Comparison of Open Versus Robotic Nephrectomy and Inferior Vena Cava Reconstruction for Renal Cell Carcinoma With Inferior Vena Cava Tumor Thrombus

Abstract

Vascular surgeons are frequently involved in inferior vena cava (IVC) reconstruction during nephrectomy for renal cell carcinoma (RCC) with tumor thrombus. Robotic nephrectomy for RCC claims shorter length of stay (LoS), faster return to work, and decreased pain medication requirements. Our goal was to compare our robotic nephrectomy with IVC reconstruction experience with our open experience. We performed a single-institution retrospective review of patients undergoing open or robotic nephrectomy for RCC with IVC tumor thrombus between January 1998 and January 2018. Patients’ characteristics, surgical records, and follow-up and survival data were recorded. Tumor level was classified according to the Mayo Clinic venous tumor thrombus (VTT) level. There were 57 patients (49 male) who underwent nephrectomy with tumor thrombectomy and IVC reconstruction; 38 (66%) had open procedures for RCC with level 1 (n = 6), level 2 (n = 21), and level 3 (n = 11) VTT. Average operative time was 251 minutes (range, 108-375 minutes), and average blood loss was 2482 mL (range, 50-10,950 mL). Average LoS was 10.79 days (range, 1-95 days). There were two (3.5%) deaths within 30 days. Short-term complications included atrial fibrillation (n = 2), ileus (n = 2), seroma (n = 1), sepsis (n = 1), pulmonary embolism (n = 1), urinary tract infection (n = 1), and pneumothorax (n = 1). Long-term complications included deep venous thrombosis (n = 1) and intra-abdominal abscess (n = 1). Nineteen patients (33%) underwent robotic nephrectomy for RCC with level 1 (n = 1), level 2 (n = 17), and level 3 (n = 1) VTT. Average operative time was 283 minutes (range, 182-382 minutes), and average blood loss was 942 mL (range, 100-3000 mL). Average LoS was 3.11 days (range, 1-8 days). There were no deaths within 30 days. Short-term complications included pulmonary embolism (n = 1) and deep venous thrombosis (n = 1). Long-term complications included pleural effusion requiring thoracentesis (n = 1). All IVC reconstructions were performed by primary closure. Three (15.7%) cases required open conversion, two for control of the retrohepatic IVC and one for posterior lumbar venous bleeding unable to be controlled robotically. Postoperative imaging was completed in 12 (63.2%) of the patients undergoing a robotic procedure at a median of 340 days postoperatively. The vena cava was patent in all studies. The median percentage of postoperative to preoperative IVC diameter was 58% (axial) and 45% (sagittal). In comparing open vs robotic procedures, the robotic approach had a shorter LoS (P < .05), less intraoperative blood loss (P < .01), and similar operative times (P = NS). Robotic nephrectomy and IVC reconstruction for RCC with level 1 to level 3 VTT can be performed safely and effectively. The minimally invasive approach offers patients a shorter LoS, less intraoperative blood loss, and similar operative times compared with open surgery. Postoperative IVC diameter is maintained after robotic reconstruction. Proper selection of patients and robotic expertise are essential to optimize outcomes.