Robotic Partial Nephrectomy with Excision of Renal Vein Thrombus

Abstract

Introduction: Renal cell carcinoma (RCC) has a predilection for extension into veins that can prevent the ability to perform partial nephrectomy when otherwise possible. Objective: Partial nephrectomy with venous tumor thrombus is feasible when venous drainage of the remaining kidney is preserved and negative surgical margins can be achieved, but this has not previously been described with robotic surgery. We present two representative cases from our experience of robotic partial nephrectomy (RPN) in the setting of venous extension of RCC. Techniques are illustrated for addressing tumor extension into a vein branch within the parenchyma in one patient and a second case with a tumor extending into the main renal vein. Methods: Standard four-port RPN was performed in both cases using two 8-mm ports for robotic instruments and two 12-mm ports, one each for the robotic camera and assistant. One 4.3-cm tumor was found to have an extension into a branch of the renal vein on intraoperative ultrasound. The laparoscopic ultrasound is a powerful tool that allows identification of the thrombus extent readily in experienced hands. The mass was excised with the vein and tumor thrombus as one unit, following the vein into the parenchyma until the end of the tumor thrombus was found. Another patient undergoing heminephrectomy for a 9.3-cm RCC had an extension from one of the two major vein branches into the main renal vein. Laparoscopic ultrasound was again used to determine the length of the thrombus and where the lumen of the vein became patent for placement of a bulldog clamp. The tumor and associated branch were excised as one unit, extracting the tumor thrombus from the main renal vein by making a linear incision along its length until reaching the end of the thrombus, allowing a traumatic removal. Suture reconstruction for drainage of the remaining half of the kidney was then performed, flushing the lumen of the renal vein with saline before unclamping. The remainder of the renorrhaphy can be performed in a standard fashion in these cases. Results: Both were performed with less than 30 minutes of warm ischemia time. Both patients were discharged on the first postoperative day without complications and with negative surgical margins. Conclusion: RPN can be successfully performed for selected tumors with venous tumor thrombus. Whereas local control can likely be achieved, systemic recurrence remains a high risk in such T3a patients. No competing financial interests exist. Runtime of video: 6 mins 50 secs