Preoperatively, we did a right renal artery angioembolisation with an IVC filter.
The patient was administered general anaesthesia and placed in a lateral position with 7 standard ports (4 robotic, 2mm-12mm assistant and 1mm-5mm assistant) placed for kidney docking. Robotic shears on right, fenestrated bipolar on the left and prograsp forceps in the fourth arm. Intra-operatively, we noted a large renal mass located in the mid and lower pole of the right kidney with dilated and enlarged right renal vein.
A tumour thrombus was seen extending up to 2cm into the IVC. The right kidney was mobilised beginning from the lower pole. The right ureter and gonadal vein were dissected and isolated. Then we performed the hilar dissection and the right renal artery was isolated and clipped. The kidney was again mobilised all around and left attached to the right renal vein. We then started IVC mobilisation from the infrarenal end. Infrarenal IVC was dissected and looped, followed by left renal vein and suprarenal IVC above the level of thrombus. Now, sequentially, lower IVC, left renal vein and suprarenal IVC were occluded by vascular loops and clamps.
The IVC was opened along the anterior border to deliver tumour thrombus and to remove the right renal mass. The IVC was closed in two layers using prolene 5.0.
The vessel lumen was flushed with heparinised saline just before complete closure and vessel loops were released. After ensuring complete haemostasis and drain placement in the right renal fossa, we extracted the specimen from a pfannenstiel incision. Postoperative recovery was uneventful and the patient was discharged on Day 4. At a recent 3-month follow up, the patient was disease-free and doing well.
Expansion of minimally invasive surgery in this patient was associated with less pain, faster recovery and early discharge from the hospital. However, such complex procedures can be accomplished robotically due to their advantages over conventional laparoscopy, such as 3D vision, Endowrist and better precision.
